ORIGINAL ARTICLE

CYP2D6 Genetic Polymorphisms and Phenotypes

in Different Ethnicities of Malaysian Breast Cancer
Patients
Fee Wai Chin, MSc,* Soon Choy Chan, PhD,† Sabariah Abdul Rahman, MD,‡,§
Sharifah Noor Akmal, MD,¶ and Rozita Rosli, PhD*,**
*Genetic Medicine Research Centre, Faculty of Medicine and Health Sciences, Universiti Putra
Malaysia, Serdang, Selangor, Malaysia; †Perdana University Graduate School of Medicine (PUGSOM),
Serdang, Selangor, Malaysia; ‡Medical Education Unit, Faculty of Medicine, Universiti Teknologi
MARA, Batu Caves, Selangor, Malaysia; §Laboratory of Medical Sciences, Faculty of Medicine,
Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; ¶Department of Pathology, Faculty of
Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia; **UPM-
MAKNA Cancer Research Laboratory, Institute of Bioscience, Universiti Putra Malaysia, Serdang,
Selangor, Malaysia

n Abstract: The cytochrome P450, family 2, subfamily D, polypeptide 6 (CYP2D6) is an enzyme that is predominantly
involved in the metabolism of tamoxifen. Genetic polymorphisms of the CYP2D6 gene may contribute to inter-individual
variability in tamoxifen metabolism, which leads to the differences in clinical response to tamoxifen among breast cancer
patients. In Malaysia, the knowledge on CYP2D6 genetic polymorphisms as well as metabolizer status in Malaysian breast
cancer patients remains unknown. Hence, this study aimed to comprehensively identify CYP2D6 genetic polymorphisms
among 80 Malaysian breast cancer patients. The genetic polymorphisms of all the 9 exons of CYP2D6 gene were identified
using high-resolution melting analysis and confirmed by DNA sequencing. Seven CYP2D6 alleles consisting of CYP2D6*1,
CYP2D6*2, CYP2D6*4, CYP2D6*10, CYP2D6*39, CYP2D6*49, and CYP2D6*75 were identified in this study. Among
these alleles, CYP2D6*10 is the most common allele in both Malaysian Malay (54.8%) and Chinese (71.4%) breast cancer
patients, whereas CYP2D6*4 in Malaysian Indian (28.6%) breast cancer patients. In relation to CYP2D6 genotype,
CYP2D6*10/*10 is more frequently observed in both Malaysian Malay (28.9%) and Chinese (57.1%) breast cancer patients,
whereas CYP2D6*4/*10 is more frequently observed in Malaysian Indian (42.8%) breast cancer patients. In terms of
CYP2D6 phenotype, 61.5% of Malaysian Malay breast cancer patients are predicted as extensive metabolizers in which
they are most likely to respond well to tamoxifen therapy. However, 57.1% of Chinese as well as Indian breast cancer
patients are predicted as intermediate metabolizers and they are less likely to gain optimal benefit from the tamoxifen
therapy. This is the first report of CYP2D6 genetic polymorphisms and phenotypes in Malaysian breast cancer patients for
different ethnicities. These data may aid clinicians in selecting an optimal drug therapy for Malaysian breast cancer patients,
hence improve the clinical outcome of the patients. n
Key Words: CYP2D6, genetic polymorphisms, Malaysian breast cancer patients, tamoxifen

B reast cancer is the most common cancer in

women worldwide including Malaysia (1). Based
on the latest census, the population of Malaysian citi-
zen was reported to be 25.98 million comprising the
major ethnic groups: Malay (67.4%), Chinese
(24.6%), Indian (7.3%), and others (0.7%) (2). The
Address correspondence and reprint requests to: Rozita Rosli, MD, Pro-
fessor and Head, UPM-MAKNA Cancer Research Laboratory, Institute of
Bioscience, Universiti Putra Malaysia, Serdang 43400 UPM, Selangor,
Malaysia, or e-mail: rozita@medic.upm.edu.my
DOI: 10.1111/tbj.12518
© 2015 Wiley Periodicals, Inc., 1075-122X/15
The Breast Journal, Volume 22 Number 1, 2016 54–62
incidence rate of breast cancer differ across these
ethnicities in which the highest rate was among the
Chinese, followed by Indian, and Malay, with age-
standardized incidence rate of 38.1, 33.7 and 25.4 per
100,000 population, respectively (1). Approximately
75% of all invasive breast cancers are estrogen recep-
tor (ER) - positive and tamoxifen is widely used as
hormonal therapy for ER-positive breast cancer
patients to reduce recurrence and mortality risks
(3–6). Tamoxifen acts as an estrogen antagonist in
breast tissue in which it competes with endogenous
estrogen for ER binding and blocks the estrogen from

binding to the receptor, thus inhibits the proliferation
of breast cancer cells (4,7,8). In human liver, tamox-
ifen is predominantly metabolized by cytochrome
P450, family 2, subfamily D, polypeptide 6 (CYP2D6)
enzyme into its most active metabolite,
4-hydroxy-N-desmethyltamoxifen (endoxifen) (9,10).
The efficacy of tamoxifen therapy varies widely
among breast cancer patients as 30% of the patients
do not benefit from tamoxifen, they experience breast
cancer recurrence and eventually die from the disease
(5,6). This might be attributed by genetic polymor-
phisms of the CYP2D6 gene that lead to inter-individ-
ual and inter-ethnic variations in tamoxifen response
(11–13).
The CYP2D6 gene is highly polymorphic with a
total of 105 CYP2D6 alleles that have been reported
in the CYP2D6 Allele Nomenclature Database as of
March 2013. CYP2D6 alleles can be classified into
functional alleles, reduced function alleles, and non-
functional alleles, which are associated with different
enzyme activity. The prevalence of CYP2D6 allele is
known to vary widely among different populations.
CYP2D6*10 occurs much more frequently in Asian
populations compared to Caucasian populations at
allele frequencies of 40–50% (14,15). The key muta-
tion of CYP2D6*10 is 100C>T in the CYP2D6 exon
1, which causes amino acid substitution of p.Pro34Ser
leading to the coding of an unstable enzyme with
reduced enzyme activity (16). On the other hand,
CYP2D6*4 is the most common allele in Caucasians
with allele frequency of 20%. However, this allele is
rare in Asians with allele frequencies of 0–2% in the
populations (15,17).
CYP2D6 phenotypes can be predicted based on
genotypes. It can be categorized into poor metabolizer
(PM), intermediate metabolizer (IM), extensive metab-
olizer (EM), and ultrarapid metabolizer, which are
associated with no, lower, normal, and ultrarapid
drug metabolism, respectively (18–21). Notably,
Asians exhibit the highest frequency of IM phenotype
in which 30% of Asians are IMs (22). The
CYP2D6*10 is known as an Asian-specific IM alleles
due to this allele being highly prevalent in Asian pop-
ulations. In contrast, PM phenotype was more fre-
quently observed in Caucasians with a frequency of
7–10% (23–27) while at less than 1% in Asians (28).
Among PM alleles, CYP2D6*4 is the most common
PM allele in Caucasians.
CYP2D6 genetic polymorphisms have been exten-
sively studied in Caucasian (29,30), African (31), as
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CYP2D6 Polymorphisms and Breast Cancer • 55
well as Asian populations (32–34). In Malaysia,
previous studies on CYP2D6 genotyping of several
commonly reported CYP2D6 alleles have been con-
ducted for Malaysian healthy subjects (35–37) as well
as cardiovascular disease patients (38). However, no
CYP2D6 genotypic data are available yet for Malay-
sian breast cancer patients although it is useful for pre-
dicting CYP2D6 phenotype of the breast cancer
patients. Therefore, this study aimed to identify genetic
polymorphisms of the CYP2D6 gene in Malaysian
breast cancer patients consisting of the major ethnic
groups, namely Malays, Chinese, and Indians by high-
resolution melting (HRM) analysis followed by DNA
sequencing. In addition, this study also aimed to deter-
mine CYP2D6 genotypes as well as to predict CYP2D6
phenotypes of the local breast cancer patients.
METHODS
Patients
Ethics approval for this study was granted by the
Universiti Kebangsaan Malaysia (UKM) Research and
Medical Research Ethics Committee. A total of 80
Malaysian female breast cancer patients consisting of
52 Malays, 21 Chinese, and 7 Indians who underwent
mastectomy or lumpectomy at Hospital Kuala Lum-
pur, Hospital UKM, and Hospital Putrajaya were
enrolled in this study. Written informed consent was
obtained from each patient prior to clinical sample
collection. Medical and histopathology reports of the
patients were reviewed at the respective hospital. Age
of the patients ranged from 22 to 81 years old with a
median age of 50 years old (Table 1). In the course of
the study, seven patients died from advanced breast
cancer with lung, liver, brain, and/or bone metastases.
Clinical samples and DNA extraction
Genomic DNA was extracted from either fresh
frozen breast cancer tissues or blood depending on the
availability of the clinical samples. DNA extraction
was carried out using QIAamp DNA Mini Kit for
tissue samples and QIAamp DNA Blood Midi Kit
(Qiagen, Hilden, Germany) for blood samples accord-
ing to the manufacturer’s protocol. Concentration of
the extracted DNA was measured using NanoDrop
2000 Spectrophotometer (Thermo Fisher Scientific,
Waltham, MA), whereas DNA integrity was assessed
using 1% agarose gel electrophoresis.
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56 • chin et al.

HRM assay and analysis ethanol precipitation method according to the manu-
facturer’s protocol. DNA sequencing was carried out
Prior to conducting the HRM assay, HRM primers
on a CEQ 8000 Genetic Analysis System (Beckman
were designed for amplifying 9 exons of the CYP2D6
Coulter). Sequencing data were then analyzed using
gene using Primer3 version 0.4.0 (http://frodo.wi.mi-
Pregap4 and Gap4 modules of the Staden Package
t.edu/primer3). Real-time PCR followed by HRM
software.
analysis were carried out in a single run on a Rotor-
Gene 6000 (Corbett Research, Mortlake, Australia).
The PCR reaction was prepared in a total reaction CYP2D6 allele nomenclature
volume of 20 lL, which constituted of 50 ng of geno-
CYP2D6 alleles were designated according to the
mic DNA, 0.2 lM of both forward and reverse pri-
CYP2D6 Allele Nomenclature Database (http://www.-
mers, 19 SensiMix HRM Master Mix (3.0 mM of
cypalleles.ki.se/cyp2d6.htm). CYP2D6 sequence with
MgCl2, 19 reaction buffer, dNTPs and Taq DNA
GenBank accession number M33388.1 was used as
polymerase; Quantace, London, UK, 0.8 lL of Eva-
reference sequence. Base numbering was according to
Green dye; Biotium, Hayward, CA and Milli-Q water;
nucleotide A of the ATG translation initiation codon
Millipore, Billerica, MA). Real-time PCR amplification
(at base number +1620 in M33388.1) designated as
was performed with an initial denaturation at 95°C
base number +1. CYP2D6 allele was designated using
for 10 minutes followed by 40 cycles of denaturation
an asterisk to indicate allele, whereas a number after
at 95°C for 15 seconds, annealing for 15 seconds and
the asterisk to represent the CYP2D6 allelic variants.
extension at 72°C for 30 seconds. HRM analysis was
immediately performed with a premelting conditioning
for 90 seconds followed by melting with temperatures RESULTS
ranging from 70°C to 95°C with an increment of
CYP2D6 alleles were designated according to the
0.1°C for every 2 seconds. Analysis of HRM data was
CYP2D6 Allele Nomenclature Database and relevant
carried out using Rotor-Gene 6000 Series version 1.7
information for the identified CYP2D6 alleles are
(Build 87; Corbett Research). Melting curve profiles of
described in Table 2. For instance, the presence of
all the samples were normalized and compared to
two single-nucleotide polymorphisms (SNPs) 100C>T
each other for identifying different variant groups.
and 4180G>C in M33388.1 give rise to CYP2D6*10.
The samples were clustered into different variant
The key mutation for this allele is a nonsynonymous
groups based on the threshold of 90% confidence in
SNP 100C>T in exon 1 of the CYP2D6 gene, which
similarity with a group control. Several samples repre-
causes substitution of proline to serine in amino acid
senting each variant group were selected for DNA
position 34 (p.Pro34Ser). On the other hand,
sequencing.
CYP2D6*4 constitutes of three SNPs 100C>T,
1846G>A and 4180G>C. The key mutation 1846G>A
Post-PCR purification and DNA sequencing
Table 1. Characteristics of 80 Malaysian Breast
Post-PCR purification for the selected samples was Cancer Patients
carried out using GeneAll PCR SV Kit (General
Biosystem, Seoul, Korea) according to the manufac- Patient

turer’s protocol. Sequencing reaction was prepared in Total Malay Chinese Indian
a 10 lL reaction volume containing 10 ng of purified Characteristic (n = 80) (n = 52) (n = 21) (n = 7)
PCR product, 3.2 lM of either forward or reverse DNA source
primer, 2 lL of DTCS with Quick Start Master Mix Tumor DNA 66 43 17 6
Germ line DNA 14 9 4 1
(Beckman Coulter, Indianapolis, IN) and Milli-Q Age
water (Millipore). Cycle sequencing was performed on <30 years 2 2 0 0
30–49 years 34 27 4 3
a Biometra T-Gradient Thermocycler (Biometra,
50–69 years 39 21 14 4
G€ottingen, Germany) with 50 cycles of denaturation >69 years 5 2 3 0
at 96°C for 20 seconds, annealing at 50°C for 20 sec- Survival status
Alive 73 47 21 5
onds and extension at 60°C for 4 minutes. Subse- Death 7 5 0 2
quently, sequencing products were purified using
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CYP2D6 Polymorphisms and Breast Cancer • 57

Table 2. Seven CYP2D6 Alleles Identified in This Study and their Corresponding SNPs

The top panel shows SNP information derived from dbSNP database, whereas the bottom panel shows CYP2D6 allele information derived from the CYP2D6 Allele Nomenclature
Database. Open and gray boxes indicate the absence and presence of the SNP(s) for a given CYP2D6 allele, respectively.

in the intron 3/exon 4 boundary of the CYP2D6 gene
causes mRNA splicing defect.
In total, seven CYP2D6 alleles were identified in 80
Malaysian breast cancer patients, which consist of
three functional alleles (CYP2D6*1, CYP2D6*2, and
CYP2D6*39), two reduced function allele
(CYP2D6*10 and CYP2D6*49), one nonfunctional
allele (CYP2D6*4), and one new unknown function
allele (CYP2D6*75) as shown in Table 3. Among
these alleles, CYP2D6*10 is the most common allele
in both Malay and Chinese breast cancer patients with
allele frequency of 54.8% and 71.4%, respectively.
On the other hand, Indian breast cancer patients have
high prevalence of CYP2D6*4 with allele frequency of
28.6%. However, the occurrence of CYP2D6*4 was
low in Malay breast cancer patients with allele fre-
quency of 2.9% and it was absent in Chinese breast
cancer patients. Interestingly, a novel CYP2D6*75
that has been previously reported in the Han Chinese
population (34) from China was also identified in
Malaysian Chinese breast cancer patients with allele
frequency of 2.4%.
In relation to CYP2D6 genotype, 12 CYP2D6
genotypes were identified in 80 Malaysian breast can-
cer patients (Table 4). Malay breast cancer patients
were relatively heterogenous in terms of CYP2D6
genotype in which 10 genotypes were observed among
them compared to Chinese as well as Indian breast
cancer patients with only five genotypes. CYP2D6*10/
*10 was found to be highly prevalent in both Malay
and Chinese breast cancer patients with genotype fre-
quency of 28.9% and 57.1%, respectively. However,
none of the Indian breast cancer patients carry this
genotype but they have high prevalence of
CYP2D6*4/*10 with genotype frequency of 42.8%.
Table 4. Frequencies of CYP2D6 Genotypes
among Different Ethnic Groups of 80 Malaysian
Breast Cancer Patients

Genotype frequency (%)

Table 3. Frequencies of CYP2D6 Alleles among
CYP2D6 genotype Predicted phenotype Malay Chinese Indian
Different Ethnic Groups of 80 Malaysian Breast
Cancer Patients *1/*1 EM 9.6 0.0 0.0
*1/*2 EM 1.9 9.5 14.3
Allele frequency (%) *1/*4 IM 0.0 0.0 14.3
*1/*10 EM 25.0 14.3 0.0
CYP2D6 allele Allele function Malay Chinese Indian *2/*2 EM 1.9 0.0 14.3
*2/*10 EM 17.3 14.3 0.0
*1 Functional 23.1 11.9 14.3 *2/*39 EM 1.9 0.0 14.3
*2 Functional 12.5 14.3 28.6 *2/*75 Unknown 0.0 4.8 0.0
*4 Nonfunctional 2.9 0.0 28.6 *4/*10 IM 5.7 0.0 42.8
*10 Reduced function 54.8 71.4 21.4 *10/*10 IM 28.9 57.1 0.0
*39 Functional 4.8 0.0 7.1 *10/*49 IM 3.9 0.0 0.0
*49 Reduced function 1.9 0.0 0.0 *39/*39 EM 3.9 0.0 0.0
*75 Unknown 0.0 2.4 0.0
EM, extensive metabolizer; IM, intermediate metabolizer.
 15244741, 2016, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/tbj.12518 by National Institutes Of Health Malaysia, Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
58 • chin et al.

Table 5. Comparison of the Distribution of CYP2D6 Alleles Frequencies among Different Populations

Functional
allele (%) Reduced function allele (%) Nonfunctional allele (%)
Unknown allele (%)
Population N *1 *2 *39 *9 *10 *17 *29 *41 *49 *3 *4 *5 *6 *14 *21 *75

Malay
This study 52 23.1 12.5 4.8 0.0 54.8 0.0 0.0 0.0 1.9 0.0 2.9 0.0 0.0 0.0 0.0 0.0
Teh et al. (2001) 107 36.0 3.3 49.5 0.5 0.0 2.8 5.1
Chinese
This study 21 11.9 14.3 0.0 0.0 71.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.4
Ismail et al. (2003) 236 38.4 1.3 57.0 0.2 0.2 2.5
Qin et al. (2008) 400 24.7 11.1 0.0 0.0 52.5 0.0 3.3 0.0 0.2 4.7 0.0 1.3 0.0 0.1
Man et al. (2010) 398 28.1 11.0 0.1 0.0 48.4 0.0 0.0 1.1 6.1 0.0 1.1 0.3
Indian
This study 7 14.3 28.6 7.1 0.0 21.4 0.0 0.0 0.0 0.0 0.0 28.6 0.0 0.0 0.0 0.0 0.0
Ismail and Teh (2001) 86 69.0 1.0 15.0 1.0 0.0 8.0 1.0
Naveen et al. (2006) 447 46.1 34.8 10.2 0.0 0.0 7.3 1.9 0.0
Korean
Lee et al. (2006) 400 33.3 10.1 0.6 0.0 45.0 0.0 1.9 0.0 0.3 6.1 0.0 0.5 0.3
Lee et al. (2009) 758 32.3 9.9 45.6 2.2 1.4 5.6 0.3 0.3
Man et al. (2010) 200 33.6 12.1 0.3 0.0 44.1 0.0 2.1 0.0 0.8 6.2 0.0 0.5 0.5
Japanese
Kubota et al. (2000) 162 40.1 13.0 38.6 6.2 2.2
Nishida et al. (2000) 206 43.0 12.3 38.1 0.2 4.5 0.7
Ebisawa et al. (2005) 286 42.7 11.4 0.4 36.2 0.4 0.2 7.2 0.7
Man et al. (2010) 500 44.5 10.0 0.1 0.0 37.8 0.0 1.6 0.0 0.1 5.1 0.0 0.1 0.6
Caucasian
Sache et al. (1997) 589 36.4 32.4 1.5 2.0 20.7 0.9 0.0
Wan et al. (2001) 143 40.6 26.2 8.0 0.3 1.4 19.9 2.1
Man et al. (2010) 454 32.0 25.1 0.0 1.7 2.8 0.1 11.7 2.2 18.8 3.3 1.7 0.0 0.0
African
Wennerholm et al. (2001) 106 27.8 20.3 3.8 17.0 19.8 0.0 0.9 6.1 0.0
Man et al. (2010) 250 29.9 30.9 1.6 0.4 5.7 20.7 3.1 0.0 6.1 1.0 0.0 0.0 0.0

N, number of individual.

70
61.5 predicted to be EMs compared to Indian (42.9%),
60 57.1 57.1
and Chinese (38.1%) breast cancer patients. Con-
50 versely, IMs were more prevalent in Chinese (57.1%)
Frequency (%)

42.9
38.1 38.5
40 as well as Indian (57.1%) breast cancer patients com-
30 pared to Malay (38.5%) breast cancer patients. Not
20 surprisingly, PM was not found in Malaysian breast
10 4.8
cancer patients enrolled in this study, as the PM phe-
0
notype is rarely observed in Asian populations.
Extensive Intermediate Poor Unknown
metabolizer metabolizer metabolizer
DISCUSSION
CYP2D6 phenotype
Malay Chinese Indian
Among the seven CYP2D6 alleles identified in this
study, the common alleles are CYP2D6*10,
Figure 1. Frequencies of CYP2D6 phenotypes among 80 Malay- CYP2D6*2, CYP2D6*1, and CYP2D6*4 followed by
sian breast cancer patients with different ethnics groups of Malay,
Chinese, and Indian.
CYP2D6*39, CYP2D6*75, and CYP2D6*49. It is
expected that CP2D6*10 is highly prevalent among
Malaysian breast cancer patients as this allele has
Based on the genotypes, CYP2D6 phenotypes can been reported to occur at high frequency across differ-
be predicted for breast cancer patients (Fig. 1). ent Asian populations including Chinese, Japanese,
Findings from this study revealed that majority of and Korean (29,33,34) (Table 5). In comparison to
Malaysian Malay (61.5%) breast cancer patients were previous studies on Malaysian healthy subjects,

findings from this study showed that the CYP2D6*10
allele frequency for Malaysian Malay (54.8%) and
Chinese (71.4%) breast cancer patients were slightly
higher than those reported for Malaysian healthy
Malay (49.5%) (37) and Chinese (57.0%) (36) sub-
jects. In contrast, CYP2D6*4 was the most common
allele in Malaysian Indian breast cancer patients in
which they demonstrated much higher allele frequency
(28.6%) compared to Malaysian healthy Indian sub-
jects (8%) (35). On the other hand, allele frequency of
CYP2D6*1 was lower for Malaysian breast cancer
patients across the three different ethnicities as com-
pared to Malaysian healthy subjects. These discrepan-
cies might due to the overestimation of both
CYP2D6*10 and CYP2D6*4 allele frequencies, and
underestimation of CYP2D6*1 allele frequency
because of relatively small sample size in this study.
As mentioned in the results, 71.4% (5 of 7)
CYP2D6 alleles were functional and reduced function
alleles, 14.3% (1 of 7) were nonfunctional, and the
remaining one allele remains unknown. It is noted
that reduced function alleles are the most prevalent
alleles in Asians, whereas nonfunctional alleles are
highest in Caucasians (14,39,40). The most common
reduced function allele in Asians is CYP2D6*10 with
allele frequency of approximately 40–50% (14,15).
For the Caucasians, CYP2D6*3, CYP2D6*4,
CYP2D6*5, and CYP2D6*6 have been reported to
account for approximately 98% of the total nonfunc-
tional alleles (41). However, these alleles are rare
among Asian populations and only CYP2D6*4 was
identified in this study (14). Interestingly, CYP2D6*2,
CYP2D6*39, CYP2D6*49, and CYP2D6*75 were
identified in this study in which these alleles have not
been previously reported in Malaysian healthy subjects
(35–37). This may be explained by the fact that there
are limited studies on CYP2D6 genetic polymorphisms
in Malaysian healthy population, and even these stud-
ies investigated only several commonly reported
known alleles. Findings from this study suggest that a
comprehensive scanning of all 9 exons of the CYP2D6
gene is critical for the identification of novel as well
as known alleles that may be missed by genotyping
studies.
This study found that IM genotype CYP2D6*10/
*10 is the most common genotype in Malaysian
Malay (28.9%) and Chinese (57.1%) breast cancer
patients, whereas CYP2D6*1/*10 is the most common
genotype reported in Malaysian healthy subjects. It is
noteworthy that CYP2D6*10/*10 has been reported
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CYP2D6 Polymorphisms and Breast Cancer • 59
clinically important to Asian breast cancer patients as
it affects the efficacy of tamoxifen therapy and clinical
outcomes of the breast cancer patients. Findings from
Lim et al. (42) demonstrated that the plasma concen-
trations of endoxifen were lower in tamoxifen treated
Korean breast cancer patients carrying CYP2D6*10/
*10 than those patients carrying CYP2D6*1/*10 or
CYP2D6*1/*1. In addition, Japanese breast cancer
patients carrying CYP2D6*10/*10 had higher 10-year
recurrence incidence compared to those patients carry-
ing CYP2D6*1/*1 (43). In comparison to Malaysian
Malay and Chinese breast cancer patients, Indian
breast cancer patients have the highest prevalence of
CYP2D6*4/*10, whereas CYP2D6*10/*10 was not
identified in this study.
Based on the predicted CYP2D6 phenotypes,
majority of Malaysian Malay breast cancer patients
were EMs in which they carry at least one functional
allele and exhibit normal tamoxifen metabolism. They
are most likely to gain optimal benefit at standard
tamoxifen dosages (44). On the contrary, majority of
both Malaysian Chinese and Indian breast cancer
patients were IMs as they carry one functional allele
and one nonfunctional allele, or one reduced func-
tional allele and one nonfunctional allele, or two
reduced functional alleles. They have lower drug
metabolism and have reduced benefit from tamoxifen
(45). Findings from this study suggest that the phar-
macokinetics of tamoxifen in Malaysian Malay breast
cancer patients may be different from that of Malay-
sian Chinese and Indian breast cancer patients, which
warrant further investigations. The metabolizer status
of breast cancer patients is potentially useful in per-
sonalized medicine, which serves as an indicator on
how an individual patient responds to tamoxifen ther-
apy. It is advisable for EM or IM patients to receive
tamoxifen as the standard drug for hormonal therapy.
However, alternative drugs may need to be considered
for PM patients to prevent adverse tamoxifen effects.
CYP2D6 genotyping in a clinical setting may be con-
sidered as a rapid and accurate alternative to tradi-
tional phenotyping as suggested by McElroy (46).
As such in 2006, the Food and Drug Administra-
tion Advisory Committee recommended an update on
tamoxifen label regarding the increased risk of breast
cancer recurrence being associated with CYP2D6
metabolizer status (47, 48). Following the recommen-
dation, several large confirmatory studies were carried
out to validate the utility of CYP2D6 as a marker in
predicting the effectiveness of tamoxifen. Two recent

60 • chin et al.
large randomized studies appear to contradict the ben-
efit of CYP2D6 genotyping for predicting the benefit
of tamoxifen therapy. Findings from the Breast Inter-
national Group (BIG) 1-98 Trial concluded that post-
menopausal breast cancer patients treated with
tamoxifen and/or letrozole (aromatase inhibitor) who
exhibited PM or IM phenotype was not associated
with reduced risk of breast cancer recurrence com-
pared with EM phenotype (49). In another study con-
ducted for the UK-specific patients from the Arimidex,
Tamoxifen, Alone or in Combination (ATAC) trial,
suggested that there was no association between
CYP2D6 genotypes and breast cancer recurrence in
patients treated with tamoxifen (50).
Contrary to the previous two studies, another large
randomized study from the Austrian Breast and
Colorectal Study 8 clinical trial found that CYP2D6
genotyping has clinical implications in predicting the
ineffectiveness of tamoxifen (51). Findings of the
study showed that breast cancer patients with PM
phenotype who were treated with tamoxifen for
5 years had 2.5 times higher risks of disease recur-
rence or death compared with patients with EM phe-
notype. Moreover, patients with IM phenotype had
1.7 times higher risks of disease recurrence or death
compared with those patients with EM phenotype.
Patients who switched to anatrozole following 2 years
of tamoxifen therapy had a reduced risk of disease
recurrence or death. The authors suggest that patients
with IM phenotype should switch from tamoxifen to
an aromatase inhibitor, whereas patients with PM
phenotype should start with an aromatase inhibitor
from the initial therapy to gain optimal therapeutic
effects.
Uncertainties on the utilities of CYP2D6 genotyp-
ing for treatment management arose due to inconsis-
tent findings from multiple studies. A review on these
published studies found that such inconsistencies may
be due to variability in the classification of CYP2D6
genotypes and also methodologic limitations (52). It
has been estimated that more than 1200 patients are
required to detect a hazard ratio of 1.85 between PM
and EM with 90% power given the variants geno-
typed in the ATAC trial (53). Thus, it may be argued
that the lack of association between the CYP2D6
genotyping and tamoxifen effectiveness in the ATAC
trial is due to insufficient sampling that affect statisti-
cal power (51). In addition, substantial departure
from the Hardy–Weinberg equilibrium as observed in
the BIG 1-98 Trial including the most important
15244741, 2016, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/tbj.12518 by National Institutes Of Health Malaysia, Wiley Online Library on [29/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
CYP2D6*4 may indicate potential genotyping error or
other biases which warrant cautious interpretation of
the results. In summary, current literature do not pro-
vide sufficient evidence to ascertain the clinical signifi-
cance of CYP2D6 genotyping and more conclusive
studies have yet to be reported.
Although both EM and IM patients are expected to
respond well to tamoxifen therapy, CYP2D6 pheno-
type is not the only determinant of breast cancer
patient survival. The relationship between ethnicity
and breast cancer survival for the Asian population
has not been investigated until recently. Bhoo-Pathy
et al. (54) studied more than 5,000 women diagnosed
with breast cancer from three different ethnic groups
of Malays, Chinese, and Indians in Malaysia and Sin-
gapore. Findings from their study indicated that
Malay patients were associated with substantially
increased risk of mortality as compared to the other
two ethnic groups. The authors concluded that the
complex relationship between breast cancer survival
and ethnicity may be explained by the following fac-
tors, i.e., socioeconomic status, difference in tumor
biology, lifestyle, and genetic polymorphism in drug
metabolizing genes. It was found that Malay patients
presented at later stages of cancer compared to other
ethnic groups. Besides, they were also less likely to
adhere and complete their local-regional as well as
hormonal therapies. From the perspective of tumor
biology, the Malay patients were found to have larger
tumors, more aggressive characteristics and higher risk
of axillary lymph node metastases. Taken together, all
these factors influence the survival of Malay patients
even if the majority of them were EMs, they may not
completely benefit from tamoxifen therapy. Although
CYP2D6 genotyping may need to be considered in a
clinical setting to select an optimal drug therapy for
personalized medicine, other factors that influence the
prognosis of breast cancer should be considered by
clinicians to ensure an overall effectiveness in design-
ing future therapeutics.
CONCLUSIONS
To date, this study represents the first report of
CYP2D6 genetic polymorphisms in Malaysian breast
cancer patients. Both allelic and genotypic data
obtained from this study may serve as a reference for
future large-scale pharmacogenetics studies for Malay-
sia breast cancer patients. The genotypic data
obtained from this study provide information on

CYP2D6 metabolizer status of Malaysian breast
cancer patients as well as the clinical implications in
prescription of tamoxifen to the local breast patients.
Acknowledgments
We are thankful to staff from surgery, oncology,
and medical records departments of Hospital Kuala
Lumpur, Hospital UKM and Hospital Putrajaya for
their assistance in the collection of clinical samples
and medical information of breast cancer patients.
This study was funded by the National Biotechnology
Directorate (NBD) research grant (09-02-02-009 BTK/
ER/37/5) from the Ministry of Science, Technology
and Innovation (MOSTI), Malaysia.
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