Abstract OT1-02-04: The DETECT V-study – Comparison of dual HER2-targeted therapy with trastuzumab plus pertuzumab in combination with chemo- or endocrine therapy in patients with HER2-positive and hormone-receptor positive metastatic breast cancer

Background: Maintenance of quality of life (QoL) is one of the main aims of treatment of incurable diseases such as metastatic breast cancer (MBC). In patients with HER2-positive MBC, taxan-based chemotherapy in combination with dual HER2 targeted therapy with trastuzumab and pertuzumab has shown promising efficacy results in terms of prolonged survival. However, cytostatic treatment is often accompanied by adverse events of grade 3 or higher, seriously impacting the patients' QoL. In patients with HER2-positive and hormone-receptor positive MBC, the combination of trastuzumab with aromatase inhibitors was shown to be a safe and effective treatment option. The synergistic combination of dual HER2-targeted therapy with trastuzumab and pertuzumab plus endocrine therapy might offer an even better treatment option for these patients. DETECT V is the first prospective randomized phase III clinical trial comparing the safety and efficacy of the dual HER2-targeted therapy in combination with either endocrine therapy or chemotherapy.

Trial design and eligibility criteria: Women with HER2-positive and hormone-receptor positive MBC with first to third line therapy are 1:1 randomized either to a dual HER2-targeted therapy with Pertuzumab and Trastuzumab plus endocrine therapy or to the dual HER2-targeted therapy plus chemotherapy.

Specific aims: The primary objective of this study is to compare the safety and QoL in both arms, as assessed by the occurrence of AEs during the treatment period. We developed a modified adverse event score - including all adverse events grade 3 or higher, except neutropenia, which is included only if rated grade 4, and alopecia, rash, hand-foot-syndrome and peripheral neuropathy which are included if rated grade 2 or higher – in order to better reflect the clinical, physiological and psychological impact of AEs on patients' QoL. Key secondary endpoint, besides the efficacy endpoints progression free survival (PFS) and overall survival, is to compare quality-adjusted survival (QAS), as measured using the quality-adjusted time without symptoms and toxicity (Q-TWiST) method, between both treatment arms. QAS as measured using the Q-TWiST method provides a single metric value that is a composite measure of quantity of survival time and quality of survival as assessed by the patients themselves. Q-TWiST analyses account for possible trade-offs between quantity and quality of life (e.g. prolonged time to progression at the cost of higher toxicity, which adversely affects QoL), and provide an excellent tool to evaluate whether two treatment options differ with regard to the overall perceived value to the patients.

Translational research projects focus on Circulating Tumor Cell(CTC)-enumeration (the presence of CTCs is not obligatory in DETECT V), prognostic role of CTC dynamics, and the assessment of marker expression on CTCs in order to calculate an endocrine responsiveness score which will be evaluated regarding its suitability to predict treatment success.

Contact: For further information on the DETECT V study please contact www.detect-studien.de or studienzentrale.ufk@uniklinik-ulm.de.

Citation Format: Polasik A, Schramm A, Friedl TWP, Rack B, Trapp E, Tzschaschel M, Fasching PA, Taran F-A, Hartkopf A, Schneeweiss A, Müller V, Aktas B, Pantel K, Meier-Stiegen F, Wimberger P, Janni W, Fehm T. The DETECT V-study – Comparison of dual HER2-targeted therapy with trastuzumab plus pertuzumab in combination with chemo- or endocrine therapy in patients with HER2-positive and hormone-receptor positive 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 OT1-02-04.

Abstract P3-11-05: Reliability and acceptance of e-based survey instruments for measuring patient reported outcomes (PRO) in breast cancer patients: First results of the ePROCOM study

Introduction

Especially in oncology patients, Patient Reported Outcomes (PRO) play an increasingly important role to measure subjectively perceived health status and treatment effects. At the moment, paper-based surveys of PRO still predominate (pPRO); in recent years, data on patient-relevant endpoints is being increasingly collected electronically (ePRO). The aim of the study was to analyze the acceptance of an ePRO-survey tool in breast cancer patients within the PRAEGNANT multicenter trial. Furthermore, it should be considered, whether differences in response behavior between pPRO and ePRO can be identified (reliability check).

Materials and Methods

ePROCOM (Patient Reported Outcomes and Compliance Anaysis) was conceptualized as a monocenter, randomized, parallel-group, cross-over study. Female patients with diagnosis breast cancer aged more than 18 years were included.We randomized the patients into one of two study arms. In study arm A the patients are first asked to use the electronic, web-based tool to document the patient questionnaire (EORTC QLQ C-30 and FACT-B). Afterwards the patients were asked to fill and evaluate the paper-based questionnaires accordingly, followed by evaluation of usability, acceptance and capability. In study arm B the course varies by meaning that paper-based evaluation will be followed by the assessment of electronic data capture.

Results

N=110 patients with breast cancer in adjuvant or neoadjuvant situation completing the study during an outpatient visit at the University Hospitals in Tuebingen and the National Cancer Centre Heidelberg (average age: 52.4). In most patients, there were no differences in terms of acceptance between pPRO and ePRO. Only in some older patients with a lower quality of life hurdles for ePRO could be identified, because of lower acceptance rates. We could not find significant differences in response behavior between pPRO and ePRO.

Discussion

Because no differences in response behavior could be identified, the tool can be define as reliable possibility to measure patient reported outcomes. E-PRO surveys appear to be suitable for use in breast cancer patients. However, there is a need of support in older and more ill patients, to participate form the technical capabilities of ePRO.

Citation Format: Wallwiener M, Simoes E, Hartkopf AD, Taran F-A, Keilmann L, Sickenberger N, Stevanovic S, Belleville E, Ladra C, Schneeweiss A, Wallwiener D, Brucker SY, Graf J. Reliability and acceptance of e-based survey instruments for measuring patient reported outcomes (PRO) in breast cancer patients: First results of the ePROCOM study [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 P3-11-05.

Abstract OT3-04-02: DETECT III and IV – Individualized CTC-based therapy of metastatic breast cancer

Background: Circulating tumor cells (CTCs) are found in patients with early and metastatic breast cancer (MBC), and both their prognostic and predictive value has been described already. There is growing evidence that CTC phenotype may differ from the primary tumor. However, CTC targeted therapy is not used in clinical routine, and treatment decisions often still are based on the primary tumor's phenotype without considering CTC-characteristics. The aim of the DETECT studies is to investigate and evaluate the role of presence and phenotype of CTC for guiding therapeutic decisions in women with HER2-negative MBC.

Trial design and eligibility criteria: In a joint screening for DETECT III and IV, women with HER2-negative MBC are tested for CTCs and their HER2-phenotype. CTC detection is performed by the FDA-approved CellSearch System® (Janssen Diagnostics, Raritan, USA).

Patients with HER2-positive CTCs are randomized in the multicenter Phase III study DETECT III to a physician's choice chemo- or endocrine therapy with or without additional HER2-targeted treatment with lapatinib.

Women with only HER2-negative CTCs are recruited to the multicenter open-label phase II study DETECT IV. Postmenopausal women with hormone-receptor positive MBC are treated with everolimus and a physician's choice endocrine therapy in DETECT IVa. Patients with hormone-receptor positive MBC and an indication for chemotherapy and patients with triple-negative MBC receive mono-chemotherapy with eribulin in DETECT IVb.

Treatment efficacy will be evaluated based on the early available CTC clearance rate (in DETECT III and DETECT IVa) and progression-free survival (in DETECT IVb) respectively, as the primary endpoint; secondary objectives will be to estimate disease control rate, progression-free (DETECT III and IVa) and overall survival, toxicity and tolerability of treatments with lapatinib, everolimus and eribulin, and quality of life.

Specific aims: Changes in CTC-dynamics during therapy and their HER2-phenotype may influence following therapy decisions. The DETECT studies evaluate the prognostic and predictive role of CTCs as well as the efficacy of CTC based therapy to enable the establishment of a more personalized therapy for patients with MBC that might lead to prolonged progressive free survival and/or improved quality of life. The accompanying translational research programs investigate various markers for molecular characterization of CTCs and prediction of therapy response.

Present accrual and target accrual: More than 1550 patients with HER2-negative MBC have already been screened within the DETECT study program. Thus, it is the worldwide largest study concept with therapy decisions resulting from CTC-testing and CTC-phenotypization.

Contact: For further information on the DETECT study program please contact www.detect-studien.de or studienzentrale.ufk@uniklinik-ulm.de.

Citation Format: Polasik A, Schramm A, Friedl TWP, Rack B, Trapp E, Fasching PA, Taran F-A, Hartkopf A, Schneeweiss A, Müller V, Aktas B, Pantel K, Meier-Stiegen F, Wimberger P, Janni W, Fehm T. DETECT III and IV – Individualized CTC-based therapy of 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 OT3-04-02.

A Case of Choroidal Melanoma Metastatic to the Breast

A 61-year-old woman developed blurred vision in her left eye in December 2006. A clinical diagnosis of choroidal melanoma was made. The patient underwent excision of the left lens, followed by vitrectomy and stereotactic radiotherapy. She remained systemically healthy until 50 months later when, during a CT scan done for staging purposes, a newly visible lump was noted in the lower quadrant of her left breast. Core needle biopsy of the lesion in the left breast was performed, and histologic examination revealed metastasis from the choroidal melanoma. The patient underwent breast-conserving surgery of the left breast. Definitive histological examination showed clear tumor margins in the resected specimen and one sentinel lymph node without evidence of metastatic cells. Twenty-nine months after surgery, a similar nodule was detected in the upper quadrant of the left breast. Core biopsy again showed metastatic melanoma, and similar breast-conserving surgery was performed. Systemic examination, including magnetic resonance imaging of the head and computed tomography of the pelvis, abdomen, and chest, was done regularly and revealed no significant findings. Solitary breast metastases from choroidal melanoma are extremely rare. Nevertheless, clinicians should be aware of this rare form of metastasis when treating patients with suspicious breast lesions and a history of choroidal melanoma. If solitary metastasis is confirmed, then breast-conserving surgery may be recommended.

Willingness of Patients with Breast Cancer in the Adjuvant and Metastatic Setting to Use Electronic Surveys (ePRO) Depends on Sociodemographic Factors, Health-related Quality of Life, Disease Status and Computer Skills

Introduction: Because of the often unfavorable prognosis, particularly for patients with metastases, health-related quality of life is extremely important for breast cancer patients. In recent years, data on patient-relevant endpoints is being increasingly collected electronically; however, knowledge on the acceptance and practicability of, and barriers to, this form of data collection remains limited. Material and Methods: A questionnaire was completed by 96 patients to determine to what extent existing computer skills, disease status, health-related quality of life and sociodemographic factors affect patients' potential willingness to use electronics methods of data collection (ePRO). Results: 52 of 96 (55 %) patients reported a priori that they could envisage using ePRO. Patients who a priori preferred a paper-based survey (pPRO) tended to be older (ePRO 53 years vs. pPRO 62 years; p = 0.0014) and typically had lower levels of education (p = 0.0002), were in poorer health (p = 0.0327) and had fewer computer skills (p = 0.0003). Conclusion: Barriers to the prospective use of ePRO were identified in older patients and patients with a lower quality of life. Given the appropriate conditions with regard to age, education and current health status, opportunities to participate should be provided to encourage patients' willingness to take part and ensure the validity of survey results. Focusing on ease of use of ePRO applications and making applications more patient-oriented and straightforward appears to be the way forward.

Clinical Characteristics, Surgical Management and Adjuvant Therapy of Patients with Uterine Carcinosarcoma: A Retrospective Case Series

Purpose: To review a single-center experience over a 27-year period of managing uterine carcinosarcoma (UCS), focusing on surgical practice, adjuvant therapy and clinical outcome. Material and Methods: This was a retrospective study of women with histologically proven UCS treated at the Department of Obstetrics and Gynecology, University of Tübingen, Germany, between 1983 and 2010. Inpatient and outpatient records were reviewed; follow-up and survival data were ascertained. Results: The study population comprised 18 patients with UCS. Primary surgical treatment consisted of total abdominal hysterectomy in 12 patients (67 %) and laparoscopic total hysterectomy in 4 patients (22 %). Bilateral salpingo-oophorectomy was performed in 94 % of patients (17/18). Lymph nodes were evaluated in 15 patients (83 %). Positive pelvic lymph nodes were present in 2 patients (11 %). A total of 17 patients (94 %) received adjuvant therapy. Disease recurred in 7 (39 %) patients of our study group, with no recurrence noted in the 4 patients who underwent laparoscopic surgical staging. Median disease-free survival (DFS) was 48.7 months (95 % CI: 0.0-157.3) and median overall survival (OS) was 49.9 months (95 % CI: 0.0-108.2). The 5-year survival rate was 40 %. Conclusion: UCS is a rare and aggressive uterine neoplasm with high recurrence rates and metastatic potential. Surgical staging consisting of total hysterectomy with bilateral salpingo-oophorectomy and systematic lymphadenectomy is the most important treatment for patients with UCS. Adjuvant radiation therapy appears to decrease pelvic recurrence, but there is a high incidence of distant recurrence, indicating the need for additional systemic treatment.

Abstract P2-08-18: Gene and protein expression profiles of HER2, ER, PR, and Ki67 in matched pair samples of primary (PBC) and metastatic breast cancer (MBC) tissues

Background: The genotype and phenotype of breast cancer may change during disease progression. But technical issues may affect biomarker assessment when comparing primary tumor tissues with biopsies of metastasis at distant sites.

As the exact determination of molecular subtype in primary tumors for prevention of distant metastasis is of the utmost importance in clinical decision making, we compared RNA expression levels of ESR1, PGR, ERBB2 and MKI67 in pairs of PBC and MBC tissue using RT-qPCR and evaluated our results against conventional immunohistochemistry (IHC).

Methods: The tumor bank of a single institution was screened for paraffin-embedded pairs of PBC and MBC tissue samples and a total of 34 matched PBC and MBC pairs.

RNA was extracted using a bead-based extraction method (RNXtract® IVD kits, BioNTech Diagnostics GmbH). Multiplex RT-qPCR was performed using TaqMan® based primer probe sets for ESR1, PGR, ERBB2 and MKI67 (MammaTyper® IVD kits, BioNTech Diagnostics GmbH). Results were compared with IHC analysis of ER (clone 1D5), PR (clone PgR636) and HER2 (A0485) in both primary and metastatic tissue. Associated survival data will be presented at the meeting.

Results: Samples from 34 patients with MBC and PBC were available. Positivity of PBC for ER, PR & HER2 IHC was 71%, 76% and 7%, while positivity for RT-qPCR for ESR1, PGR and ERBB2 was 78%, 70% and 3%. The overall agreement between matched primary and metastatic lesions by IHC was 80%, 60% and 100% by IHC and 90%, 70% and 100% for RT-qPCR of ESR1, PGR and ERBB2. When comparing PBC with MBC the NPA was substantially lower for IHC (ER 56%, PR 50% and HER2 100%) than for RT-qPCR (ESR1 100%, PGR 100% and ERBB2 100%). Strikingly, there were some shifts from negative to positive for IHC based ER/PR determination, and from positive to negative for RT-qPCR, when comparing differences between PBC and matched MBC. By IHC several primary "non-luminal tumors" turned into metastatic "luminal" tumors exhibiting hormone receptor expression, while no such case was observed for RT-qPCR determination.

Conclusion: Overall concordance between PBC and MBC is high, particularly when tested by RT-qPCR. As shifts from non-luminal to luminal and aggressive to less aggressive subtypes does not seem to reflect the more aggressive nature of metastatic lesions, the RT-qPCR based methods seem to be more reliable. Metastatic tissue should therefore be reevaluated with regard to markers relevant to treatment such as ESR1 and ERBB2; preferably by standardized RT-qPCR methods. Validation of these findings in an independent cohort of similar size is ongoing and will be presented at the meeting.

Citation Format: Wallwiener M, Deutsch TM, Hartkopf AD, Domschke C, Taran F-A, Brucker S, Wirtz R, Trumpp A, Schneeweiss A. Gene and protein expression profiles of HER2, ER, PR, and Ki67 in matched pair samples of primary (PBC) and metastatic breast cancer (MBC) tissues. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-08-18.