Tamoxifen, taken for five years, is the standard adjuvant treatment for postmenopausal women with primary, estrogen-receptor-positive breast cancer. Despite this treatment, however, some patients have a relapse. methodsWe conducted a double-blind, randomized trial to test whether, after two to three years of tamoxifen therapy, switching to exemestane was more effective than continuing tamoxifen therapy for the remainder of the five years of treatment. The primary end point was disease-free survival. resultsOf the 4742 patients enrolled, 2362 were randomly assigned to switch to exemestane, and 2380 to continue to receive tamoxifen. After a median follow-up of 30.6 months, 449 first events (local or metastatic recurrence, contralateral breast cancer, or death) were reported -183 in the exemestane group and 266 in the tamoxifen group. The unadjusted hazard ratio in the exemestane group as compared with the tamoxifen group was 0.68 (95 percent confidence interval, 0.56 to 0.82; P<0.001 by the log-rank test), representing a 32 percent reduction in risk and corresponding to an absolute benefit in terms of disease-free survival of 4.7 percent (95 percent confidence interval, 2.6 to 6.8) at three years after randomization. Overall survival was not significantly different in the two groups, with 93 deaths occurring in the exemestane group and 106 in the tamoxifen group. Severe toxic effects of exemestane were rare. Contralateral breast cancer occurred in 20 patients in the tamoxifen group and 9 in the exemestane group (P=0.04). conclusionsExemestane therapy after two to three years of tamoxifen therapy significantly improved disease-free survival as compared with the standard five years of tamoxifen treatment.

Summary 1. Thermal tolerance may limit and therefore predict ectotherm geographic distributions. However, which of the many metrics of thermal tolerance best predict distribution is often unclear, even for drosophilids, which constitute a popular and well-described animal model. 2. Five metrics of cold tolerance were measured for 14 Drosophila species to determine which metrics most strongly correlate with geographic distribution. The species represent tropical to temperate regions but all were reared under similar (common garden) conditions (20°C). The traits measured were: chill coma temperature (CT min ), lethal temperature (LTe 50 ), lethal time at low temperature (LTi 50 ), chill coma recovery time (CCRT) and supercooling point (SCP). 3. Measures of CT min , LTe 50 and LTi 50 proved to be the best predictors to describe the variation in realized latitudinal distributions (R 2 = 0Á699, R 2 = 0Á741 and 0Á550, respectively) and estimated environmental cold exposure (R 2 = 0Á633, R 2 = 0Á641 and 0Á511, respectively).Measures of CCRT also correlated significantly with estimated minimum temperature (R 2 = 0Á373), while the SCP did not. These results remained consistent after phylogenetically independent analysis or when applying nonlinear regression. Moreover, our findings were supported by a similar analysis based on existing data compiled from the Drosophila cold tolerance literature. 4. Trait correlations were strong between LTe 50 , LTi 50 and CT min , respectively (0Á83 > R 2 > 0Á55). However, surprisingly, there was only a weak correlation between the entrance into coma (CT min ) and the recovery from chill coma (CCRT) (R 2 = 0Á256). 5.Considering the findings of the present study, data from previous studies and the logistical constraints of each measure of cold tolerance, we conclude that CT min and LTe 50 are superior measures when estimating the ecologically relevant cold tolerance of drosophilids. Of these two traits, CT min requires less equipment, time and animals and thereby presents a relatively fast, simple and dynamic measure of cold tolerance.

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Many insects, including Drosophila, succumb to the physiological effects of chilling at temperatures well above those causing freezing. Low temperature causes a loss of extracellular ion and water homeostasis in such insects, and chill injuries accumulate. Using an integrative and comparative approach, we examined the role of ion and water balance in insect chilling susceptibility/ tolerance. The Malpighian tubules (MT), of chill susceptible Drosophila species lost [Na+] and [K+] selectivity at low temperatures, which contributed to a loss of Na+ and water balance and a deleterious increase in extracellular [K+]. By contrast, the tubules of chill tolerant Drosophila species maintained their MT ion selectivity, maintained stable extracellular ion concentrations, and thereby avoided injury. The most tolerant species were able to modulate ion balance while in a cold-induced coma and this ongoing physiological acclimation process allowed some individuals of the tolerant species to recover from chill coma during low temperature exposure. Accordingly, differences in the ability to maintain homeostatic control of water and ion balance at low temperature may explain large parts of the wide intra- and interspecific variation in insect chilling tolerance.