In addition, Wardell et al., 2020 concluded that antagonism rather than ERα degradation/downregulation drives most of fulvestrant efficacy in suppressing primary tumor growth in xenograft assays, based on observations that a dose of fulvestrant affording a non-significant reduction in ER levels led to significant growth suppression of a long-term estrogen-deprived breast cancer cell model over 4 weeks (). This evidence concerns the gene ESR1 and breast carcinoma.