An international update of the EORTC questionnaire for assessing quality of life in breast cancer patients: EORTC QLQ-BR45

BACKGROUND

The European Organization for Research and Treatment of Cancer (EORTC) QLQ-BR23 was one of the first disease-specific questionnaires developed in 1996 to assess quality of life (QoL) in patients with breast cancer (BC). However, since 1996 major changes in BC treatment have occurred, requiring an update of the EORTC BC module. This study presents the results of the phase I-III update of the QLQ-BR23 questionnaire.

PATIENTS AND METHODS

The update of the EORTC QLQ-BR23 module followed standard EORTC guidelines. A systematic literature review revealed 83 potential relevant QoL issues during phases I and II. After shortening the issues list and following interviews with patients and health care providers, 15 relevant issues were transformed into 27 items. The preliminary module was pretested in an international, multicentre phase III study to identify and solve potential problems with wording comprehensibility and acceptability of the items. Descriptive statistics are provided. Analyses were qualitative and quantitative. We provide a psychometric structure of the items.

RESULTS

The phase I and II results indicated the need to supplement the original QLQ-BR23 with additional items related to newer therapeutic options. The phase III study recruited a total of 250 patients (from 12 countries). The final updated phase III module contains a total of 45 items: 23 items from the QLQ-BR23 and 22 new items. The new items contain two multi-item scales: a target symptom scale and a satisfaction scale. The target symptom scale can be divided into three subscales: endocrine therapy, endocrine sexual and skin/mucosa scale.

CONCLUSION

Our work has led to the development of a new EORTC QLQ-BR45 module that provides a more accurate and comprehensive assessment of the impact of new and scalable treatments on patients' QoL. The final version of the EORTC QLQ-BR45 is currently available for use in clinical practice. The final phase IV study is underway to confirm psychometric properties of the module.

P6579Genetic profile and predictors of positive genetic test in Brugada syndrome

Introduction

Brugada syndrome (BS) is a channelopathy with autosomal dominant transmission, incomplete penetrance and variable expression. There are 18 different gene mutations described in association with this syndrome, however 70% of patients remain without identifiable genetic cause. Genetic testing is appropriated for patients with clinical diagnosis but it is also a very important tool in familiar screening.

Aim

We aim to characterize genetic profile of patients with clinical diagnosis of BS and identify differences between patients with and without causative mutation.

Methods

We included patients followed by the arrhythmology department of our hospital with diagnosis of BS and that have performed genetic test (or patients who were identified through familiar screening and with negative genetic test in the index case). Patients identified through familiar screening with positive genetic test but no spontaneous electrocardiographic pattern, still awaiting pharmacologic provocative test at the time of enrolment – no clinical diagnosis - were excluded. Genetic test was considered positive when we found a pathogenic or probably pathogenic mutation. Mutations in PKP, SLMAP, CACNA, CACNB, SCN10A and CLASP genes considered of uncertain clinical relevance were not included as positive genetic test. We analysed differences between subset of patients with and without causative mutation regarding clinical and electrocardiographic variables. We performed multivariate analysis to find predictors of positive genetic test.

Results

From our 173 patients, 140 met the inclusion criteria and none exclusion criteria so they were enrolled. Patients were 61% male with mean age of 50±15 years old. Mean follow-up was 26±28 months; 24,4% of index cases were positive for causative mutation, 6,8% patients with pathogenic mutation in SCN5A gene and 17,6% with probably pathogenic mutation in SCN5A.

We haven't found significant differences between the 2 groups (negative and positive genetic test) in any clinical variable included. Regarding electrocardiographic variables, patients in whom a mutation was identified had longer PR interval (192±36 vs 170±28, p=0.001), longer QRS (121±19 VS 111±18 p=0.017), particularly when QRS>110ms (p=0,002), and longer QT (398±25 VS 370±45 p=0.015) In multivariate analysis, PR interval (p=0.032) and QRS>110ms (p=0,041) were independent predictors for positive genetic test.

Conclusion

In our BS population, there were no clinical differences between patients with and without causative mutation, also concerning events rate. Patients with positive genetic test have significantly longer PR interval and QRS>110ms than in patients with genetic test negative. Those results can be interpreted in relation to sodium channel disfunction in patients with SCN5A mutation.

Characterization of male breast cancer: results of the EORTC 10085/TBCRC/BIG/NABCG International Male Breast Cancer Program

Background

Male breast cancer (BC) is rare, managed by extrapolation from female BC. The International Male BC Program aims to better characterize and manage this disease. We report the results of part I, a retrospective joint analysis of cases diagnosed during a 20-year period.

Methods

Patients with follow-up and tumor samples, treated between 1990 and 2010, in 93 centers/9 countries. Samples were centrally analyzed in three laboratories (the United Kingdom, the Netherlands and the United States).

Results

Of 1822 patients enrolled, 1483 were analyzed; 63.5% were diagnosed between 2001 and 2010, 57 (5.1%) had metastatic disease (M1). Median age at diagnosis: 68.4 years. Of 1054 M0 cases, 56.2% were node-negative (N0) and 48.5% had T1 tumors; 4% had breast conserving surgery (BCS), 18% sentinel lymph-node biopsy; half received adjuvant radiotherapy; 29.8% (neo)adjuvant chemotherapy and 76.8% adjuvant endocrine therapy (ET), mostly tamoxifen (88.4%). Per central pathology, for M0 tumors: 84.8% ductal invasive carcinomas, 51.5% grade 2; 99.3% estrogen receptor (ER)-positive; 81.9% progesterone receptor (PR)-positive; 96.9% androgen receptor (AR)-positive [ER, PR or AR Allred score ≥3]; 61.1% Ki67 expression low (<14% positive cells); using immunohistochemistry (IHC) surrogates, 41.9% were Luminal-A-like, 48.6% Luminal-B-like/HER-2-negative, 8.7% HER-2-positive, 0.3% triple negative. Median follow-up: 8.2 years (0.0-23.8) for all, 7.2 years (0.0-23.2), for M0, 2.6 years (0.0-12.7) for M1 patients. A significant improvement over time was observed in age-corrected BC mortality. BC-specific-mortality was higher for men younger than 50 years. Better overall (OS) and recurrence-free survival (RFS) were observed for highly ER+ (P = 0.001), highly PR+ (P = 0.002), highly AR+ disease (P = 0.019). There was no association between OS/RFS and HER-2 status, Ki67, IHC subtypes nor grade.

Conclusions

Male BC is usually ER, PR and AR-positive, Luminal B-like/HER2-negative. Of note, 56% patients had T1 tumors but only 4% had BCS. ER was highly positive in >90% of cases but only 77% received adjuvant ET. ER, PR and AR were associated with OS and RFS, whereas grade, Ki67 and IHC surrogates were not. Significant improvement in survival over time was observed.

Abstract P6-18-04: Ribociclib with a non-steroidal aromatase inhibitor and goserelin in premenopausal women with hormone receptor-positive, HER2-negative advanced breast cancer: MONALEESA-7 age subgroup analysis

Background: Younger patients (pts) with breast cancer may experience more aggressive disease and are more likely to die from their cancer vs older pts. In the Phase III MONALEESA-7 study (NCT02278120), the addition of ribociclib (RIB; cyclin-dependent kinase 4/6 inhibitor) to a non-steroidal aromatase inhibitor (NSAI) or tamoxifen (TAM) + goserelin significantly prolonged progression-free survival (PFS) in premenopausal women with hormone receptor-positive (HR+), HER2-negative (HER2–) advanced breast cancer (ABC; hazard ratio 0.553; p&lt;0.0001). RIB treatment benefit was observed irrespective of endocrine partner (NSAI or TAM). Here we report results from a MONALEESA-7 subgroup analysis in pts aged &lt;40 yrs and ≥40 yrs who received RIB or placebo (PBO) in combination with an NSAI + goserelin.

Methods: Pre- or perimenopausal women with HR+, HER2– ABC who had received no prior endocrine therapy and ≤1 line of chemotherapy for ABC were enrolled. Of the 672 pts randomized, 495 (74%) received RIB (600 mg/day, 3-weeks-on/1-week-off) or PBO + an NSAI (letrozole [2.5 mg/day] or anastrozole [1 mg/day]) and goserelin (3.6 mg every 28 days). The primary endpoint was locally assessed PFS; secondary endpoints included overall response rate (ORR), clinical benefit rate (CBR), and safety. A prespecified subgroup analysis was performed in pts aged &lt;40 yrs and ≥40 yrs.

Results: A total of 144 pts were aged &lt;40 yrs (RIB vs PBO arm: 78 vs 66) and 351 were aged ≥40 yrs (170 vs 181). As of August 20, 2017, in the RIB vs PBO arms, treatment was ongoing in 50% vs 23% of pts aged &lt;40 yrs and 54% vs 43% of pts aged ≥40 yrs; disease progression was the most common reason for treatment discontinuation (&lt;40 yrs: 37% vs 68%; ≥40 yrs: 35% vs 44%). Median PFS was prolonged in the RIB vs PBO arms both in pts aged &lt;40 yrs (not reached vs 10.8 months; hazard ratio 0.435; 95% confidence interval [CI] 0.276–0.686) and in pts aged ≥40 yrs (27.5 vs 19.1 months; hazard ratio 0.625; 95% CI 0.449–0.870). In pts with measurable disease, the ORR (RIB vs PBO arm) was 49% vs 32% in pts aged &lt;40 yrs and 51% vs 38% in pts aged ≥40 yrs; CBR was 81% vs 61% and 82% vs 65%, respectively. The most common Grade 3 adverse events (AEs; ≥5% of pts in either arm; RIB vs PBO arm) were neutropenia (&lt;40 yrs: 47% vs 5%; ≥40 yrs: 58% vs 3%), leukopenia (&lt;40 yrs: 18% vs 2%; ≥40 yrs: 14% vs 1%), diarrhea (&lt;40 yrs: 5% vs 0; ≥40 yrs: 1% vs 0), and increased alanine aminotransferase (&lt;40 yrs: 4% vs 2%; ≥40 yrs: 5% vs 1%); neutropenia was the only Grade 4 AE occurring in ≥5% of pts in either arm (&lt;40 yrs: 15% vs 0; ≥40 yrs: 8% vs 1%). New post-baseline QTcF &gt;480 ms (RIB vs PBO arm) occurred in 3% vs 2% of pts aged &lt;40 yrs and 7% vs 1% of pts aged ≥40 yrs.

Conclusions: Consistent treatment benefit was observed with RIB + NSAI vs PBO + NSAI in premenopausal women with HR+, HER2– ABC irrespective of age. RIB + NSAI had a manageable safety profile in pts aged &lt;40 yrs and in those aged ≥40 yrs, with a safety profile similar to that observed in the full study population.

Citation Format: Tripathy D, Campos-Gomez S, Lu Y-S, Franke F, Bardia A, Wheatley-Price P, Cruz FM, Hegg R, Cardoso F, Gaur A, Kong O, Diaz-Padilla I, Miller M, Hurvitz S. Ribociclib with a non-steroidal aromatase inhibitor and goserelin in premenopausal women with hormone receptor-positive, HER2-negative advanced breast cancer: MONALEESA-7 age subgroup analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-04.

Abstract P6-19-01: Evaluation of multiple transcriptomic gene risk signatures in male breast cancer

Introduction: Male breast cancer (MBC) is a rare disease accounting for less than 1% of all breast cancers (BC) and 1% of all cancers in males. The clinical management is largely extrapolated from female BC. Several multigene assays are increasingly used to guide clinical treatment decisions in female BC, however there is little data on the utility of these tests in MBC.

Methods: Here we present the gene expression results of 380 M0, ER+ve, HER2-ve MBCs enrolled in the Part 1 (retrospective joint analysis) International Male Breast Cancer Program of 1483 patients diagnosed between 1990-2010 (Cardoso et al. Annals of Oncology, 2018). Using a custom Nanostring™ panel comprised of the genes from the commercial risk tests Prosigna®, OncotypeDx® and Mammaprint®, risk scores and intrinsic subtyping data were generated to recapitulate the commercial tests as described by Bayani and Yao et al (npjBreast Cancer, 2017). Survival outcomes by risk classification were analyzed using Cox models with time-dependent covariates when the proportional hazard assumption was not met and adjusted for clinical and treatment variables.

Results: Prosigna-like risk scores identified 99 (26.1%) as low-risk, 159 (41.8%) as intermediate-risk, and 122 (32.1%) as high-risk. Using the TAILORx cut-off (25) for OncotypeDx-like risk of recurrence scoring, 158 (41.6%) were identified as low-risk, while 222 (58.4%) were identified as high-risk. MammaPrint-like results identified 175 (46.1%) as low-risk and 205 (53.9%) as high-risk. Overall, patients classified as high-risk had higher grade, more nodal involvement, larger tumors, and more frequently treated with chemotherapy than low-risk patients. Survival analyses demonstrated clear clinical utility for each test, showing patients at high-risk with poor relapse-free survival (RFS) as compared to patients classified as low-risk: Prosigna-like RFS at 3-years (HR=2.20, 95% CI, 1.28-3.80); Oncotype-like RFS at 3-years (HR=1.92, 95% CI, 1.17-3.17); MammaPrint-like RFS (HR=1.51, 95% CI, 1.00-2.27); with similar findings for distant relapse-free survival (DRFS) and overall survival (OS). Across outcomes and all gene signatures, patients with concordant Low/Low risk classification had better prognosis than those with concordant High/High risk classification. PAM50 intrinsic subtyping identified 147 (38.7%) as Luminal A, 57 (15.0%) as Luminal B, 80 (21.1%) as Her2-enriched and 96 (25.3%) as Basal-like; showing overall 34.5% concordance to clinic-pathological subtyping by central pathology (95% CI, 29.7%-39.5%). Comparison between the tests in the MBC cohort and a comparable cohort of female BC from the Tamoxifen Exemestane Adjuvant Multinational (TEAM) trial processed in the same way will be presented.

Conclusion: Common transcriptomic assays designed to assess residual risk, validated in female BC, provide similar information in male BC patients. Not surprisingly, disagreement between test results at the individual patient level was observed. To our knowledge, this is the largest study of MBC assayed to generate risk scores of the current commercial BC tests to demonstrate their clinical utility and their differences and similarity to female BC.

This work has been funded by the Breast Cancer Research Foundation (BCRF).

Citation Format: Bayani J, Poncet C, Yao CQ, Crozier C, Anouk N, Piper T, Cunningham C, Sobol M, Aebi S, Benstead K, Bogler O, Dal Lago L, Fraser J, Hilbers FH, Hedenfalk I, Korde L, Linderholm B, Martens J, Middleton L, Murray M, Kelly C, Nilsson C, Nowaczyk M, Peeters S, Peric A, Porter P, Schröder C, Rubio IT, Ruddy KJ, van Asperen C, Van Den Weyngaert D, van Deurzen C, van Leeuwen-Stok E, Vermeij J, Winer E, Boutros PC, Giordano SH, Cardoso F, Bartlett JM. Evaluation of multiple transcriptomic gene risk signatures in male breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-19-01.

Abstract OT3-04-03: KEYNOTE-756: A randomized, double-blind, phase III study of pembrolizumab versus placebo in combination with neoadjuvant chemotherapy and adjuvant endocrine therapy for high-risk early-stage ER+/HER2– breast cancer

Background:Although ER+/HER2– breast cancer has a better overall prognosis than other breast cancer subtypes, there is a high-risk subpopulation characterized by high-grade tumors and decreased sensitivity to endocrine therapy, higher responsiveness to chemotherapy and worse prognosis. A large meta-analysis of prospective studies focusing on neoadjuvant chemotherapy (NAC) for treatment of stage I-III breast cancer demonstrated that increased pathologic complete response (pCR) rates at surgery were associated with improved survival. This correlation was observed across triple-negative breast cancer (TNBC), HER2+ breast cancer, and high-grade HR+/HER2- breast cancer. Specifically, patients with a pCR after NAC had a 5-year event-free survival (EFS) rate of 90%, whereas patients who did not achieve a pCR had a 5-year EFS rate of 60%.Therefore, increasing pCR rates after NAC may have a substantial impact for patients with high-risk early-stage HR+/HER2– breast cancer. KEYNOTE-756 is a global, randomized, double-blind, phase III study of pembrolizumab (vs placebo) + chemotherapy as neoadjuvant treatment, followed by pembrolizumab (vs placebo) plus endocrine therapy as adjuvant treatment for patients with high-risk, early-stage ER+/HER2– breast cancer.

Methods: Patients with T1c-2 cN1-2 or T3-4 cN0-2 grade 3 or grade 2 with Ki-67 ≥30%, invasive, ductal ER+/HER2– breast cancerwill be stratified by lymph node involvement (positive vs negative), tumor PD-L1 status (positive vs negative), ER positivity (≥10% vs &lt;10%), and anthracycline dosing schedule (Q3W vs Q2W), and then randomized 1:1 to receive neoadjuvant treatment with pembrolizumab 200 mg Q3W or placebo in combination with paclitaxel (80 mg/m2 QW) for 4 cycles followed by (doxorubicin [60 mg/m2] or epirubicin [100 mg/m2]) plus cyclophosphamide (600 mg/m2) Q2/3W for another 4 cycles. After definitive surgery (± radiation therapy, as indicated), patients will receive adjuvant treatment with pembrolizumab (200 mg Q3W) or placebo for 9 additional administrations, in combination with endocrine therapy, which can be given for up to 10 years. Co-primary end points are pCR rate and EFS. Secondary end points are safety and overall survival. The global study will open in North America and Latin America, Europe, and Asia Pacific in the second half of 2018.

Citation Format: Cardoso F, Bardia A, Andre F, Cescon DW, McArthur H, Telli M, Loi S, Cortés J, Schmid P, Harbeck N, Denkert C, Jackisch C, Jia L, Tryfonidis K, Karantza V. KEYNOTE-756: A randomized, double-blind, phase III study of pembrolizumab versus placebo in combination with neoadjuvant chemotherapy and adjuvant endocrine therapy for high-risk early-stage ER+/HER2– breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT3-04-03.

Supporting Breast Cancer Early Detection and Diagnosis: A Global Metastatic Breast Cancer Policy Analysis and Promising Practice From Brazil

Background and context: Control of metastatic breast cancer (mBC) is an area with high unmet need. Along the patient journey, policy development remains limited and varied across countries, particularly in detection, diagnosis and treatment. Multistakeholder engagements aim to address these policy gaps. Aim: 1. Understand breast cancer (BC)/mBC policy development in 16 countries and identify opportunities for improvement. 2. Illustrate promising practices spearheaded by civil society (NGOs and academia) that demonstrate success addressing identified gaps and exemplify models for replication. 3. Establish the importance of stakeholder collaboration to implement policies that support timely BC/mBC detection and treatment initiation. Strategy/Tactics: An analysis of National Cancer Control Plans (NCCPs), policies and programs was conducted across 16 countries representing different healthcare systems. Key BC diagnosis policy components were identified and evaluated, using standardized criteria on adoption and implementation of NCCP goals, and BC/mBC-specific policies and programs. Promising practices, spearheaded by civil society, that demonstrate success at filling policy gaps were identified. Their objective was to develop an information resource that other organizations can use as practice-based evidence. An example implemented in Brazil is presented. Program/Policy process: Although mBC screening is ineffective, national BC screening programs (NSPs) implementation promotes BC education and encourages prompt symptom reporting. Structured diagnosis guidelines and upskilled healthcare professionals (HCPs) also facilitate timely detection, as evidenced in Brazil, where diagnosis delays are prevalent. Outcomes: Despite policy efforts, gaps persist for timely BC/mBC detection and diagnosis. Implementation of official NSPs, diagnosis guidelines and HCP educational initiatives varied across countries. In Brazil, the Integrated Approach to Improving Oncology Care project brought together various stakeholders. The initiative aimed to use existing community resources as a pivot to address and improve BC diagnosis gaps, including HCP oncology education/training, capacity building in community health centers and increasing patient support. The initiative provided training to over 150 BC HCPs. Upskilled HCPs were supported to improve skills and system capacity to facilitate timely diagnosis. What was learned: Disparities in BC policy development exist across and within countries. Progress in BC policy is skewed toward the early part of the patient journey e.g., awareness, with key gaps remaining in diagnosis. Although national official action is indispensable, collaboration between different stakeholders is critical to address BC/mBC patient unmet needs. As exemplified in Brazil, we see that policy initiatives and promising practices demonstrate successful multistakeholder engagement to inform further advocacy and policy development.

Perspectives on preoperative systemic treatment and breast conservative surgery: One step forward or two steps back?

Preoperative systemic therapy (PST) has become an accepted treatment not only for locally advanced but also for early stage breast cancer patients. Clinical trials have demonstrated that the use of PST is equally to adjuvant treatments in terms of overall survival, and has the advantage of increasing rates of breast conservative surgery and rates of pathologic complete response, a surrogate endpoint for the effectiveness of systemic therapy. Initial studies have suggested higher rates of locoregional recurrence with this approach. However, the optimization of systemic and targeted therapy and the multidisciplinary care is key to achieving optimal outcomes in this setting.

Abstract PD7-12: Molecular subtyping of male breast cancer by the International male breast cancer program (IMBC): EORTC 10085/TBCRC 0-29/BIG 2-07/NABCG/BOOG 2009-04

Introduction. Male breast cancer (male BC) is a rare disease for which disease management is extrapolated from females. IMBC, an international consortium, which previously reported on clinico-pathological aspects, now reports on molecular subgroups revealed by RNA sequencing and their relation to patient outcome.

Methods. Tumor samples from the retrospective MALE BC registry diagnosed between 1990-2010 and with pathology and outcome data (relapse-free- (RFS) and overall survival (OS)) were included (n=699). To allow the discovery of prognostic features, we selected, stratified for known risk factors (TN stage, grade, age at diagnose and adjuvant endocrine treatment), from the cohort 152 cases with poor (RFS &lt;= 4 yrs) and good outcome (RFS &gt; 7yrs) evenly distributed. Here, we report RNA sequencing results of the first 73 cases, 38 with poor and 35 with good outcome. RNA sequencing reads were used to generate gene expression values and to report transcripts carrying driver mutations. Unsupervised clustering identified subgroups and within subgroups differentially expressed genes were identified. The reported prognostic male BC subgroups M1 and M2 (Johansson BCR 2012(14):R31) were also annotated. All identified subgroups were related to outcome using logistic regression (p-value using Wald test).

Results. Unsupervised clustering revealed 2 main subgroups of which group 1 was enriched for expression of ER target genes, WNT3 and genes from amplicons known for female BC, e.g. 19p13 (CCNE1), 8q24 (MYC), and 11q13 (CCND1). The biology of the smaller group 2 was less defined but TGFβ2 expression was high as were various kallikreins (KLK) including interestingly KLK3 (prostate specific antigen). Other known amplified regions [(8p11 (FGFR1), 20q13 (ZNF217) and 12q15 (MDM2)] and mutated transcripts [PIK3CA (H1047R/L/Q; E542K, E545K, N345K; 16% of cases), TP53 and SF3B1 (K700E) (2% of cases)] were identified. Profound tumor infiltrate gene expression was present in 5% of cases and one third of cases expressed proliferation markers. Except for TP53, none of these latter characteristics were unevenly distributed among the 2 main subgroups. ER and AR were highly correlated, particularly in group 1. The two main groups could be further subdivided. Group 1 comprised 3 subgroups of which subgroup 1a expressed TFF1/3 and NAT1, well-known ER targets, while subgroups 1b and 1c expressed other ER targets,respectively BEX1 and PITX1. HOXC cluster expression differentiated subgroup 1b from 1a and 1c. None of these intrinsic subgroups were, however, related to RFS. The previously reported M2 subgroup, which largely segregated with subclusters 1a and 1b, was associated with a better RFS than the M1 subgroup (OR=2.9; 95%CI 1.1-7.5; p-value=0.03).

Conclusions. 1) Intrinsic subtypes of male BC were revealed and their subgrouping is defined by ER associated subsets of genes. 2) The association of the reported M2 subgroup of male BC with longer RFS was validated; 3) Currently identified biological characteristics of male BC may improve future treatments. The full report on 152 cases including a comparison to female BC will be presented at the conference.

This research was funded by Breast Cancer Research Foundation

Citation Format: Martens JWM, Sieuwerts A, Ponchet C, Smid M, de Weerd V, Slaets L, Piper T, van Deurzen CHM, Schroder CP, Stangle C, Kloosterman W, van Leeuwen-Stok E, Nilsson C, Vermeij J, Peeters S, Goulioti T, Nowaczyk M, Aebi S, Rubio IT, Kelly C, Bayani J, Porter P, Murray M, Hudis C, Middleton L, Korde L, Ruddy K, Winer E, Bogler O, van den Weyngaert D, dal Lago L, Fraser J, Benstead K, van Asperen C, Linderholm B, Hedenfalk I, Tryfonidis K, Giordano S, Bartlett J, Cardoso F. Molecular subtyping of male breast cancer by the International male breast cancer program (IMBC): EORTC 10085/TBCRC 0-29/BIG 2-07/NABCG/BOOG 2009-04 [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD7-12.

Abstract P5-23-02: Quality of life (QoL) in male breast cancer (BC): Prospective study of the EORTC10085/TBCRC029/BIG2-07/NABCG International male BC program

Introduction: Male BC is a rare disease (dx) for which management is extrapolated from trials in female BC. Comprehensive prospective data about QoL in men with BC could inform treatment. The international Male BC Consortium conducted a prospective registry of male BC patients of all stages who newly presented to a participating center between October 2013 and February 2017. A QoL substudy was conducted as part of this registry at most participating sites.

Methods: Informed consent for participation in the QoL substudy was requested from new enrollees. Those who consented were asked to complete a survey including the EORTC QLQ-C30 and BR23 (breast cancer specific module), adapted by replacing female-specific items with male-specific sexual activity/function items from the prostate module (PR25). Outcomes were scored according to standard EORTC QLQ procedures on a 0-100 scale (with higher scores on QoL/functioning scales representing better QoL and functioning, and higher scores on symptom scales representing worse symptoms). Forms were analyzed centrally by EORTC. In order to compare to female BC, we used reference data from 2782 mixed age (62% under age 60) women with BC (of whom 1,147 had recurrent or metastatic dx, and 464 had stage 1-2 dx) reported in the EORTC QLQ-C30 Reference Values manual (2008).

Results: A total of 557 men were enrolled in EORTC10085, 445 at sites participating in the QoL substudy. Consent forms were received from 422/445 (95%) for the substudy. Baseline survey (required to be completed within 30 days of enrollment) compliance was 85% (359/422). Median age at diagnosis was 67 years. There were 111 men (45%) with node-positive M0/MX dx and 27 men (8%) with M1 dx. Their median global health status score at baseline was 75 (IQR 67-83), higher than that documented historically in female BC (67, with IQR 50-83, in both the 2782 women with mixed stage and the subgroup of 464 with stage 1-2 tumors). The participating men's median social functioning score was 100 (IQR 67-100), also higher than the 83.3 (IQR 67-100) reported in mixed stage female BC patients, though no different than the 100 (IQR 67-100) found in women with stage 1-2 dx. Men's most commonly reported symptoms included fatigue (median score 13.9, IQR 0-33), insomnia (median score 0, IQR 0-33), and pain (median score 0, IQR 0-33), for which women's median scores were 33 (IQR 11-44), 33 (IQR 0-33), and 17 (IQR 0-50) with mixed stage dx, and 22 (IQR 0-33), 33 (IQR 0-33), and 17 (IQR 0-33) with stage 1-2 dx. Men's median sexual activity score was 33.3 (IQR 0-50), with less sexual activity reported by older patients and men with M1 dx. In those who were sexually active, median sexual function score was 83 (IQR 75-92), with no difference by age or stage.

Conclusions: QoL and symptom burden in male BC patients appears no worse (and possibly better) than that in female patients. Future analyses of 1- and 5-year surveys from this study will assess the impact of specific treatments on changes in symptoms and QoL over time. These data will be useful in future efforts to tailor treatments and target interventions for male BC.

Funding: Breast Cancer Research Foundation, Dutch Pink Ribbon Foundation, Swedish BRO, and EBCC Council.

Citation Format: Schroder C, Cardoso F, Dijkstra N, van Leeuwen-Stok E, Linderholm B, Morgenstern D, Van Poznak C, Wolff AC, Poncet C, Gomez HL, Aalders K, Bjelic-Radisic V, Werutsky G, Tryfonidis K, Coens C, Giordano SH, Ruddy KJ. Quality of life (QoL) in male breast cancer (BC): Prospective study of the EORTC10085/TBCRC029/BIG2-07/NABCG International male BC program [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-23-02.

Abstract P1-07-02: Withdrawn

This abstract was withdrawn by the authors.

Abstract PD3-09: Pertuzumab and trastuzumab with or without metronomic chemotherapy for older patients with HER2- positive metastatic breast cancer: Results from the EORTC 75111- 10114 ETF/BCG randomized phase II study

Introduction: Pertuzumab (P) is approved as first line therapy for HER2-positive (HER2+) metastatic breast cancer (MBC) combined with trastuzumab (T) and docetaxel. However older patients are at higher risk of chemotherapy-induced toxicity raising high interest in a less toxic backbone such as metronomic chemotherapy and in chemo-free dual HER2 blockade (TP). Patients and Methods: This phase II selection study randomized (1:1) patients with HER2+ MBC, aged 70+ or frail 60+, to first line chemotherapy with metronomic oral cyclophosphamide 50 mg/day + TP (TPM) or TP alone. Prior endocrine therapy and up to 1 line of anti-HER2 therapy (without chemotherapy) for MBC were allowed.T-DM1 was offered in case of progression. Randomization was stratified according to hormonal receptors, previous anti-HER2 treatment and geriatric assessment. Primary endpoint was progression-free survival (PFS) rate at 6 months seeking a difference of ≥ 10% between the two arms. Results: Between July 2013 and May 2016, 39 and 41 patients were randomized to TP and TPM arm respectively: median age 76.7 years, hormone receptor positivity 69%, prior adjuvant T 11%, prior metastatic T (with endocrine therapy) 3%, visceral involvement 93.7%, potential frailty profile according to geriatric screening G8 (≤14) 71% and/or to short physical performance battery (&lt;10) 81%, Charlson comorbidity score &gt; 0 in 40%. With 20.7 months of median follow-up, 6-month and median PFS were 46.2% (95% CI 30.2-60.7) and 5.6 months (95% CI 3.6-16.8) versus 73.4% (95% CI 56.6-84.6) and 12.7 months (95% CI 6.7-24.8) for TP and TPM, respectively. Four patients in TPM and 2 in TP developed brain metastases only as progression event. OS and breast cancer specific survival were comparable between the two arms; 9/29 deaths were not breast cancer-related. Response rate was 44% in TP arm and 53% in TPM arm. In 29 patients who received T-DM1 second line, 6-month PFS, median PFS and response rate were 49.5% (95% CI 29.2-66.9), 5 months (95% CI 2.5-12.5) and 13.5%. In patients who discontinued TP(M), 37, 9 and 14 stopped because of progression, toxicity or other reasons, respectively. During TPM treatment, 1 patient died of heart failure and 1 developed grade 3 heart failure; 1 patient in each arm developed a ≥ 10% asymptomatic left ventricular ejection fraction decrease below 50%. Diarrhea any grade and grade ≥ 3 were observed in 56% and 8% versus 71% and 12% patients in TP and TPM arms, respectively. No grade 3 or febrile neutropenia was reported. There was no relevant difference in functional evolution between both groups. In the whole population, several geriatric items were of prognostic value by multivariate analysis: e.g. for OS, G8 &gt;14 vs ≤ 14 HR=0.12 (95% CI 0.03-0.55, p 0.006). In 29 patients receiving T-DM1, grade 3 toxicity was rare: fatigue (2 patients), thrombocytopenia and epistaxis (1 patient). Conclusions: Metronomic chemotherapy-based dual blockade (TPM) seems to be superior to dual blockade alone (TP) in an elderly/frail HER2+ MBC population, with an attractive safety profile. TPM, followed by T-DM1 after progression, may delay or supersede taxane chemotherapy in this population.

Citation Format: Wildiers H, Tryfonidis K, dal Lago L, Vuylsteke P, Curigliano G, Waters S, Brouwers B, Aalders K, Meulemans B, Litiere S, Touati N, Cardoso F, Brain E. Pertuzumab and trastuzumab with or without metronomic chemotherapy for older patients with HER2- positive metastatic breast cancer: Results from the EORTC 75111- 10114 ETF/BCG randomized phase II study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD3-09.

Abstract P4-12-01: MammaPrint is cost-effective compared to clinical risk assessment in early stage breast cancer

Rationale: The 70-gene signature (MammaPrint®, MP) is a prognostic test which guides treatment decisions in patients with early breast cancer. After level 1A evidence for clinical utility of MP has been proven, cost-effectiveness data is important to inform reimbursement.

Research objectives: To compare cost-effectiveness of adding MP to clinical risk assessment versus clinical risk assessment alone for the US and EU. Clinical risk was assessed by Adjuvant Online! (AOL) as described in Cardoso et al. NEJM 2016. We used prospective survival data from the large randomized phase 3 trial 'Microarray In Node-negative and 1 to 3 positive lymph node Disease may Avoid ChemoTherapy' (MINDACT).

Methods: We used a Markov decision model to estimate the expected costs and outcomes (quality adjusted life years; QALYs) for MP versus AOL in early breast cancer patients from a payers perspective in the US and a societal perspective in the EU over a 5 year time horizon. Five year breast cancer overall- and distant metastasis free survival was calculated based on the MINDACT population (n=6,693). Utility scores were collected by means of the EuroQol-5D in the pilot phase of MINDACT(the first n=800 MINDACT patients). Cost data were for the US based on published insurance claim data, for the EU on published health care- and societal costs. The cost-effectiveness was calculated for: (1) total early stage breast cancer population, (2) clinical high risk population and (3) clinical high risk group in the ER+/HER2- population. Finally, budget impact for a high-low range of different countries was calculated, as the application and costs of chemotherapy can be highly variable between countries.

Results: For all groups (1,2,and 3) in the US, using MINDACT survival data and insurance claim data, adding MP to AOL saved costs and gained more QALYs compared to AOL alone (total costs per patient $42,223 vs $45,566 and 4.035 vs 4.031 QALYs respectively). Thus, a small difference in quality adjusted life years (0,0041) was observed, whereas a large difference in costs ($3,342) renders MP a highly cost-effective test (less costly & more effective in 64% of the cases). The largest cost-benefit effect was seen for group 3. The cut-off point for MP being cost-effective in the total population (group 1) is when the chemotherapy costs (and consequences) together are above $30,000. In the US, with approximately 250,000 new breast cancer patients per year, and a cost saving of $3,342, annual budget savings are expected to be $836M. Similar results for the Netherlands (15,000 breast cancer patients per year), reveal a cost difference of $300 per patient, and overall annual budget savings are expected to be $4,5M.

Conclusion: Adding MP to clinical risk assessment is highly cost-effective compared to clinical risk assessment alone, based on the MINDACT survival data and US insurance claim data, for all above mentioned groups. When costs for chemotherapy (and consequences) exceed $30,000, MP is cost-effective for the total early breast cancer population. When costs for chemotherapy (and consequences) are below $30,000, the MP is cost-effective for the clinical high risk early breast cancer group. The separate results for EU countries will follow.

Citation Format: Retèl VP, Joore MA, van 't Veer LJ, Cardoso F, Piccart MJ, Rutgers EJ, Tryfonidis K, Poncet C, van Harten WH. MammaPrint is cost-effective compared to clinical risk assessment in early stage breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-12-01.

Abstract P1-07-08: Young age and the risk of disease recurrence as assessed by the 70-gene signature – an analysis from the EORTC 10041/BIG 03-04 MINDACT trial

Purpose: Increased insight in tumor biology has revealed that not all young women are at high risk of disease recurrence. Therefore, in some patients extent of treatment could probably be safely scaled down. We aimed to evaluate the risk of breast cancer (BC) relapse according to the 70-gene signature (70-GS) result in relation to young age, in early-stage BC patients enrolled in the MINDACT trial.

Patients and Methods: The analyzed population consisted of enrolled BC patients in the MINDACT trial with available clinical (C), as per a modified version of Adjuvant!Online, and genomic (G), according to the 70-GS, risk assessments and known age (n=6693). Patients were categorized in three age groups; &lt;45 (young), 45-55 (peri-menopausal) and &gt;55 years (post-menopausal). Clinicopathological and treatment characteristics as well as gene expression were compared for the different age groups further split by corrected risk groups (C-low/G-low, C-low/G-high, C-high/G-low, C-high/G-high). Subsequently, the 5-year distant metastasis-free survival according to risk category was calculated.

Results: The study included 1100 patients &lt;45 (16%), 2272 aged 45-55 (34%) and 3321 patients &gt;55 years of age (50%). Median age of the young group was 41 (25.8-45.0) years. The young age group had a higher frequency of lymph node involvement (25% vs. 22% and 19%), poorly differentiated tumors (42% vs. 26% and 27%), ER-negative tumors (20% vs. 11% and 11%) and triple negative molecular IHC subtype (16% vs. 9% ad 8%). Median tumor size was the same across the 3 age groups (17mm). Of the 1100 young patients, 61% were C-high while the 70-GS assessed 48% as G-high. Overall, 31% were CL/GL (vs. 43% in other age groups), 9% CL/GH, 21% CH/GL and 40% CH/GH (vs. 24% and 25%).

In the discordant risk groups, chemotherapy (CT) allocation when randomized to no chemo occurred in 5% of young women as compared to 3% and 1% in the older age groups. Reason for non-compliance was 50/50 between patient refusal and PI decision.

Overall, the 5-year DMFS was 94.1% (95% CI 92.4-95.4) in &lt;45 age group, 95.3% (95% CI 94.2-96.1) in 45-55 and 94.9% (95% CI 94.0-95.6) in &gt;55. For the young patients, 5-year DMFS was 98.3% for the CL/GL (96.0-99.3), 97.4% in CL/GH (90.0-99.4), 95.5% in CH/GL (91.6-97.7) and 89.2% in CH/GH (85.6-92.0). In the older two age groups (45-55 and &gt;55), the 5-year DMFS rates were 97.8% (96.5.98.6) and 97.2% (96.2-98.0) for CL/GL, 93.9% (88.8-96.7) and 94.5% (91.0-96.7) for CL/GH, 94.5% (92.0-96.3) and 95.4% (93.5-96.8) for CH/GL and 92.0% (89.2-94.1) and 90.4% (88.0-92.4) for CH/GH, respectively. With 9 events in the &lt;45 group at a CH/GL risk, numbers were too small to evaluate chemotherapy effect in this population.

Conclusion: The use of the 70-GS reduces the proportion of patients characterized as high risk as compared to traditional clinical risk assessment (48% vs. 61%). Outcome was comparable for the 3 age categories with a very good 5-year DMFS of 95-98% in all GL groups. Performing the 70-GS provides clinically relevant information concerning the prognosis for young early-stage BC patients categorized as CH. These results add important new data to the limited available evidence on genomic expression in young BC patients.

Citation Format: Aalders K, Genbrugge E, Poncet C, Kuijer A, Pistilli B, Piccart M, Tryfonidis K, van Dalen T, Cardoso F, van 't Veer L, Rutgers E. Young age and the risk of disease recurrence as assessed by the 70-gene signature – an analysis from the EORTC 10041/BIG 03-04 MINDACT trial [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-08.

Abstract P5-23-01: Clinical and biological characterization of male breast cancer (BC) EORTC 10085/TBCRC 029/BOOG 2013-02/BIG 2-07: Baseline results from the prospective registry

BACKGROUND: Through the International Male Breast Cancer Program, a prospective registry for male BC was created with the goals of evaluating 1) the clinical and biological features of this disease and 2) assessing feasibility of a prospective therapeutic clinical trial.

METHODS: All men, with any stage histologically proven invasive breast cancer, age 3 18 years, and newly presenting at the participating institutions (within 3 months prior) were eligible. Patients were enrolled for 30 months after activation of the first center, through February 2017. Per the study design, if &lt;100 men enrolled, the study would be considered a failure and therapeutic trials would not be pursued through this network. Epidemiologic data, staging, pathologic features, and BRCA status were collected. Treatment and outcome data collection is ongoing. Optional collection of FFPE tumor samples, blood, and QOL were performed in the US, the Netherlands, and Latin America. Clinical database lock for this report was May 30, 2017. We currently report patient and disease characteristics and will update with patterns of treatment for the presentation. Outcomes and biological samples will be analyzed in the future.

RESULTS: 557 patients were enrolled: 75% in Europe, 20% in United States, 5% in other countries. 6.3% of patients had missing forms. Median age was 67 years (range 26-92). 93% were diagnosed 2010-2017. Among patients with complete data, 79% presented with a breast mass. 88% were M0 and 12% M1. Among M0 patients: 47%, 39%, 2%, and 11% had T1, T2, T3, and T4 disease respectively; 52% were N0. Overall, 98% had ER+ disease and 11% had HER2+ cancer. 14% had grade 1, 56% had grade 2, and 30% had grade 3 tumors. Among 112 men who underwent BRCA1 testing, 1 was positive. Among 118 men who had BRCA2 testing, 18 (15%) were positive. 21% of men had prior or concurrent malignancies, with the following most common sites: prostate, non-melanoma skin, colorectal, and melanoma. The prevalence of previously identified possible risk factors for male breast cancer were: overweight/obesity (72%), former/current smoker (51%), current alcohol 31 drink daily (41%), family history of breast cancer (35%), gynecomastia (16%), history radiation exposure (8%), use of anti-androgens (1%), and use of estrogens (1%).

CONCLUSION: Through an international collaborative effort, we were able to prospectively accrue 557 patients to a male breast cancer registry. These results demonstrate feasibility of pursuing a therapeutic clinical trial in men with breast cancer. In addition, this study shows the relatively low uptake of BRCA testing, high rates of concurrent/prior malignancy, and the rates of potentially modifiable risk factors in this patient population.

Funding from Breast Cancer Research Foundation, Susan G. Komen, Dutch Pink Ribbon Foundation, Swedish Breast Cancer Association (BRO) and EBCC Council.

Citation Format: Giordano SH, Schröder CP, Poncet C, van Leeuwen-Stok E, Linderholm B, Abreu MH, Rubio I, Van Poznak C, Morganstern D, Cameron D, Vleugel MM, Smilde TJ, Bozovic-Spasojevic I, Korde L, Russell NS, den Hoed IDM, Honkoop AH, van der Velden AWG, van 't Riet M, Dijkstra N, Bogler O, Goulioti T, Hilsenbeck S, Ruddy KJ, Wolff A, van Deurzen CHM, Martens J, Bartlett JMS, Aalders K, Tryfonidis K, Cardoso F. Clinical and biological characterization of male breast cancer (BC) EORTC 10085/TBCRC 029/BOOG 2013-02/BIG 2-07: Baseline results from the prospective registry [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-23-01.

Research needs in breast cancer

New research questions emerge as medical needs continue to evolve and as we improve our understanding of cancer biology and treatment of malignancies. Although significant advances have been made in some areas of breast cancer research resulting in improvements in therapies and outcomes over the last few decades, other areas have not benefited to the same degree and we continue to have many gaps in our knowledge. This article summarizes the 12 short and medium-term clinical research needs in breast cancer deemed as priorities in 2016 by a panel of experts, in an attempt to focus and accelerate future research in the most needed areas: (i) de-escalate breast cancer therapies in early breast cancer without sacrificing outcomes; (ii) explore optimal adjuvant treatment durations; (iii) develop better tools and strategies to identify patients with genetic predisposition; (iv) improve care in young patients with breast cancer; (v) develop tools to speed up drug development in biomarker-defined populations; (vi) identify and validate targets that mediate resistance to chemotherapy, endocrine therapy and anti-HER2 therapies; (vii) evaluate the efficacy of local-regional treatments for metastatic disease; (viii) better define the optimal sequence of treatments in the metastatic setting; (ix) evaluate the clinical impact of intra-patient heterogeneity (intra-tumor, inter-tumor and inter-lesion heterogeneity); (x) better understand the biology and identify new targets in triple-negative breast cancer; (xi) better understand immune surveillance in breast cancer and further develop immunotherapies; and (xii) increase survivorship research efforts including supportive care and quality of life.

De-escalating and escalating treatments for early-stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017

The 15th St. Gallen International Breast Cancer Conference 2017 in Vienna, Austria reviewed substantial new evidence on loco-regional and systemic therapies for early breast cancer. Treatments were assessed in light of their intensity, duration and side-effects, seeking where appropriate to escalate or de-escalate therapies based on likely benefits as predicted by tumor stage and tumor biology. The Panel favored several interventions that may reduce surgical morbidity, including acceptance of 2 mm margins for DCIS, the resection of residual cancer (but not baseline extent of cancer) in women undergoing neoadjuvant therapy, acceptance of sentinel node biopsy following neoadjuvant treatment of many patients, and the preference for neoadjuvant therapy in HER2 positive and triple-negative, stage II and III breast cancer. The Panel favored escalating radiation therapy with regional nodal irradiation in high-risk patients, while encouraging omission of boost in low-risk patients. The Panel endorsed gene expression signatures that permit avoidance of chemotherapy in many patients with ER positive breast cancer. For women with higher risk tumors, the Panel escalated recommendations for adjuvant endocrine treatment to include ovarian suppression in premenopausal women, and extended therapy for postmenopausal women. However, low-risk patients can avoid these treatments. Finally, the Panel recommended bisphosphonate use in postmenopausal women to prevent breast cancer recurrence. The Panel recognized that recommendations are not intended for all patients, but rather to address the clinical needs of the majority of common presentations. Individualization of adjuvant therapy means adjusting to the tumor characteristics, patient comorbidities and preferences, and managing constraints of treatment cost and access that may affect care in both the developed and developing world.

Characterisation of multifocal breast cancer using the 70-gene signature in clinical low-risk patients enrolled in the EORTC 10041/BIG 03-04 MINDACT trial

BACKGROUND

In multifocal breast cancer, guidelines recommend basing adjuvant systemic treatment decisions on characteristics of the largest lesion, disregarding multifocality as an independent prognosticator. We assessed the association between multifocal disease and both the 70-gene signature (70-GS), and distant metastasis-free survival (DMFS) in clinical low-risk breast cancer patients enrolled in the European Organisation for Research and Treatment of Cancer 10041/BIG 03-04 Microarray In Node-negative and 1 to 3 positive lymph node Disease may Avoid ChemoTherapy (MINDACT) trial.

PATIENTS AND METHODS

The analysed population consisted of enrolled patients in the MINDACT trial with clinical low-risk disease, defined by a modified Adjuvant! Online cut-off for the 10-year risk of recurrent disease or death. Eligibility criteria of MINDACT dictate that patients with multifocal disease could be included if the different lesions had similar pathological characteristics. The presence of multifocal disease was deducted from the case report form (CRF)-question for sum of diameter for all invasive tumour foci. Clinicopathological characteristics and gene expression of patients with unifocal and multifocal (largest lesion) disease were compared. Subsequently, the association between multifocal disease and the 70-GS was evaluated as well as the association between multifocality and 5-year DMFS.

RESULTS

The study included 3090 clinical low-risk patients with unifocal and 238 patients with multifocal disease. Apart from a higher prevalence of lobular tumours (21.8% versus 10.8%, by local pathology), we did not observe differences in baseline characteristics between multifocal and unifocal tumours. Patients with multifocal tumours were more likely to be at high genomic risk as compared to patients with unifocal tumours (22.7% versus 17.3%, odds ratio [OR] 1.45, 95% confidence interval [CI] 1.02-2.07, P = 0.038). We did not find a significant association between tumour focality and DMFS (97.1% for unifocal versus 96.9% for multifocal, hazard ratio [HR] = 1.55, 95% CI 0.68-3.46, P = 0.172), nor a signal for a potential interaction between the prognostic effect of the 70-GS and focality of the tumour regarding DMFS.

CONCLUSION

In the group of clinical low-risk MINDACT patients, multifocal tumours were more likely to have a high-risk 70-GS profile compared to unifocal tumours. We did not observe a significant interaction between multifocality and the 70-GS with respect to survival without distant metastasis in these patients.

Abstract OT1-02-07: SOPHIA: A phase 3, randomized study of margetuximab plus chemotherapy vs trastuzumab plus chemotherapy in the treatment of patients with HER2+ metastatic breast cancer

Background: Despite significant advances in targeted therapy, HER2+ metastatic breast cancer (MBC) remains incurable. Ideal treatment includes pertuzumab and trastuzumab in combination with a taxane in the first line setting, followed by ado-trastuzumab emtansine on progression. Optimal treatment regimens in the third and greater line of therapy are not defined, but continued anti-HER2 therapy is recommended. Margetuximab is a Fc-modified monoclonal antibody to HER2 that recognizes the same epitope on HER2 as does trastuzumab, with similar affinity. Margetuximab demonstrates increased affinity to the activating CD16A Fc-receptor found on NK cells and macrophages and decreased affinity to the inhibitory CD32B receptor compared to trastuzumab. In vitro studies showed enhanced antibody dependent cell-mediated cytotoxicity compared to trastuzumab. In a Phase 1 dose escalation and expansion trial, margetuximab showed single agent clinical activity against HER2+ tumors in patients previously treated with trastuzumab and other anti-HER2 agents. Methods: SOPHIA is a randomized, prospective study testing the hypothesis that margetuximab plus chemotherapy (CTX) is more effective than trastuzumab plus CTX in patients previously treated for HER2+ MBC. Sequential primary endpoints are centrally assessed progression free survival (PFS) and overall survival (OS). The study size of 530 patients is determined to have 80% power to detect a hazard ratio for OS of 0.75. Secondary endpoints are investigator assessed PFS and centrally assessed overall response rate. Eligibility includes prior treatment with trastuzumab, pertuzumab, and ado-trastuzumab emtansine; no more than 3 prior lines of therapy in the metastatic setting; prior demonstration of HER2+ status at a local reference laboratory; and absence of active brain metastases. Eligible patients are randomized 1:1 to receive CTX (physician's choice: capecitabine, eribulin, gemcitabine or vinorelbine) plus either margetuximab or trastuzumab until disease progression or toxicity. Antibody may be continued after stopping CTX in patients with responding or stable disease. Progress to date: The trial was initiated July 2015 and is ongoing in the US and Europe with planned expansion to Korea and Israel. ClinicalTrials.gov Identifier NCT02492711; Eudract 2015-000380-13.

Citation Format: Rugo HS, Pegram MD, Gradishar WJ, Cortes J, Curigliano G, Hong S, Wigginton JM, Lechleider RJ, Cardoso F. SOPHIA: A phase 3, randomized study of margetuximab plus chemotherapy vs trastuzumab plus chemotherapy in the treatment of patients with HER2+ metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT1-02-07.

Abstract P2-11-08: Stomatitis in patients treated with first-line everolimus (EVE) plus letrozole (LET): Results from BOLERO-4 trial

Background

Stomatitis is the most frequent adverse event reported in trials of mTOR-inhibitors, including EVE. In the pivotal phase 3 BOLERO-2 study, stomatitis incidence in the EVE + exemestane (EXE) arm was 59%. The BOLERO-4 study (NCT01698918) evaluated the efficacy and safety of first-line EVE + LET in postmenopausal pts with HR+, HER2− metastatic or locally advanced breast cancer (ABC). BOLERO-4 also assessed the effectiveness of an alcohol-free dexamethasone (0.5 mg/ 5ml; DEX) oral rinse for treating stomatitis in a subset of pts (USA).

Methods

Postmenopausal pts with HR+, HER2− ABC previously untreated for advanced disease received EVE (10 mg/day) + LET (2.5 mg/day).At disease progression, pts were offered EVE (10 mg/day) + EXE (25 mg/day). Pts who had at least one episode of stomatitis received oral stomatitis daily questionnaire (OSDQ), which is a 6 question pt-reported outcome (PRO) survey (Stiff et al, JCO. 2006). A subset of these pts (USA) was randomized (1:1) to receive DEX or standard of care (SOC). The primary objective of investigator-assessed progression-free survival in the first-line setting for ABC was presented previously. A secondary objective was to evaluate the effectiveness of the DEX oral rinse in reducing the severity and duration of stomatitis, using OSDQ data.

Results

Of the total 202 pts enrolled in this study, 52 pts were enrolled in USA, of which, 24 (46.2%) were randomized to receive DEX (n=11) or SOC (n=13), upon confirmation of stomatitis. The median duration of first stomatitis episode was longer per OSDQ (DEX, not estimable vs SOC, 13.7 wk) compared with physician-reported duration (DEX, 1.6 wk vs SOC, 1.9 wk). PRO OSDQ results were similar in both arms.

Among the 202 pts enrolled, 89 (44.1%) filled the OSDQ at their first stomatitis episode. The median time from treatment initiation to first stomatitis episode was 1.7 wk; median duration of stomatitis was 13.7 wk (OSDQ) vs 2.1 wk (physician reported). The majority of pts experiencing stomatitis had moderate/little/no soreness, moderate/low/no pain, and stomatitis had low/no effect on daily activities (Table 1).

Table 1. OSDQ Key Results (N=87)Questions (Score)First Day of Stomatitis Episode, n (%)End of First Stomatitis Episode, n (%)Overall healthPoor (0-4)20 (23.0)23 (26.4)Moderate (5-7)40 (46.0)32 (36.8)Perfect (8-10)27 (31.0)32 (36.8)Mouth and throat sorenessNo/a little/moderate (0-2)64 (73.6)84 (96.6)A lot or extreme (3-4)23 (26.4)3 (3.4)Mouth pain severityNo/low/moderate (0-4)51 (58.6)73 (83.9)Severe (5-7)24 (27.6)10 (11.5)Unbearable (8-10)12 (13.8)4 (4.6)Effect on daily activitiesNo/low (0-4)70 (80.5)78 (89.7)Moderate (5-7)11 (12.6)4 (4.6)High (8-10)6 (6.9)5 (5.7)

Conclusions

Overall, patient-reported median duration of stomatitis was longer than that reported by physicians, most likely due to differences in perceptions and the challenges in collecting and cleaning PRO data. Overall good health score was maintained in the majority of pts experiencing stomatitis and stomatitis had low/no effect on daily activities. However, these results, especially in the randomized subset need to be interpreted with caution owing to the small sample size, missing data and lack of commercially available DEX in most countries.

Citation Format: Villanueva C, Tsugawa K, Toyama T, Noh W, Jeong J, Cardoso F, Sriuranpong V, Srimuninnimit V, Ozguroglu M, Kendall S, Falkson C, Cianfrocca M, Manlius C, Lin JCJ, Ringeisen F, Ridolfi A, Royce M. Stomatitis in patients treated with first-line everolimus (EVE) plus letrozole (LET): Results from BOLERO-4 trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-11-08.

Abstract PD7-01: Can surrogate pathological subtyping replace molecular subtyping? Outcome results from the MINDACT trial

Background

Molecular subgroups within early breast cancer (EBC), such as Luminal A, Luminal B, HER-2+, Basal-like may help to best to identify patients for specific treatment regimens. Controversy exists as to which methodology is best at identifying these molecular subgroups. Immunohistochemistry (IHC) may be used as a surrogate method to stratify patients. Molecular subtyping gene expression based tests, such as BluePrint, measure a greater number of genes than pathological criteria. ER, PgR, HER-2 and Ki67 are measured individually at the protein level, while BluePrint is designed to capture the functional underlying biologic pathway regulated by these receptors.

Methods

The MINDACT trial is an international, prospective, randomized, phase III trial which has proventhe clinical utility of MammaPrint in selecting EBC patients who can safely avoid chemotherapy. Here we present the results of a preplanned MINDACT sub-study to compare outcome based on molecular subtyping (MS) to surrogate pathological subtyping (PS) as endorsed by 2013 St. Gallen Consensus. MS data were obtained by MammaPrint (MP) and BluePrint classifying patients in the following subtypes: Luminal A (MP Low Risk); Luminal B (MP High Risk); HER2-type; and Basal-type. ER, PgR, HER2 and Ki67 protein status were centrally assessed by IHC/FISH. The primary hypothesis was that among PS Luminal patients, patients with HER-2+ or Basal-type tumors by MS would have a decreased DMFS compared to MS Luminal patients. At α=5% with 220 events, the study has 80% power to demonstrate this for HR=2.44.

Results

The table depicts classification of tumors according to PS versus MS for all patients (n=5,806).

PS versus MSMSPSLum ALum BHER-2+BasalTotalLum A24562708132747Lum B106979422861971HER-2 enriched1189531826557TN14107500531Total365711693556255806

Most pronounced differences: MS classified 54% as Luminal A among the Luminal B by PS. MS classified 38% as Luminal (A and B) and 5% as Basal-type among the HER-2+ by PS. MS classified 5% as Luminal (A and B) among the TN cases by PS.

MS identifies 63% of patients as Luminal A, while PS identifies 47%; 5yr DMFS for both methods was ≥ 96.0%.

PS Luminal cancers that were classified as HER-2+ or Basal-type by MS had a lower 5yr DMFS (88.0% for HER-2+ and 90.2% for Basal), albeit non-significant, than those who were also Luminal by MS (95.9%): HR= 1.40, 95% CI = 0.75-2.60.

In PS TN cancers, MS identified 24 out of 500 patients (5%) as Luminal-type with excellent prognosis (5yr DMFS of 100% versus 71.4% for MS HER-2+ or 90.1% for MS Basal-type).

Among the PS Luminal patients, Ki67 cut at 20% identified patients with ki67 low (69%), with 5yr DMFS ≥ 96.0% (better compared to the 14% cut-off).

Conclusions

1) MS was able to re-stratify 16% of patients to a low risk Luminal A-type group with an excellent outcome. 2) Among TN EBC, 5% were classified as Luminal by MS and had an excellent outcome. 3) Albeit limited by low numbers of patients in each subgroup, this study suggest that MS is better correlated with outcome. 4) The observed subtype discrepancies may have an impact on treatment decision making. 5) Centrally assessed Ki67 labeling index of 20% may be the best cut-off for surrogate differentiation between Luminal A and B.

Citation Format: Cardoso F, Slaets L, de Snoo F, Bogaerts J, van 't Veer LJ, Rutgers EJ, Piccart-Gebhart MJ, Stork-Sloots L, Russo L, Dell'Orto P, Viale G. Can surrogate pathological subtyping replace molecular subtyping? Outcome results from the MINDACT trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD7-01.

Abstract P5-14-01: Chemotherapy randomization of the EORTC 10041/ BIG 3-04 MINDACT (microarray in node-negative and 1 to 3 positive lymph node disease may avoid chemotherapy) trial

This abstract was withdrawn by the authors.