Factors described as contributing to the risk of NSI and sharps injuries in veterinarians.
\r\n\tThe classic definition of organic chemistry as a study of the structure, properties and reactions of organic compounds is found in the chapters of this book, starting from the composition, structure and properties of organic compounds, continuing with electronic effects, reaction mechanisms, stereochemistry, synthesis and reactivity of functional groups. The book will also address applications of organic compounds as drugs, dyes, food, materials used in nonlinear optics, various techniques. It will also focus on the role of carbohydrates, amino acids, proteins, DNA, lipids, vitamins, enzymes, antioxidants in life processes.
\r\n\tThe chapters of this book aim to illustrate the problems of organic chemistry through the various studies presented, which update the knowledge of organic chemistry and its latest applications in various fields of activity.
Occupational health problems in veterinary medicine are very frequent, and veterinarians are considered to be members of a high-risk group for occupational hazards [1].
\nA needlestick injury (NSI) can be defined as an inadvertent (accidental) penetrating wound from a needle that may result in exposure to the blood or other body fluids. A sharps injury includes needles or other sharp objects, such as scalpels, lancets, razor blade, scissors, nose tongs for cattle, halters, calf pulling equipment and metal cattle chutes [2, 3]. These types of injuries are considered a major occupational health problem and of serious concern for veterinarians and other healthcare workers [4]. NSI injuries usually occur during activities such as taking blood and body fluid specimens and processing, needle disposal, waste collection and transferring blood from a syringe into another vessel [5].
\nAwareness of the transmissibility of bloodborne infectious agents in human medicine, including human immunodeficiency virus (HIV), hepatitis B virus and hepatitis C virus, has led to the identification of percutaneous sharps injury resulting in exposure to bloodborne pathogens as an important occupational health risk for people employed in the healthcare industry [6]. It is estimated that more than 2 million healthcare workers experience an NSI or sharps injury with a contaminated sharp instrument every year [7]. Injuries associated with NSI are associated with the potential exposure to infectious agents and syringe contents [8]. Injuries due to contact with contaminated needles may also have serious physical and psychological consequences [9].
\nThere has been less concern regarding NSI and sharps injuries in veterinary practice, and only a few epidemiological studies have been conducted in this area. On the other hand, methodological aspects are not comparable with different design approaches [8]. The analysis of NSI is essential to identifying areas of improvement.
\nIn order to understand the epidemiology of NSI in veterinarians over the last four decades, in this chapter we review the literature, focusing on the epidemiology of NSI and sharps injuries in veterinary practice.
\nEpidemiologic data on NSI and sharps injuries are essential for targeting and assessing interventions [10]. However, a few studies have looked at the epidemiology of NSI and sharps injuries in veterinary practice. Despite significant effort for reduction, NSI and sharps injuries continue to pose a significant risk in human medicine [11], and a similar risk occurs in veterinary medicine. Reports carried out in small and large-animal practice show a large variability in the prevalence and incidence.
\nBloodborne infections are recognized for a long time, and they are the main risk to the health of workers exposed to blood and other biological materials. However, it was only after the discovery of HIV that occupational injuries with potentially contaminated biological material were treated as a public health problem [12]. Infection control guidelines in human medicine put emphasis on protection against bloodborne pathogens. In veterinary medicine few serious zoonotic infections are currently considered to be bloodborne which reduces concern in the veterinary community [13]. HIV and hepatitis viruses are of potential concerns in human medicine but are absent in veterinary medicine [2]. However, veterinarians, by maintaining direct contact with animals, are often exposed to biological agents found in the blood and body fluids. In veterinary hospitals and clinics, occupational risk by biological agents is universally distributed; the risks are proportional to the amount of contacts with patients and blood, secretions and other body fluids [14, 15].
\nThe risk of transmission of infectious agents after the injury with biological material depends on several factors such as host susceptibility and resistance, virulence of the agent, the route of exposure and amount of the infectious agent. As such, the greater the manipulation of sharp objects, blood and other body fluids, the greater the exposure and risk of acquiring infectious diseases [16].
\nThe few recognized bloodborne pathogens that can be transmitted between animals and humans probably are the reason for the less concern regarding NSI and sharps in veterinary practice [17]. The most important bloodborne pathogens in veterinary work are
Approximately 1.2 million occupational NSI and sharps injuries occur in the European Union (EU) each year [26]. It is very difficult to conduct studies in prevalence or incidence (per time per person) or exposure rate of NSI and sharps injuries in veterinary medicine, but these studies are important to determine the risk factors associated with occurrence of injuries [1]. Another problem is that the rate of underreporting of NSI and sharps events is very high [27], and the quality of available data is variable [2].
\nThe studies available about NSI and sharps injuries in veterinary medicine reported different prevalence, ranging from 1% to 86.7%. However, their comparison is difficult since prevalence is calculated from different data sources. In one study conducted in veterinarians in Wisconsin, the incidence of NSI and sharps exposures to Johne’s bacterin during vaccination against paratuberculosis was 5.5/100 person-years [28]. A survey conducted in female veterinarians reported 63.9% of one or more needlesticks after graduation from veterinary college. The incidence of NSI was 9.3/100 person-years [27]. The prevalence of NSI and sharps injuries in American zoo veterinarians was 86.7% [29]. The overall exposure rate reported by Australian veterinarians was 75.3%, but those reported suffering from at least one contaminated NSI in the previous year were 58.9% [30]. A survey of veterinary technicians reported that 93% had at least one NSI over the course of their career and 74% had experienced a needlestick injury during the previous 12 months of the study [8]. In another study, veterinarians that reported at least one unintentional NSI were 74.2 in the previous year of the study [31]. A survey of veterinarians from Uganda reported a NSI prevalence of 15.0% [32]. In a study performed in Portugal, 78.5% of veterinarians enrolled in the study reported having had at least one NSI during their careers [33]. The prevalence of NSI in Japanese veterinarians during containment measures of foot-and-mouth diseases was 1%, and NSI accounted for 18% of all reported injuries in all veterinarians [34].
\nRates observed in veterinary medicine are variable, but in some epidemiological studies, values are much higher than the prevalence rates described for human medicine [35, 36].
\nAccurate reporting of NSI and sharps injuries is essential, to ensure that incidents are appropriately managed [37]. An accident with a needlestick or a sharp should be reported immediately to the supervisor, which supports the workers in administrative and legal terms if they develop a disease resulting from an accident [38]. Surveillance in NSI and sharps injuries should be activated in every healthcare setting to monitor injuries and contaminations and identify the need for corrective interventions [39]. It is difficult to provide accurate statistics on the incidence of NSI or sharps injuries because even in developed countries in human medicine, all cases are not reported [40]. Reasons for underreporting in human medicine include the lack of necessity of reporting with a presumption that the risk of bloodborne pathogens transmission is low and lack of knowledge of systems [37]. There is no single reporting system for injuries or disease in veterinarians, and reported cases of NSI and sharps may greatly underestimate the real number of occurrences [1]. Recall bias and deterioration of memory with the passage of time are other problems associated with the rates of prevalence reported. The true incidence may be underreported owing to the incapacity of busy professionals to remember and write down the details [27].
\nIdentification of risk factors of NSI and sharps has been reported in few epidemiological studies involving veterinarians. As a consequence, little information is available concerning the risk factors for NSI and sharps injuries. Some risk factors associated with NSI and sharps have been referred to in the literature as presented in Table 1.
\nFactors described | \nReference | \n
---|---|
Poor quality of restraint | \n[30] | \n
Inadequate access to sharps containers | \n[49] | \n
Poor needle handling practices by veterinarians | \n[13, 29, 52] | \n
Female gender | \n[30] | \n
Working in small-animal practice | \n[30] | \n
Working with large animals | \n[46, 47] | \n
Veterinarians working with dogs | \n[33] | \n
Less experienced veterinarians (years as veterinarian) | \n[30, 41] | \n
Veterinarians with more than 10 years of practice | \n[33] | \n
Seeing excessive numbers of patients per week | \n[30] | \n
Working longer than normal hours per week | \n[30] | \n
Number of patients treated per week | \n[30] | \n
Household bovines and sheep during childhood | \n[33] | \n
Factors described as contributing to the risk of NSI and sharps injuries in veterinarians.
The influence of sex in the prevalence of NSI and sharps injuries has been studied. Female veterinarians presented higher odds of injury than male veterinarians [30].
\nYears as veterinarians have been described as risk factors. Less experienced veterinarians [30, 41] were more likely to report injuries, which is consistent with that observed in human medicine where the probability of injuries by sharp devices among new personnel or healthcare students is superior when compared to healthcare workers with more years of experience [42]. Clinical experience may have provided expertise and techniques for handling needles and sharp devices, reducing the risk of occupational injuries [43]. However, other studies of veterinarians are contradictory and showed that the proportion of veterinarians who experienced NSI increases with years of practice [33]. This is probably because younger veterinarians may apply the knowledge in infection control acquired in the university and put safety procedures into practice, while practitioners with experience have familiarity with needles and sharp instruments and pay less attention to risks and have lower compliance with biosafety measures [44].
\nIn human medicine, increased risk of injury incidents is positively associated with time constraints and rushing to complete procedures, nervousness, tiredness and loss of concentration. The predisposition to increased risk was also noted to be associated with high workload, working hastily, a crowded work environment, times when personnel are fatigued, do not have a patient’s collaboration or when the medical team was not fully present [12, 45]. In veterinary medicine there are no studies that associate time constraints with NSI and sharps injuries, but these injuries were directly connected with working longer hours per week and number of patients treated per week [30].
\nHousehold association with cattle during childhood has previously been identified as a risk factor. Interaction with animals in infancy could lead to a sense of security in the handling of animals. This can give rise to overconfidence and generate negligent safety behaviours [33].
\nThere is no consensus about the link between the type of practice and the occurrence of accidents that cause injuries. Working in small or mixed animal practice was associated with a significantly higher exposure rate for contaminated NSI in one study [30]. In another study, working with dogs was a risk factor for NSI occurrence, probably, because these animals are extremely mobile animals that are seldom fully restrained during the course of veterinary care and they are often treated with parenteral drugs [33]. According to another study, people working with large animals were more likely to report injuries [46] suggesting that the treating of large animals is more hazardous than the treating of small animals [47]. Animal handling and environmental problems probably influence the occurrence, such as working in semi-dark settings, confinement in closed spaces and high animal densities. However, in a Minnesota and Wisconsin survey, the type of practice did not affect the exposure rate to NSI and sharps injuries, although large animals caused more severe injuries—which is not surprising [48].
\nVeterinary occupational injury can increase with prior injuries, participation in sports, current smoking and six or fewer hours of sleep [49]. Neglected management of occupational health and a failure to comply with simple proactive measures are risk factors for NSI events [38].
\nPoor quality of restraint caused by lack of adequate personnel or inadequate assistance with restraint of animals is considered as a risk factor for an NSI event. Animals are far less obedient than human patients, and movement of the animal at the time of needle puncture is more common if the animal patient is not well restrained [30]. It is probable that the large-animal veterinarians may experience a lower rate of needlestick puncture wounds because they are more likely to restrain their large-animal patients compared to the small-animal clinicians [27, 50]. Poor restraint can compromise not only the person inoculating but also other healthcare workers and animal owners who may be helping [2].
\nNo sharps boxes present increased rates to injuries [49]. Sharps should be disposed of immediately after use directly into a container (i.e. not left bare on any surface) [17]. These sharps containers need to be in close proximity so that the staff can place the sharps into the appropriate containers immediately after use [51]. Pocketing of needles poses a risk for NSI to other staff whilst doing unrelated tasks such as in the laundry [2, 8]. Poor needle handling practices, such as not firmly recapping needles or not bothering to recap them at all, is an important risk factor [13, 29, 52]. But it is likely that this behaviour is improving. In a study performed in small-animal veterinary practices, 89% of practices dispose of sharps directly, rather than recapping them, though a few even indicated a preference for careful recapping [53]. If an appropriate disposal container is not in proximity and available, recapping should be done using some procedures and techniques such as the one-handed ‘scoop’ or using a device to handle the needle cap [54, 55].
\nNeedlestick and sharps injuries most often occur before disposal of a needle or sharp device, during the use of a sharp device, after a procedure and after improper disposal (leaving needles in a laboratory coat with subsequent needlestick injury to laundry personnel) [2]. There are many possible mechanisms of injury. Some circumstances associated with NSI and sharps have been referred to in the literature.
\nRegarding the circumstances in which incidents of NSI and injuries by sharp instruments occurred, it is possible to observe that injury can occur during vaccination and other procedures, in which veterinarians are frequently accidentally ‘self-inoculated’ or suffer other self-inflicted wounds [20, 31, 32, 56, 57]!
\nConcerning veterinary activity at time of injury, it has been demonstrated that vaccine administration is an activity that accounts for a lot of accidents. Within the studies reviewed which evaluated substances involved, two studies refer to injury during
Procedures involving large animals were reported in more studies [27, 29, 30, 32, 34, 46, 47, 52, 58, 59] of epidemiology occurrence than small animals. Zoo animals were also involved in accidents [29].
\nRecapping needles is another activity that increased the risk of percutaneous injury. There was an association between recapping needles in small-animal practice and in large-animal practice and NSI and sharps injuries [13, 52]. A study of zoo veterinarians reported that 86.0 % of NSIs involved recapping needles [29]. Uncapping of needles by the mouth can be a relatively common but risky form of behaviour [17]. Another practice of risk for parenteral exposures, especially in large-animal medicine, is the reuse of needles and syringes [13]. Standard precautions for human medicine guidelines recommend never recapping needles [51].
\nThere was little information about the most affected anatomical parts of the body injured. There was no agreement between studies with respect to the most frequent site of the involvement. In one study, a veterinarian experienced an NSI in the right index finger [19]; in other two studies, veterinarians experienced an NSI into the right thumb [20, 56]; and in another study, seven veterinarians were said to have experienced an NSI in the upper limb [32].
\nThe consequences of occupational exposure to the blood and other body fluids are not only related to infections but also the psychological trauma, anxiety, relationships and prophylactic drugs [60]. NSI and sharps injuries can produce physical trauma, but it is unlikely that they cause severe injuries alone. Physical trauma such as severe laceration can be significant, especially from large-bore needles, and can result from animal movement during injection or blood collection [2]. Every needlestick and sharps injury carries a risk of trauma or inoculation of harmful substances. While the physical trauma caused by needle or a sharp in the body may often be minor, introduction of hazardous compounds such as chemical or biological contaminants has been associated with severe sequelae, including serious infections and damage to tissue [27]. Side effects of NSI and sharps injuries following accidental exposures were normally characterized as mild or severe and local or systemic. Serious adverse effects, while uncommon, do occur [2]. Local adverse events are characterized by one or more of the following symptoms: pain, erythema, local swelling and superficial abscess [27, 52, 58]. These were frequently reported after an injury. Systemic adverse effects experienced after NSI or sharps injuries included myalgia, fever, arthralgia, headaches, fatigue, sweats, severe allergic reaction, chills, lacerations, psychedelic experience, diarrhoea, vomiting or granuloma [27, 56, 58, 59]. Severe reactions included severe local inflammation, abscess formation, localized necrosis, local nerve damage, disease, severe allergic reaction and miscarriage [2, 23].
\nVeterinarians experiencing adverse reactions are more likely to report having had a NSI than others [2].
\nPsychological and psychiatric consequences of NSIs are not yet quantified in veterinary medicine. In human medicine occupational blood exposure can lead to posttraumatic stress, anxiety and depression and is a major contributing factor of time loss from work [60–62].
\nAlthough many types of sharps injure veterinarians, the most common causative devices associated with a higher rate of injury were syringes and needles [19, 30, 47], needle biopsy [56], scalpel blades [63] and ampoule/vial [30]. Although some accidents occurred with empty or clear needles [27, 52], NSI injuries may involve the risk of self-injecting drugs or other hazardous substances, which can result in mild or severe allergic reactions or other more severe consequences [2, 27].
\nAgents producing a side effect most often include anthelmintics [27, 52], euthanasia agents and anaesthetics and steroids [27], immobilizing agents [29], hormones, vaccines [20, 21, 28, 29, 31, 32, 46, 56] and antibiotics [29, 30, 32]. Mineral oil adjuvants of veterinary vaccines can produce a chronic granulomatous reaction with sterile abscess formation [64]. Accidental needlestick injuries and conjunctival or open wound exposures of humans involving the RB51 vaccine were associated with both local and systemic adverse events in the United States [58].
\nOccupational NSI and sharps injuries may also represent a serious human reproductive health hazard, notably the unintentional injection of dinoprost tromethamine, a prostaglandin compound leading to miscarriage in a previous study [27].
\nIn some cases NSI and sharps injuries require medical treatment with hospital admission, in which case medical attention [20, 29, 34, 56, 57] and sometimes surgical intervention are needed [56, 58]. In a study examining zoo veterinarians, 6.5% of veterinarians required medical care after a NSI event [29]. The demand for medical treatment occurs in cases of adverse reactions to injected harmful substances and severe trauma. Self-treatment of injuries was common [48].
\nNeedlestick and sharps injuries are a serious problem in veterinary medicine, but it is often preventable. In human medicine almost 83% of needlestick injuries can be prevented [65]. However, preventive efforts can reduce the risk of exposures, but not eliminate them [66].
\nIn human medicine, time and considerable economic resources have been expended to reduce the incidence of NSI associated with bloodborne agents. Some countries and governments have invested in the need to introduce safety devices, educating healthcare workers on the safe handling and disposal of sharp devices and developing strategies to prevent them [67, 68]. Aggressive educational campaigns concerning NSI prevention are lacking in veterinary medicine. Probably, the factor associated with the lack of this approach is a poorly developed culture of concern about biosafety in veterinary medicine, and only a few bloodborne zoonotic pathogens are recognized in clinically normal animals [2, 8].
\nAdherence and compliance with the universal precaution recommendations proposed by the Centers for Disease Control and Prevention (CDC) are important factors for the prevention of NSI [69]. Recommended prevention strategies include educational programmes, avoidance of recapping, better needle disposal systems and careful handling and disposal of sharp devices [12]. Infection control and workplace safety include safe handling of sharps [17]. Avoid recapping needles or use a ‘one-handed scooping technique’ to recap is a simple infection control procedure which may substantially reduce this form of occupational injury [46]. The CDC recommended the use of gloves and gowns during patient contact that requires handling of blood [69]. Although this equipment does provide a physical barrier to shield the skin and mucous membranes from contact with blood, most protective equipment is easily penetrated by needles [10]. Universal precautions recommended that persons that manipulate needles and other sharps wear gloves and have eye protection and reduce the risk of exposure to needlestick [58]. In previous studies, wearing two pairs of gloves seems to protect because when the outer glove is perforated, the inner glove can protect the hand [70, 71]. Previous studies suggest a low compliance with personal protective equipment in healthcare workers [39]. Discomfort, reduction of agility and decreased sensation of touch were reported to outweigh the benefits afforded by double gloving [72]. The use of personal protective equipment could be affected by availability [51].
\nThe risk of NSI can also be reduced by the use of safety medical devices, which are becoming more commonly used in human healthcare [73] incorporating safety-engineered protection mechanisms (safety-engineered devices, e.g. retractable needles, fixed-needle safety syringes). These modern safety devices minimize the risk and impact of NSI injuries [39, 45]. However some healthcare workers refuse to use such devices [4]. Cost is an obvious concern with needle safety devices, particularly when the benefits are difficult to quantify [2]. And in veterinary medicine, the cost of using the safety-engineered devices can be unaffordable, and cost may be a limiting factor for the use of this kind of device [52].
\nRisk management prevention is necessary to reduce the likelihood of NSI and sharps injuries [2]. The implementation of legislation into the field can help identify and reduce future risk of these injuries [67, 74]. In Europe, legislation to improve the safety and health of personnel has been in place since 1989 and was published to protect healthcare workers and requires an integrated approach [74]. However, in some countries, this legislation is not adapted to veterinary medicine. Current guidelines to reduce NSI and sharps injuries in veterinary practice are not based on veterinary data, but are modified from studies in human medicine [30]. On the other hand, it is very important that veterinarians understand the reasons to comply with safe procedures, which include good needle and sharp handling practices and correct disposal by veterinarians [39]. Veterinarians should be familiar with the recommendations of the CDC guidelines on universal precautions [51]. Work-practice controls are important in preventing exposures to blood and hazardous substances and include verbal statements when passing sharps, avoiding hand-to-hand passage of sharp instruments [75].
\nCosts are harder to quantify. They include the direct costs associated with the initial and follow-up treatment when necessary [76], the emotional cost associated with fear and anxiety associated with the possible consequences of the injury, direct and indirect costs related with lost productivity and cost of any associated legal action [10, 11]. Occupational hazards in the work of American veterinarians resulted in an estimated US$ 4 million in losses [77], and the costs of injuries related to sharp contaminated instruments in the USA have been estimated to be around 118–591 million dollars in 2010 [78]. These costs associated with NSI can be reduced and healthcare protected with investment in safety-engineered sharp devices [79].
\nEducation plays an important role in decreasing NSI rates as it decreased recapping, unnecessary needle manipulation and improper disposal of used devices [39]. Training should always be provided for new employees and periodically for veterinary clinical personnel, as well as for supporting staff [7]. Educational interventions including videotaping and performance feedback proved effective in the short term; however, long-term adherence was not observed [80]. To encourage constant compliance with good safety standards, educational sessions incorporating regular teaching, practical classes and reminders in the form of posters could be used [51]. Education and training need to be encouraged in older workers who receive less training and have more limited access to new technologies than younger workers [39, 81]. Adequate staffing and personnel training in proper animal restraint are also important, as poor restraint is an important risk factor [50]. To prevent injuries with aggressive animals, it is important to handle those animals with care and to make proper use of restraining devices and protective equipment [47].
\nThis chapter describes the epidemiology of NSI and sharps injuries in veterinary medicine and emphasizes the importance of compliance with international standards of infection control practices, of training and of the education of veterinarians. It emphasizes the need for reporting and prevention of NSI and sharps injuries. Increasing awareness of hazards and how to avoid them and establishing better work environments are also crucial. Education regarding the use of personal protective equipment and the importance of reporting accidents should be promoted. There is a need to assess accurately the risk of NSI and sharps hazards in veterinary practice in order to develop effective measures for reducing related incidents. More epidemiological studies in this field are needed to study risk factors, to determine knowledge, attitudes and practices. It is also essential to put a cost-effective and efficient injury and control programme into place.
\nThe work was supported by the strategic research project PEst-OE/AGR/UI0772/2014 financed by the Foundation for Science and Technology [FCT] and to Prof. D.A. Davis that fully revised English text.
\nBreast cancer (BC) is the most common malignant tumor in women (12%) worldwide and is the second leading cause of cancer mortality after lung cancer (26%) [1].
Approximately 95–97% of tumors are estrogen-dependent in the early stages of their development [2, 3] and more than 70% express very high levels of estrogen receptor alpha (ERα) [4]. The fundamental difference of extragonadal estrogen synthesis is its autocrine nature—that an organ producing estrogens is a target organ at the same time. Thus, local concentration of estrogens in such organs may be markedly elevated. Peripheral estrogens formation is increased after menopause, and compensates estrogens deficiency in different organs and tissues [5]. Extragonadal estrogens’ production may rise with the aging. Moreover, it was continually emphasized in the literature that the increased level of estrogens in the body is considered as a risk of the BC development [6, 7].
Biologically active hormones, in particular the most active estrogen estradiol (E2), play a critical role in the initiation and development of hormone-dependent breast cancer (HDBC). In premenopausal women, estrogens are mainly (75%) synthesized in the ovaries, and thus, a luteinizing hormone-releasing hormone (LH-RH) agonist [8, 9] is useful to suppress the function of pituitary hormone. In postmenopausal women estrogens are produced in peripheral tissues such as adipose tissues, skin, and mammary glands [10, 11].
Adrenal dehydroepiandrosterone sulfate (DHEAS), dehydroepiandrosterone (DHEA), and adrenal or ovarian androstenedione are also sources of E2 in peripheral tissues. In postmenopausal women, concentrations of DHEAS, DHEA, and androstenedione in plasma are relatively high; approximately 1.8, 6.6, and 1.9 nM, respectively. In contrast, plasma concentrations of estrone (E1) and (E2) are several-fold lower (70 and 30 pM, respectively) [12].
Another important steroid precursor for estrogen formation is E1-sulfate (E1S). It is the most important estrogen in the peripheral blood, with relatively high (0.6 nM) concentrations in postmenopausal women. E1S levels are associated with high body-mass index, which suggest that E1S originates from adipose tissue. Concentrations of E1S in plasma are 10–20 times higher than those of E1 and E2, as well as its half-life in the plasma is longer than the half-life of unconjugated estrogens.
Enzyme steroid sulfatase (STS) converts E1S to E1, followed by the reduction to the biologically active estrogen, E2, by 17β-hydroxysteroid dehydrogenase type 1 (17β-HSD1), which is overexpressed in many breast tumors.
In BC tissues estrogens can be locally produced
The level of estrogens in BC tissues of postmenopausal women can be 10–40 folds higher than in blood circulation and 5–10 times higher than in noncancerous breast tissues [13]. Furthermore, the intratumoral E2/E1 ratio is significantly higher in postmenopausal BC than in premenopausal BC. High concentrations of estrogen in breast tissue increase the risk of BC development [14, 15].
Thus, inhibition of enzymatic synthesis of estrogens is an effective therapeutic strategy for postmenopausal women with estrogen receptor-positive (ER+) tumors [16, 17].
The scheme of estrogens formation in human body includes: (a) formation of E1 from androstenedione under the action of cytochrome P450 aromatase, (b) reduction of E1 by 17β-HSD1 leads to more active E2. Importantly, almost insoluble in aqueous media E1 is converted into water-soluble E1S under the action of sulfotransferase (STS). E1S does not possess hormonal activity, however it may be transported into various targets (Figure 1) [18, 19]. Several reviews focus on aspects of human steroidogenesis [18, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29].
Estrogens formation in human body.
Free hormones are formed from sulfates of estrogen and androgens under action of steroid sulfatase. At high concentrations, androgens compete for binding with ERs. The activation of ERα under the action of androstenediol and DHEA in BC cells has been detected. It is confirmed by the inhibition of cell growth in the presence of antiestrogens. The evaluation of E1S level during diagnostic of various oncological diseases (for example, prostate cancer) is of high importance [30].
Hormonal (endocrine) therapy is effectively used for the treatment of HDBC. Most types of BCs are estrogen-dependent, with approximately 55% in premenopausal women and 75% in postmenopausal women [31, 32, 33, 34].
Selective estrogen receptor modulators (SERMs) or down-regulators (SERD), such as tamoxifen, raloxifene, ospemifine, and fulvestrant are compounds that are currently used in clinical practice to treat BC [9, 35]. In breast tissues, SERMs effectively block the activation of ER(α) by endogenous ligands, preventing the transcription of genes mediated by estrogen response elements [36, 37]. SERMs have tissue-specific effects on ERα that results in antagonist activity in breast and uterus tissues as well as agonist activity in bone. Although tamoxifen and raloxifene possess the desired SERM activity, they also increase the risk of venous thromboembolism [38] and exhibit toxicity [22]. Given that resistance (
The aromatase enzyme is responsible for the conversion of testosterone and androstenedione to E2 and E1, respectively. Thus, inhibition of the aromatase enzyme is one of the approaches for the development of new drugs to treat BC [41, 42, 43].
Nonsteroidal third-generation aromatase inhibitors (AIs), such as anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin), are often used for postmenopausal hormone-dependent BC treatment in clinical practice. Despite the success of AIs in the clinic, numerous BC patients still progress after AI therapy due to the development of resistance to AIs and side-effects such as osteoporosis caused by whole-body deprivation of estrogen [44, 45]. Mechanisms of AI resistance include ligand-independent activation of the ER and signaling via other growth factor receptors; new insights about resistance are published recently [45].
The overall response rates for AIs (40–50%) suggest the presence of alternative sources of estrogens. The production of E1, DHEA and androstenediol is an important mechanism of resistance to AI treatment [46].
It was demonstrated that AIs used sequentially with tamoxifen had higher efficacy compared to tamoxifen alone, with an improvement in overall survival [47].
There are other factors involved in tumor growth [48]. The enzymes STS and 17β-HSD1 have been identified as essential parts in E2 production and subsequent promotion of cancer growth. Recently it was shown that 17β-HSD7 also plays a key role in increasing the E2/E1 ratio in BC tumors [49]. Very recently, some evaluations of the “sulfatase pathways” in tumor stroma have been carried out [50].
The STS is also responsible for the hydrolysis of DHEAS to DHEA, which is an immediate precursor of androstenediol, a potent estrogenic steroid [51], whose formation is not influenced by AIs. DHEAS stimulates proliferation of MCF-7 cells from BC, which could be blocked by an antiestrogen or STS inhibitor but by an AI. E1S and DHEAS are particularly abundant in blood circulation and could act as a reservoir of steroid precursors, specifically in BC [29, 52]. The formation of DHEA through the STS pathway accounts for the production of 90% of the androgen androstenediol [52], which possesses estrogenic properties, that are 100-times weaker than estradiol [13, 53]. Androstenediol is present at 100-fold higher concentrations than estradiol in the circulation, and may have estrogenic properties that are equal to estradiol [54]. Thus, inhibition of STS has the dual property of reducing local androstenediol biosynthesis [55, 56].
The STS enzyme (EC 3.1.6.2, aryl sulfatase C, steryl-sulfatase) is widely distributed throughout the body and plays critical role in steroidogenesis [54]. Publications in recent years indicate the role of STS activity in gynecological diseases [57], mentioning diminished endometriosis
According to the
The human STS is a protein, integrated in microsomal membrane. Its three-dimensional structure has been determined (PDBcode 1P49) [66]. However, knowledge about regulation of its expression as well as activity is limited. The topology of the active site of the steroid sulfatase and the arylsulfatases A and B is similar [66].
Most of the STS inhibitors discovered to date, act as irreversible active-site-directed inhibitors. An aryl sulfamate group (ArOSO2NH2) is considered as the pharmacophore for irreversible inhibition of the enzyme. One of the first time-, pH-, and concentration-dependent irreversible active-site directed-steroidal inhibitor is estrone-3-O-sulfamate (EMATE), which inhibit STS in MCF-7 cells from BC by 99% at 0.1 μM and has an IC50 value of 65 pM (IC50 = 80 nM in placental microsomes). EMATE was evaluated in clinical trials [67]. The highest effectiveness of EMATE has been demonstrated in rats (subcutaneous and oral administration). STS activity was also inhibited when EMATE was administered to humans in dose 0.5 mg/kg [68].
Despite the exceptional potency of the EMATE [67, 68], it is not used in clinical practice to treat hormone-dependent BC because metabolic conversion of EMATE by STS releases estrone, which act via estrogen receptors, and can directly promote tumor growth [69]. Nevertheless, EMATE is now the prototypical inhibitor, and used as standard during evaluation of other potential STS inhibitors [19].
Several research groups made attempts to establish the mechanism(s) of sulfatase inactivation. However, the precise mechanism of inhibition is still uncertain. In 2010, Spillane and Malaubier have established that the hydrolysis of EMATE occurs by two different mechanisms: an SN2 mechanism below pH 9.5 and E1cB mechanisms involving N-sulfonylamines at higher pHs [70]. Detailed presumable mechanisms have been discussed in recent reviews [71, 72, 73].
Based on the mechanisms, the result of the hydrolysis is free estrone. Moreover, under per os administration, the activity of EMATE is several times higher than the activity of estrone, due slow metabolism of EMATE in liver [68]. EMATE is not subjected to metabolic inactivation in red blood cells. Thus, consideration of hormonal activity and side-effects of steroids with free phenolic group is important in the modeling of sulfatase inhibitors for therapeutic use [54, 74, 75].
The knowledge of the crystal structure opens the rational drug design of molecules for the inactivation of steroid sulfatase.
Many investigations have been carried out to develop nonsteroidal STS inhibitors, because nonsteroidal drugs and their metabolites may have less undesirable effects.
4-Methylcoumarin-7-O-sulfamate (
A search of an orally active, nonestrogenic, nonsteroidal STS inhibitors among tricyclic compounds based around the coumarin core resulted in the discovery of Irosustat (667-coumate, STX64, BN83495) [77], which is the first-in-class irreversible time- and concentration-dependent STS inhibitor for the treatment of hormone-dependent BC in postmenopausal women that has been clinically evaluated in breast, endometrial, and prostate cancers [77] and there is potential for innovative dual-targeting approaches [78, 79], with an IC50 value of 8 nM in placental microsomes. The inhibitor (
The optimum dose of 40 mg/day was estimated in phase I/II trials [81]. Efficiency of Irosustat has also been demonstrated in a phase II study in (ER+) endometrial cancer in women with advanced or recurrent disease [82]. The high bioavailability of Irosustat is explained by the prevention of degradation by sequestration inside red blood cells where it, similarly to EMATE, binds to (and inhibits) carbonic anhydrase II (IC50 = 22 nM) [83]. The inactivation mechanism suggests that a sulfamate group is transferred to the gem-diol form of formylglycine 75 of steroid sulfatase due to a facile E1cB elimination of sulfamate anion to give the corresponding coumarin, which has a long half-life in blood [84]. However, the further development of Irosustat in monotherapy was stopped in the phase I/II clinical studies, because Irosustat does not possess superior properties to the current standard of care megesterol acetate, and its relative bioavailability decreases with increasing dose. The study of its combination with other hormonal therapies (for example, with the aromatase inhibitor anastrozole) is underway [85]. Metabolism of Irosustat has been investigated [86]. Irosustat also inhibits skin and liver STS [86].
One of the first examples of the dual SERM/STS inhibitor was published by Duquesne University [87]. 4-Hydroxytamoxifen is a metabolite of main drug tamoxifen used as endocrine therapy in (ER+) BCs [88]. This metabolite is a SERM and has antiestrogen effects in breast tissues, however, acts as an estrogen agonist in other tissues such as bone marrow. The sulfamate derivative
Surprisingly, among silicon-containing derivatives compound
Poirier with colleagues, among tetrahydroisoquinoline-N-substituted derivatives [90], found second-generation dual-action compounds that inhibit STS and act as a SERM. These compounds are devoid of estrogenic activity and toxicity. Their sulfamate derivatives possess high inhibitory activity toward STS (IC50 of 3.9, 8.9, and 16.6 nM). Both phenolic and their sulfamate derivatives show no estrogenic activity and moderate antiestrogenic properties. All compounds significantly stimulate osteoblast-like Saos-2 cell proliferation, thus suggesting a SERM activity. The results of molecular docking experiments suggest that the most active compounds
Another approach for the treatment of hormone-dependent BC is the development of DASIs, which may have an additive or synergistic antitumor effect. The potential advantages of a single chemical agent with the ability to interact with multiple biological targets were highlighted previously [92]. In the case of DASIs, this goal is being pursued by the introduction of the critical sulfamate unit in structures with known aromatase-inhibiting properties [93, 94]. All DASIs are still in preclinical investigations [95].
One of the best dual inhibitors is compound
One of the most potent dual inhibitor is compound
Among compounds on letrozole and vorozole templates, the most potent inhibitors were compounds
Potter with coauthors published the successful realization of the strategy when the core components of the two leading DASIs resulted in the hybrid structures that exhibit a very high level of dual inhibition against aromatase and STS
The latest achievements in the field of nonsteroidal AIs are presented in recent reviews [105, 106].
Nonsulfamated STS inhibitors based on estrogens are weaker than EMATE. Most active STS inhibitors without sulfamate group with highest activity are represented by compounds
Estradiol dimer
In the series of 4-substituted 17β-arylsulfonamides of 17β-aminoestra-1,3,5(10)-trien-3-ol, compounds
The estrogenicity of EMATE and estradiol-3-O-sulfamate (
The sulfamate
D-ring lactone
Simple modifications of the D-ring have led to dramatic variations in estrogenicity. Thus, the conversion of EMATE to the oxime results in a super-estrogen. From the other hand, D-ring heterocyclic derivatives exhibit reduced estrogenicity [121, 122].
The replacement of ring D with N-substituted piperidinedione moiety results in the loss of estrogenic properties and greater STS inhibitory activity
Among various 2- and 4-substituted and 2,4-disubstituted EMATE derivatives, most active compounds are 2-(2-prop-2-enyl)-EMATE (
Cyclic sulfamate
17βHSD converts E1 to E2 and DHEA to androstanediol [132]. Several inhibitors based on steroidal skeleton have been successfully developed [133, 134]. Few dual inhibitors of 17β-HSD and STS for the treatment of steroid hormone-dependent diseases are patented [135]. The example of such inhibitors is represented by the compound
A-ring-modified steroidal sulfamates, for example, series of 2-OMe-estradiol sulfamates and analogs have been investigated as nonestrogenic STS inhibitors [136, 137]. 2-MeO-EMATE
2-Ethyl-EMATE
It is known that 2-methoxyestradiol, a metabolite of E2, possesses antiangiogenic properties and prevents tumor growth through disrupting tubulin polymerization by binding at the colchicine-binding site [142, 143]. 2-Methoxyestradiol is considered as the perspective compound for the treatment of endometriosis [144].
The anticancer effects of the 2-substituted sulfamate estrogen derivatives arise from disruption of tubulin polymerization, and the compounds also binding at the colchicine site [145]. 3,17β-Bissulfamates of estrogens are other representatives of multitargeted antitumor agents, acting as STS inhibitors with antiproliferative activity (IC50 = 18–250 nM) [146]. Such bissulfamates compete with colchicine for tubulin binding and disrupt microtubules resulting into cell cycle arrest just by apoptosis
STX140 (
Coordination of the 17-sulfamate residue to the zinc in active site of the complex of STX140 with human carbonic anhydrase II is revealed [155].
STX140 depolarizes mitochondrial bioenergetics, activates caspase 3/7 causing apoptosis through the intrinsic mitochondrial pathway, and downregulates the expression of caspase inhibitors [156]. The activity of such compounds is also explained by their ability to disrupt the tubulin-microtubule equilibrium in cells as being central to their antitumor activity. STX140 and STX243 bind with the colchicines binding site of tubulin. 2-(11C)Methoxy-3,17β-OO-bis(sulfamoyl)estradiol has been proposed as a new potential PET agent for imaging of steroid sulfatase in cancers [157].
One more example of 2-MeO-derivatives as effective STS inhibitors is illustrated by compound
2-Difluoromethyl-E1-3-O-sulfamate (
The level of STS inhibition for 17β-(N-alkylcarbamoyl)-estra-1,3,5(10)-trien-3-O-sulfamates (
Among a series of C17-ketone and amide-modified estrone-derived sulfamates, compound KW-2581 (
Diverse 17α-alkylated estradiol sulfamates as STS inhibitors have been patented [163] and 17α-benzyl-derivatives have been investigated [164].
Compound EM-1913 (
17α-Benzyl substituent yields reversible STS inhibitors in the absence of a sulfamate group, and incorporation of an aryl sulfamate onto the A-ring results in a potent time-dependent irreversible inhibitor. The IC50 of the tert-butylbenzyl derivative
In the series of A-ring thioether-modified sulfamates, the steroid
Maximum estrogen blockade in the treatment of (ER+) BC may be achieved using dual ERα antagonists and STS inhibitors, which might cause osteoporosis as a side effect [169]. In this case, the compound possessing SERM properties is needed.
Thus, a novel orally available irreversible dual STS/SERM inhibitor SR16157 (NSC 732011) (
Desulfamoylation of SR16157 (
We demonstrated that 8-alpha-analogs of steroid estrogens effectively inhibit the growth of BC cells, including triple negative BC [173, 174].
Manipulation of hormone biosynthesis in tumors by enzymes inhibitors is a very attractive approach for the treatment of hormone-dependent tumors such as breast, prostate cancer, and endometriosis.
The importance of STS in human body has been underlined by many investigations. Thus, STS-catalyzed hydrolysis of pregnolone-3-sulfate and dehydroepiandro-sterone-3-sulfate in the brain regulates neurosteroid synthesis and influences memory. STS inhibition for the potentiation of memory in sufferers of neurological diseases such as Alzheimer’s disease and dementia has been postulated [175]. The role of STS inhibitors as agents to reveal beneficial endogenous glucocorticoid effects was also claimed. The use of STS inhibitors in combination with the immunosuppressive ascomycin for the treatment of acne, seborrhoea, androgenetic alopecia, and hirsutism is patented. The administration of an estrogen (including norgestimate and norelgestromin), in combination with a progestogen in hormone-replacement therapy act by inhibiting STS, thus reduce estrogen production and protect the endometrium and breast from hormone-dependent cancers [176]. STS inhibitors prevent ovarian cycle disturbance, prolonged unopposed secretion of estrogens, and ovarian follicular cyst formation in premenopausal women, as well as prevent premature uterine contractions, particularly for preterm labor [177].
The importance of STS inhibition in endometriosis, prostate cancer, as well as latest discussions about mechanism of inhibition is well considered in the review of Prof. Potter [178]. The significance of steroid sulfatase and sulfotransferases in gynecological diseases are summarized in the review [57].
As far as estrogenic compounds may stimulate tumor cells growth, the main requirement for STS inhibitors and their metabolites is the absence of estrogenicity. Among nonsteroidal STS inhibitors only one nonestrogenic compound-Irosustate was evaluated in clinical trials with excellent properties, however its further development was stopped. Currently, the action of Irosustate in the combination with AIs is investigated.
The discovery of dual (multitargeted) inhibitors is the most promising nowadays. For example, several DASIs based on anastrazole, letrozole, and vorozole templates inhibit both STS and aromatase in nanomolar concentrations, being nonestrogenic; and have a chance to be introduced in clinical trials.
Among STS inhibitors based on steroid skeleton 17α-benzyl-derivatives, 17β-arylsulfonamides, and 17-diisopro-pylcarbomoyl-3-O-sulfamates exhibit the best properties, especially as multitargeted (dual) anticancer potential drugs. The same modifications result in the increased activity against STS in the case of 2-OMe-3-O-sulfamates as well as 2-OMe-3,17β-bissulfamates. The latter also possess activity against most aggressive form—triple negative BC.
Additionally, 8α-steroid estrogen analogs without estrogenic properties possess high STS activity and block BC cells growth with the activity comparable to standard of care for BC treatment tamoxifen.
The authors greatly appreciate Dr. Anna S. Chentsova for careful reading of the manuscript and her valuable comments. The reported study was funded by RFBR according to the Research Project No. 16-54-76024.
The authors confirm that this article content has no conflicts of interest.
AIs | aromatase inhibitors |
BC | breast cancer |
COMT | catechol-O-methyltransferase |
Coumate | 4-methylcoumarin-7-O-sulfamate |
DASI | dual aromatase-sulfatase inhibitor |
DHEAS | dehydroepiandrosterone sulfate |
FGly | for-mylglycine |
GPER, GPR30 | G-protein-coupled estrogen receptor |
HDBC | hormone-dependent breast cancer |
17βHSD | 17β-hydroxysteroid dehydrogenase |
E1 | estrone |
E2 | estradiol |
E2MATE | estradiol-3-O-sulfamate |
EMATE | estrone-3-O-sulfamate |
ER | estrogen receptor |
LH-RH | luteinizing hormone-releasing hormone |
2-OHE1 | 2-hydroxyestrone |
4-OHE1 | 4-hydroxyestrone |
2-OHE2 | 2-hydroxyestradiol |
4-OHE2 | 4-hydroxyestradiol |
STS | steroid sulfatase |
SERD | selective estrogen receptor down-regulators |
SERM | selective estrogen receptors modulator |
UGT | UDP-glucuronosyltransferase |
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