Pertuzumab and trastuzumab as adjuvant treatment for HER2-positive early breast cancer: outcomes in Chinese patients in the APHINITY study

BACKGROUND

The addition of pertuzumab to trastuzumab plus standard chemotherapy as adjuvant therapy following surgery significantly improved invasive disease-free survival (IDFS) in patients with HER2-positive early breast cancer in the multinational randomized APHINITY trial (NCT01358877, BIG 4-11/BO25126/TOC4939G). We analyzed clinical outcomes in the subgroup of patients recruited at Chinese sites.

METHODS

Patients were randomized to standard adjuvant chemotherapy plus 1 year of trastuzumab with pertuzumab or placebo. Patients recruited in mainland China, Hong Kong and Taiwan are included in this descriptive analysis.

RESULTS

Chinese patients had similar demographic characteristics to the global population, but a higher proportion had nodal involvement. Although this subgroup analysis was not powered to detect statistical significance, a numerical improvement in IDFS was observed with the addition of pertuzumab to trastuzumab in Chinese patients (hazard ratio, 0.69; 95% confidence interval: 0.39-1.19; 3-year IDFS event-free estimates 92.5% [pertuzumab] and 91.7% [placebo]), which was consistent with the primary analysis of the global population. Further subgroup analyses showed numerical improvements in the Chinese node-positive, hormone receptor-negative and -positive subgroups, although confidence intervals were wide due to the low number of events. The incidence of diarrhea was higher in the pertuzumab arm, and no primary cardiac events occurred in Chinese patients in either arm.

CONCLUSIONS

Pertuzumab, used in combination with trastuzumab and chemotherapy in APHINITY, is effective as an adjuvant treatment regimen for Chinese patients with HER2-positive early breast cancer in a setting with curative intent. The safety profile in Chinese patients was consistent with that of the global population.

The impact of a surgery-first approach on oral health-related quality of life

Orthognathic surgery using a surgery-first approach (SFA) has been shown to result in better quality of life (QoL) throughout the treatment duration; however, the effects of gender, age and type of dentofacial deformity on SFA-related QoL remain unknown. In total, 228 consecutive patients underwent SFA for correction of dentofacial deformities (skeletal class III, bimaxillary protrusion and facial asymmetry). We assessed their QoL before surgery and at 1, 6 and 12 months after surgery using the Orthognathic Quality of Life Questionnaire (OQLQ). The results indicated a significant decrease in the total OQLQ, facial aesthetics and social aspect domain scores 1, 6 and 12 months after surgery. Among all domains, the greatest improvement was noted in the facial aesthetics domain. The oral function scores declined significantly immediately after surgery, but improved significantly 6 and 12 months after surgery; however, the awareness scores remained relatively stable. At each time point, women and the bimaxillary protrusion group exhibited a significantly higher total and specific domain scores. Patients aged 18-22 years exhibited lower total and four specific domain scores than older patients. Thus, QoL improves in all aspects, except awareness domain, by 12 months after SFA, but gender, age, and type of dentofacial deformity affect this improvement.

Abstract PD12-06: Treatment-related amenorrhea with T-DM1 plus pertuzumab (KP) is lower than with docetaxel/carboplatin/trastuzumab/pertuzumab (TCHP) in the phase III neoadjuvant KRISTINE trial

Background: Cytotoxic chemotherapy (CT) in combination with trastuzumab and pertuzumab (HP) is standard of care for patients (pts) diagnosed with HER2-positive early breast cancer (EBC). While highly effective, the toxicity associated with CT is challenging. In KRISTINE/TRIO-021, neoadjuvant T-DM1 was combined with pertuzumab (KP) and compared to standard TCHP. Pts. received six cycles of neoadjuvant treatment followed by adjuvant therapy (KP or HP). Pts. in the KP arm were allowed to receive standard adjuvant CT. Pathologic complete response (pCR) rate was significantly lower with KP versus TCHP and more pts. had disease progression prior to surgery with KP, resulting in a meaningfully lower event-free survival rate vs. the control (85.3% vs 94.2%). However, 3-year invasive disease-free survival was numerically similar in both arms. Neoadjuvant KP demonstrated less toxicity than standard CT, although treatment discontinuation was higher post-surgery. Association of KP and TCHP with treatment-related amenorrhea (TRA) in premenopausal EBC pts. has not been ascertained. Methods: All pts. with premenopausal status at study entry (those not meeting the menopause definition based on National Comprehensive Cancer Network Guidelines v3, 2012) and with menstrual period documented within 3 months of randomization, were independently evaluated for presence or absence of TRA by two reviewers. TRA, a prespecified exploratory endpoint of KRISTINE, was defined as cessation of menstruation for >12 months in the absence of treatment with ovarian suppression or other interventions that can induce amenorrhea. Pts. were followed from the time of study entry through the 3-year follow up period after surgery. For cases with inconsistent determination between the two reviewers, a third reviewer adjudicated. TRA rates were calculated per arm, hormone-receptor (HR) status, adjuvant CT and age group. Proportions were compared by estimating the odds ratio (OR) and the 95% confidence interval. Results: Of 444 pts. enrolled, 205 were excluded based on being post-menopausal per NCCN guidelines. Of 239 pts. remaining, 56 were excluded due to insufficient data. The median age of pts. included was 40 years (range: 22-53) for TCHP and 42.5 (range: 23-52) for KP. TRA was observed in 55% (50/91) of pts. treated with TCHP compared to 30% (28/92) treated with KP (OR=2.79; 95% CI 1.52-5.12). In pts. with HR-positive EBC, TRA occurred in 62% with TCHP vs 35% for KP (OR=2.998; 95% CI 1.44-6.25). In those with HR-negative EBC, TRA was observed in 42% with TCHP vs. 21% with KP (OR=2.77; 95% CI 0.88-8.72). In the KP arm, TRA was observed in 38% (8/21) of pts. treated with standard adjuvant CT vs. 28% (20/71) of those that did not (OR 1.57; 95% CI 0.57-4.36). For women age ≤ 40, the rate of TRA was 38% with TCHP vs. 17% with KP (OR=3.00; 95% CI 1.05-8.60). For those > 40 years, TRA was observed in 74% treated with TCHP vs. 39% of those with KP (OR=4.50; 95% CI 1.88-10.73). Conclusion: The rate of TRA with standard TCHP is nearly double that observed with KP, suggesting that targeted CT with an antibody-drug conjugate regimen is associated with less gonadal toxicity. Rates of TRA are higher in women over the age of 40 for each treatment arm however KP is associated with lower rate of TRA in each age group. Association of TRA with efficacy outcomes (pCR, iDFS) will be presented.

Citation Format: Sara A Hurvitz, Rodrigo Fresco, Karen Afenjar, Daniil Stroyakovskiy, Chiun-Sheng Huang, Hans Wildiers, Kyung Hae Jung, Jean-François Boileau, Mario Campone, Miguel Martín, Vicente Valero, Joseph A. Sparano, W. Fraser Symmans, Peter A. Fasching, Alastair M. Thompson, Nadia Harbeck, Vanesa López-Valverde, Chunyan Song, Thomas Boulet, Eleonora Restuccia, Dennis J. Slamon. Treatment-related amenorrhea with T-DM1 plus pertuzumab (KP) is lower than with docetaxel/carboplatin/trastuzumab/pertuzumab (TCHP) in the phase III neoadjuvant KRISTINE trial [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD12-06.

Abstract OT-13-10: Global Phase 3 Study of Adagloxad Simolenin (OBI-822) and OBI-821 Versus Placebo Treatment for High Risk Early Stage Triple Negative Breast Cancer Patients (TNBC) Following Neoadjuvant or Adjuvant Chemotherapy

Background: Triple-negativebreast cancer (TNBC) has the highest rate of distant metastasis and poorestoverall survival among all breast cancer subtypes. Adagloxad simolenin (AS; OBI-822)is a therapeutic vaccine comprising the synthetically manufactured tumor-associatedantigen Globo H linked to the carrier protein keyhole limpet hemocyanin (KLH).The KLH provides antigenic immune recognition and T-cell responses. AS isco-administered with a saponin-based adjuvant OBI-821 to induce a humoralresponse. A phase 2 trial showed that AS/OBI-821exhibited a trend for superior progression-free survival vs placebo in patientswhose breast cancers had higher Globo Hexpression. Administrationof AS/OBI-821 resulted in IgM and IgG anti-Globo H humoral response and a trendtowards improved PFS in patients with metastatic breast cancer overexpressingGlobo H. We describe the rationale and design of GLORIA, an ongoing Phase III,randomized, open-label study to evaluate efficacy, safety, and quality of life(QoL) of AS plus standard of care (SOC) versus SOC alone in patients withhigh-risk, early-stage TNBC. The primary endpoint is invasive progression-freesurvival; secondary endpoints include overall survival, QoL, breast cancer-freeinterval, distant disease-free survival, safety, and tolerability.

Trial Design: A phase 3 trial was initiated inDecember 2018 and had been slowly enrolling until being put on hold due to theCovid-19 pandemic. While the study wason hold the design waschanged from a placebo-control to a standard-of-care control trial based onfeedback from investigators and leading breast cancer advisers, that the numberof placebo injections was a serious burden on patients. Furthermore, it wasapparent that blinding was questionable given the expected and frequent localskin inflammation and low-grade fevers that accompany the AS/OBI-821 vaccineadministration and the absence of these obvious clinical signs and symptomswith the normal saline placebo control.The main changes to the protocol are as follows:

Methods: Eligibility includes patients with TNBC (estrogen receptor/progesterone receptor <5%,and HER2-negative) with nonmetastatic disease and 1) either residual invasive disease of ≥1 cm in breast or ≥1 positive axillary node following neoadjuvantchemotherapy; Pathological Stage IIB or III disease treated with adequateadjuvant chemotherapy alone; received ≥4 cycles of standard taxane- and/oranthracycline-based chemotherapy; randomized within 12 weeks of surgery, adjuvant multi-agent chemotherapy,or radiation therapy.In addition, tumors must express Globo H (H-score of ≥15 by central laboratory analysis using a validated immunohistochemical assay). Subjects in the AS/OBI-821 group will receive 30 μg of AS in combination with 100 μg ofOBI-821.This revised study will start re-enrolling patients as soon as Covid-19 restrictions are lifted with the first country being South Korea with an anticipated start date in Q4/2020.

Citation Format: Hope Rugo, Louis W.C. Chow, Javier Cortes, Peter A. Fasching, Xu-Bing He, Pei Hsu, Chiun-Sheng Huang, Sung-Bae Kim, Yen-Shen Lu, Michelle Melisko, Rita Nanda, Tillman E Pearce, Priyanka Sharma, Richard Schwab. Global Phase 3 Study of Adagloxad Simolenin (OBI-822) and OBI-821 Versus Placebo Treatment for High Risk Early Stage Triple Negative Breast Cancer Patients (TNBC) Following Neoadjuvant or Adjuvant Chemotherapy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr OT-13-10.

Abstract PS6-40: Clinical risk criteria and recurrence index for distant recurrence for patients with early stage luminal breast cancer

Background:Clinical risk criteria (CRC) has been used in two well-known gene-expression trials (TAILORX and MINDACT) to predict the risk of distant recurrence (DR). The definition of clinical low-risk patients was (1) node-negative associated with (grade 1 with tumor ≤3cm, grade 2 with tumor≤2cm, or grade 3 with tumor ≤1cm) and N1 with grade 1 and tumor ≤2cm. Recurrence Index for distant recurrence (RI-DR) is a clinical-genomic model, based on genomic profiling derived from Asian women. The primary purpose of this study is to access the clinical utility of RI-DR and CRC in Asian breast cancer patients.

Methods:A total of 208 patients (N0 70.2%, N1 29.8%) with luminal-like breast cancer were enrolled in a retrospective study across Taiwan medical centers. Kaplan-Meier method was used to calculate the survival rates and the log rank test was applied for the survival difference between two or more independent groups. The primary endpoint was the recurrence-free interval (RFI).

Results:With a median follow-up of 49.05 [IQR 29.72-71.96], the 5-year RFI was significantly poorer in the high-risk group than the low-risk group (87.2% [95% CI, 80.0-95.0] versus 95.2% [89.75-100] by the RI-DR, p = 0.011; and 86.9% [79.8-94.6] versus 97.0% [92.9-100] by the clinical risk, p = 0.03). Combined the CRC and RI-DR together, clinical high (CH) and RI-DR high (RH)had the poorest 5-year RFI (85.2%, [76.6-94.8]); clinical low (CL) and RI-DR low (RL) had the best 5-year RFI (98.0% [94.08, 100]). Among CL-risk patients, RL group has a trend towards less recurrence than RH group (1/66 [1.51%] versus 2/19 [10.52%], p= 0.15). Similar trend was observed in CH-risk patients (RL: 2/41 (4.88%) versus RH: 12/82 [14.63%], p = 0.17) (Table 1).

Conclusions:The present study provides robust evidences that clinical-risk criteria and RI-DR testing could partition patients into good and poor prognosis in early-stage luminal breast cancer. RI-DR has a trend to identify low- and high-risk patients if clinical risk criteria have been applied in clinical practice.

Analyses of Clinical Risk Criteria and Recurrence Index TogetherNo. of PatientsNo. of Events5-year RFI % (95% CI)Log rank, P valueClinical-Clinical-HighRI-DR high821285.20 [76.55, 94.81]0.17RI-DR low41291.30 [80.15, 100]Clinical-LowRI-DR high19294.12 [83.57, 100]0.15RI-DR low66197.96 [94.08, 100]

Citation Format: Skye Hung-Chun Cheng, Liang-Chih Liu, Ling-Ming Tseng, Chuan-Hsun Chang, Chiun-Sheng Huang, Ji-An Liang, Yu-Chen Hsu, Chia-Ming Hsieh, Jun-Ru Wei. Clinical risk criteria and recurrence index for distant recurrence for patients with early stage luminal breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS6-40.

Abstract GS1-01: Primary outcome analysis of invasive disease-free survival for monarchE: abemaciclib combined with adjuvant endocrine therapy for high risk early breast cancer

Background monarchE is a phase 3, open-label study evaluating abemaciclib combined with endocrine therapy (ET) compared to ET alone in patients with node positive, HR+, HER2-, high risk early breast cancer (EBC) that resulted in a statistically significant improvement in invasive disease-free survival (IDFS) at a pre-planned interim analysis. Following the positive interim analysis, patients continued to be followed for IDFS, distant recurrence, and overall survival.

Methods After surgery and, as indicated, radiotherapy and/or chemotherapy, 5,637 patients with HR+, HER2-, high risk EBC were randomized (1:1) to standard of care adjuvant ET with or without abemaciclib (150 mg BD for 2 years). Patients with ≥4 positive nodes, or 1-3 nodes and either grade 3 disease, tumor size ≥5 cm, or central Ki-67 ≥20% were eligible. Here we present results of the primary outcome IDFS analysis which was planned after approximately 390 IDFS events.

Results At the primary outcome analysis, median follow-up was approximately 19 months in both arms (an increase of 3.5 months from the interim analysis). A total of 1437 (25.5%) patients had completed the 2-year treatment period; 3281 (58.2%) were still in the 2-year treatment period. With 395 IDFS events observed in the intent-to-treat population, abemaciclib plus ET continued to demonstrate superior IDFS versus ET alone, with a 28.7% reduction in the risk of developing invasive disease (p=.0009; HR = 0.713; 95% CI = 0.583, 0.871). Two-year IDFS rates were 92.3% in the abemaciclib plus ET arm and 89.3% in the ET alone arm. There was a consistent benefit of abemaciclib in all prespecified subgroups. The addition of abemaciclib to ET also resulted in an improvement in distant relapse-free survival (DRFS). Overall survival was immature at the time of analysis. A key secondary endpoint was efficacy in patients with centrally assessed high Ki-67 (≥20%) (Ki-67H) (n=2498). Disease characteristics were well balanced between the arms of this population. Abemaciclib plus ET demonstrated superior IDFS vs ET alone, with a 30.9% reduction in risk of developing invasive disease (p=.0111; HR = 0.691; 95% CI = 0.519, 0.920) and 2-year IDFS rates of 91.6% and 87.1%, respectively. An improvement in DRFS treatment effect was also observed in the Ki-67H population. At the time of data cutoff, the median treatment duration of abemaciclib was 17.3 months and the median duration of ET was balanced between the arms (18.3 months in the abemaciclib arm and 18.7 months in the ET alone arm). Safety was consistent with the results at the interim IDFS analysis and with the known safety profile of abemaciclib.

Conclusions At the primary outcome analysis, with a median follow-up of approximately 19 months, abemaciclib combined with ET continued to demonstrate a clinically meaningful improvement in IDFS in patients with HR+, HER2-, node-positive, high risk, EBC with a statistically significant improvement in IDFS in patients with central Ki-67 ≥20%. ClinicalTrials.gov: NCT03155997

Table 1: PrimaryOutcome EfficacyIntent-to-Treat PopulationIntent-to-Treat PopulationKi-67 ≥20% (Ki-67H) PopulationKi-67 ≥20% (Ki-67H) PopulationEndpointAbemaciclib + ET N=2808ET alone N=2829Abemaciclib + ET N=1262ET alone N=1236IDFS# events, n (%)163 (5.8)232 (8.2)82 (6.5)115 (9.3)log rank P value, HR (95% CI)p=.0009 0.713 (0.583, 0.871)p=.0111 0.691 (0.519, 0.920)Rate (%) at 2 years (95% CI)92.3 (90.9, 93.5)89.3 (87.7, 90.7)91.6 (89.4, 93.4)87.1 (84.3, 89.5)Difference (%) in 2-year rates (95% CI)3 (1.1, 5.0)4.5 (1.2, 7.7)DRFS# events, n (%)131 (4.7)193 (6.8)65 (5.2)102 (8.3)log rank P value, HR (95% CI)p=.0009 0.687 (0.551, 0.858)0.609 (0.445, 0.833)Rate (%) at 2 years (95% CI)93.8 (92.6, 94.9)90.8 (89.3, 92.1)93.6 (91.6, 95.1)88.5 (85.7, 90.7)Difference (%) in 2-year rates (95%CI)3 (1.2, 4.8)5.1 (2.1, 8.1)

Citation Format: Joyce A. O'Shaughnessy, Stephen Johnston, Nadia Harbeck, Masakazu Toi, Young-Hyuck Im, Mattea Reinisch, Zhimin Shao, Pirkko Liisa Kellokumpu Lehtinen, Chiun-Sheng Huang, Alexey Tryakin, Matthew Goetz, Hope S Rugo, Elzbieta Senkus, Laura Testa, Michael Andersson, Kenji Tamura, Guenther G. Steger, Lucia Del Mastro, Joanne Cox, Tammy Forrester, Sarah Sherwood, Xuelin Li, Ran Wei, Miguel Martin, Priya Rastogi. Primary outcome analysis of invasive disease-free survival for monarchE: abemaciclib combined with adjuvant endocrine therapy for high risk early breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr GS1-01.

Axillary lymph node metastasis status prediction of early-stage breast cancer using convolutional neural networks

Deep learning (DL) algorithms have been proven to be very effective in a wide range of computer vision applications, such as segmentation, classification, and detection. DL models can automatically assess complex medical image scenes without human intervention and can be applied as a second reader to provide an additional opinion for the physician. To predict the axillary lymph node (ALN) metastatic status in patients with early-stage breast cancer, a deep learning-based computer-aided prediction system for ultrasound (US) images was proposed. A total of 153 women with breast tumor US images were involved in this study; there were 59 patients with metastasis and 94 patients without ALN metastasis. A deep learning-based computer-aided prediction (CAP) system using the tumor region and peritumoral tissue in ultrasound (US) images were employed to determine the ALN status in breast cancer. First, we adopted Mask R-CNN as our tumor detection and segmentation model to obtain the tumor localization and region. Second, the peritumoral tissue was extracted from the US image, which reflects metastatic progression. Third, we used the DL model to predict ALN metastasis. Finally, the simple linear iterative clustering (SLIC) superpixel segmentation method and the LIME explanation algorithm were employed to explain how the model makes decisions. The experimental results indicated that the DL model had the best prediction performance on tumor regions with 3 mm thick peritumoral tissue, and the accuracy, sensitivity, specificity, and AUC were 81.05% (124/153), 81.36% (48/59), 80.85% (76/94), and 0.8054, respectively. The results indicated that the proposed CAP system could help determine the ALN status in patients with early-stage breast cancer. The results reveal that the proposed CAP model, which combines primary tumor and peritumoral tissue, is an effective method to predict the ALN status in patients with early-stage breast cancer.

Automated whole breast segmentation for hand-held ultrasound with position information: Application to breast density estimation

BACKGROUND AND OBJECTIVE

Women with higher breast densities have a relatively higher risk to be diagnosed with breast cancer. Hand-held ultrasound (HHUS) can provide precise screening results and detect masses in dense breasts. However, its lack of position information and automatic extraction of breast area hinder the implementation of density estimation. To facilitate reliable breast density evaluation, this study proposed an upgraded version of our whole-breast ultrasound (WBUS) system, which not only can provide precise position information, but also can extract precise breast area automatically based on deep learning method.

METHODS

WBUS images with probe position information were collected from 117 women. For each case, an automatic breast region segmentation by DeepResUnet was conducted, then fibroglandular tissues were extracted from breast region using fuzzy c-mean (FCM) classifier. Finally, the percentage of breast density and breast area of the DeepResUnet predicted region and the breast region of the ground truth were calculated and compared.

RESULTS

The average and standard deviation of each breast case for DeepResUnet predicted breast region of 10-fold in Accuracy (ACC) was 0.963±0.054. Sensitivity (SENS) was 0.928±0.11. Specificity (SPEC) was 0.967±0.054. Dice coefficient (Dice) was 0.916±0.98. Region intersection over union (IoU) was 0.856±0.134. Significant and very high correlations of breast density, fibroglandular tissue area and breast area (R = 0.843, R= 0.822 and R = 0.984, all p values < 0.001) were found between the ground truth and the result of the proposed method for ultrasound images.

CONCLUSIONS

Breast density, fibroglandular tissue, and breast volume evaluated based on the proposed method and WBUS system have significant correlations with ground truth, indicating that the proposed method and WBUS system has the potential to be an alternative modality for breast screening and density estimation in clinical use.

Artificial Intelligence Aids Cardiac Image Quality Assessment for Improving Precision in Strain Measurements

OBJECTIVES

The aim of this study was to develop an artificial intelligence tool to assess echocardiographic image quality objectively.

BACKGROUND

Left ventricular global longitudinal strain (LVGLS) has recently been used to monitor cancer therapeutics-related cardiac dysfunction (CTRCD) but image quality limits its reliability.

METHODS

A DenseNet-121 convolutional neural network was developed for view identification from an athlete's echocardiographic dataset. To prove the concept that classification confidence (CC) can serve as a quality marker, values of longitudinal strain derived from feature tracking of cardiac magnetic resonance (CMR) imaging and strain analysis of echocardiography were compared. The CC was then applied to patients with breast cancer free from CTRCD to investigate the effects of image quality on the reliability of strain analysis.

RESULTS

CC of the apical 4-chamber view (A4C) was significantly correlated with the endocardial border delineation index. CC of A4C >900 significantly predicted a <15% relative difference in longitudinal strain between CMR feature tracking and automated echocardiographic analysis. Echocardiographic studies (n =752) of 102 patients with breast cancer without CTRCD were investigated. The strain analysis showed higher parallel forms, inter-rater, and test-retest reliabilities in patients with CC of A4C >900. During sequential comparisons of automated LVGLS in individual patients, those with CC of A4C >900 had a lower false positive detection rate of CTRCD.

CONCLUSIONS

CC of A4C was associated with the reliability of automated LVGLS and could also potentially be used as a filter to select comparable images from sequential echocardiographic studies in individual patients and reduce the false positive detection rate of CTRCD.

Investigating the Association of the Biogenic Amine Profile in Urine with Therapeutic Response to Neoadjuvant Chemotherapy in Breast Cancer Patients

Neoadjuvant treatment (NAT) can downstage breast cancer and can be utilized for different clinical applications. However, the response to NAT varies among individuals. Having effective biomarkers is important to optimize the treatment of breast cancer. Concentrations of biogenic amines have been found to show an association with cancer cell proliferation, but their clinical utility remains unclear. This study developed a postcolumn-infused internal standard (PCI-IS)-assisted liquid chromatography combined with tandem mass spectrometry (LC-MS/MS) method for profiling biogenic amines in human urine. Putrescine-d₈ was selected as the PCI-IS to calibrate the errors caused by matrix effects in the urine sample. The optimized method was applied to investigate the association between changes in 14 amines and the therapeutic response to NAT in breast cancer patients. Urine samples were collected before initiation of chemotherapy (n = 60). Our results indicated that the levels of N¹-acetylspermine, spermidine, norepinephrine, and dopamine were significantly higher in the responder group than the nonresponder group. These metabolites were incorporated with clinical factors to identify NAT responders, and the prediction model showed an area under the curve value of 0.949. These observations provide remarkable insights for future studies in elucidating the roles of biogenic amines in breast cancer. Additionally, the PCI-IS-assisted amine profiling method can facilitate these studies.

A case-control study of perfluoroalkyl substances and the risk of breast cancer in Taiwanese women

Breast cancer (BC) is a common cancer in women worldwide; however, the incidence of BC is increasing in younger women, possibly associated with the environment. Perfluoroalkyl substances (PFAS) are one of endocrine disruptors that accumulate in environment and impact human health. This study aimed to investigate whether the PFAS and BC are associated. We enrolled 120 BCE patients and 119 controls at National Taiwan University Hospital (NTUH) and also collected bio-specimen and questionnaire from 2013 to 2015. All subjects' plasma PFAS levels were analyzed by ultra-performance liquid chromatography tandem mass spectrometry method with electrospray ionization (UHPLC-ESI-MS/MS). A logistic regression model was used to estimate the association between PFAS and BC. In the ≤50 years age group, the adjusted odds ratio (OR) was 2.34 (95% CI = 1.02, 5.38) for perfluorooctane sulfonate (PFOS) exposure per natural log unit increase. After stratifying the estrogen receptor (ER) status and age group, we obtained a positive association for PFHxS and PFOS concentrations with respect to the risk of ER positive tumors for ≤50 years age group. In conclusion, we found that PFAS were associated with the BC risk of ER positive tumors in young Taiwanese women. Further studies are needed to follow and explore whether these associations are causal.

Abstract 720: Analysis of circulating tumor DNA after neoadjuvant therapy to predict disease relapse in patients with stage II-III breast cancer

The therapeutic efficacy of neoadjuvant chemotherapy for patients with breast cancer is usually assessed by the reduction of tumor size and lymph nodes. The pathologic complete response (pCR) is considered as a marker related to good prognosis. However, patients who can achieve pCR is a minor population, and pCR may be not a robust marker predicting prognosis in patients with ER-positive breast cancer. Additional markers allowing the assessment of prognosis is needed. Circulating tumor DNA (ctDNA) has been proved as a marker to detect disease progression in metastatic breast cancer and predict relapse in patients after resection of breast cancer. Therefore, we would like to assess the value of ctDNA in breast cancer patients receiving neoadjuvant therapy. The ctDNA was collected before and after completion of the neoadjuvant chemotherapy (Tend). The presence of ctDNA was detected by ultra-deep targeted next-generation sequencing. We enrolled 82 patients and 62 patients were found to have ctDNA as the biomarkers. The presence of ctDNA included nonsynonymous variants and copy number variations in TP53, PIK3CA, HER2, CDH1, PTEN, S100A, CCND1 and c-MYC. Among the 62 patients, there were 24 patients with hormone receptor (+)/Her2(-), 20 with Her2(+) and 18 with triple-negative breast cancer (TNBC). Pathologic complete response (pCR) occurred in 9 patients, partial response in 32 patients and stable/progression in 21 patients, according to the RECIST 1.1 criteria. Univariate analysis showed tumor reduction&gt;50% (p=0.032), number of metastatic lymph node (p=0.039), and status of ctDNA at Tend (p&lt;0.001) were significantly associated with disease-free survival (DFS). The 5-year DFS of patients with undetectable ctDNA at Tend (74.0%, 95% confidence interval (CI) range 98%-50%) was significantly superior to those with detected ctDNA (16.8%, 95% CI range 36.1%-0%). Multivariate analysis revealed that status of ctDNA at Tend was the only one independent factor predicting relapse (hazard ratio 7.74, 95% CI 2.81-21.35). Two patients had pCR and were found to have alterations of ctDNA at Tend; one with TNBC had distant metastases at 6 months after mastectomy and the other with Her2 (+) breast cancer had brain metastasis at the end of adjuvant trastuzumab treatment. Therefore, we concluded that the presence of ctDNA at the end of the neoadjuvant chemotherapy was a poor prognostic factor predicting relapse in patients with stage II-III breast cancer.

Citation Format: Po-Han Lin, Sung-Sheng Kuo, Chiun-Sheng Huang. Analysis of circulating tumor DNA after neoadjuvant therapy to predict disease relapse in patients with stage II-III breast cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 720.

Palbociclib and beyond for the treatment of HR + HER2- metastatic breast cancer: an Asian-Pacific perspective and practical management guide on the use of CDK4/6 inhibitors

Breast cancer is the most frequent cancer amongst women worldwide including in Asia where the incidence rate is rapidly increasing. Even with treatment, around 30% of patients with early breast cancer progress to metastatic disease, with hormone receptor positive (HR+) and human epidermal growth factor receptor 2 negative (HER2-) breast cancer the most common phenotype. First-line endocrine therapy targeting the estrogen receptor signaling pathway provides a median progression-free survival or time to progression of 6-15 months in HR + HER2- metastatic breast cancer. Recently, cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors, combined with endocrine therapy, have achieved more than two years median progression-free survival in HR + HER2- metastatic breast cancer. However, the characteristics of the Asian breast cancer population differ from those of Western populations and need to be considered when selecting a suitable treatment. Breast cancer is diagnosed at a younger age in Asian populations and late stage at presentation is generally more common in low-/middle-income countries than high-income countries. Consequently, the proportion of premenopausal women with metastatic breast cancer is higher in Asian compared with Western populations. While CDK4/6 inhibitors have been approved in the USA (FDA) since 2015, experience with them in Asia is more limited. We review the experience with the CDK4/6 inhibitor palbociclib in Asian patients with HR + HER2- metastatic breast cancer and provide guidance on the use of palbociclib in these patients.

Computer-aided diagnosis of breast ultrasound images using ensemble learning from convolutional neural networks

Breast ultrasound and computer aided diagnosis (CAD) has been used to classify tumors into benignancy or malignancy. However, conventional CAD software has some problems (such as handcrafted features are hard to design; conventional CAD systems are difficult to confirm overfitting problems, etc.). In our study, we propose a CAD system for tumor diagnosis using an image fusion method combined with different image content representations and ensemble different CNN architectures on US images. The CNN-based method proposed in this study includes VGGNet, ResNet, and DenseNet. In our private dataset, there was a total of 1687 tumors that including 953 benign and 734 malignant tumors. The accuracy, sensitivity, specificity, precision, F1 score and the AUC of the proposed method were 91.10%, 85.14%, 95.77%, 94.03%, 89.36%, and 0.9697 respectively. In the open dataset (BUSI), there was a total of 697 tumors that including 437 benign lesions, 210 malignant tumors, and 133 normal images. The accuracy, sensitivity, specificity, precision, F1 score, and the AUC of the proposed method were 94.62%, 92.31%, 95.60%, 90%, 91.14%, and 0.9711. In conclusion, the results indicated different image content representations that affect the prediction performance of the CAD system, more image information improves the prediction performance, and the tumor shape feature can improve the diagnostic effect.

Computer-aided tumor detection in automated breast ultrasound using a 3-D convolutional neural network

BACKGROUND AND OBJECTIVES

Automated breast ultrasound (ABUS) is a widely used screening modality for breast cancer detection and diagnosis. In this study, an effective and fast computer-aided detection (CADe) system based on a 3-D convolutional neural network (CNN) is proposed as the second reader for the physician in order to decrease the reviewing time and misdetection rate.

METHODS

Our CADe system uses the sliding window method, a CNN-based determining model, and a candidate aggregation algorithm. First, the sliding window method is performed to split the ABUS volume into volumes of interest (VOIs). Afterward, VOIs are selected as tumor candidates by our determining model. To achieve higher performance, focal loss and ensemble learning are used to solve data imbalance and reduce false positive (FP) and false negative (FN) rates. Because several selected candidates may be part of the same tumor and they may overlap each other, a candidate aggregation method is applied to merge the overlapping candidates into the final detection result.

RESULTS

In the experiments, 165 and 81 cases are utilized for training the system and evaluating system performance, respectively. On evaluation with the 81 cases, our system achieves sensitivities of 100% (81/81), 95.3% (77/81), and 90.9% (74/81) with FPs per pass (per case) of 21.6 (126.2), 6.0 (34.8), and 4.6 (27.1) respectively. According to the results, the number of FPs per pass (per case) can be diminished by 56.8% (57.1%) at a sensitivity of 95.3% based on our tumor detection model.

CONCLUSIONS

In conclusion, our CADe system using 3-D CNN with the focal loss and ensemble learning may have the capability of being a tumor detection system in ABUS image.

Contrasting Epidemiology and Clinicopathology of Female Breast Cancer in Asians vs the US Population

BACKGROUND

The incidence of breast cancer among younger East Asian women has been increasing rapidly over recent decades. This international collaborative study systemically compared the differences in age-specific incidences and pathological characteristics of breast cancer in East Asian women and women of predominantly European ancestry.

METHODS

We excerpted analytic data from six national cancer registries (979 675 cases) and eight hospitals (18 008 cases) in East Asian countries and/or regions and, for comparisons, from the US Surveillance, Epidemiology, and End Results program database. Linear regression analyses of age-specific incidences of female breast cancer and logistic regression analyses of age-specific pathological characteristics of breast cancer were performed. All statistical tests were two-sided.

RESULTS

Unlike female colorectal cancer, the age-specific incidences of breast cancer among East Asian women aged 59 years and younger increased disproportionally over recent decades relative to rates in US contemporaries. For years 2010-2014, the estimated age-specific probability of estrogen receptor positivity increased with age in American patients, whereas that of triple-negative breast cancer (TNBC) declined with age. No similar trends were evident in East Asian patients; their probability of estrogen receptor positivity at age 40-49 years was statistically significantly higher (odd ratio [OR] = 1.50, 95% confidence interval [CI] = 1.36 to 1.67, P < .001) and of TNBC was statistically significantly lower (OR = 0.79, 95% CI = 0.71 to 0.88, P < .001), whereas the probability of ER positivity at age 50-59 years was statistically significantly lower (OR = 0.88, 95% CI = 0.828 to 0.95, P < .001). Subgroup analyses of US Surveillance, Epidemiology, and End Results data showed similarly distinct patterns between East Asian American and white American patients.

CONCLUSIONS

Contrasting age-specific incidences and pathological characteristics of breast cancer between East Asian and American women, as well as between East Asian Americans and white Americans, suggests racial differences in the biology.

Phase III, randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of adagloxad simolenin (OBI-822) and OBI-821 treatment in patients with early-stage triple-negative breast cancer (TNBC) at high risk for recurrence

TPS599

Background: Adagloxad simolenin (AS) is a therapeutic vaccine comprising the tumor-associated antigen Globo H linked to the carrier protein keyhole limpet hemocyanin (KLH). The KLH provides antigenic immune recognition and T-cell responses. AS is co-administered with a saponin-based adjuvant OBI-821 to induce a humoral response. A phase 2 trial showed that AS/OBI-821 exhibited a trend for superior progression-free survival vs placebo in patients whose breast cancers have higher Globo H expression. Methods: Patients with TNBC (ER/PR < 5%, and HER2-negative) with nonmetastatic disease and either 1) residual invasive disease of ≥1 cm in the breast or ≥1 positive axillary node following neoadjuvant chemotherapy or 2) ≥4 axillary lymph nodes with invasive carcinoma treated with adjuvant chemotherapy are included. Patients are prescreened for Globo H expression using a validated IHC assay (H-score of ≥15). Patients will receive either AS (30 μg) with OBI-821 (100 μg) or volume-matched placebo (1:1), administered as SC injections. Up to 21 SC injections of study treatment (or placebo), will be administered over 100 weeks, given on the following schedule: weekly for 4 doses; every 2 weeks for 4 doses; every 4 weeks for 4 doses; and then every 8 weeks for 9 doses. Patients may terminate treatment due to disease recurrence or unacceptable toxicity, withdrawal of consent, protocol violation, loss to follow-up or death. The primary objective is to determine the effect of AS/OBI-821 treatment on invasive disease-free survival in patients with TNBC at high risk for recurrence. Secondary objectives are to determine the impact of AS/OBI-821 treatment on overall survival, quality of life (QoL), breast cancer-free interval, distant disease-free survival, safety, and tolerability. Imaging and clinical examination will be performed regularly for 5 years. QoL will be assessed using the EORTC Core Quality of Life Questionnaire (QLQ)-C30 plus the EORTC Breast Cancer-specific QLQ-BR23 questionnaire and the European Quality of Life 5 Dimensions 5 Levels (EQ-5D-5L) questionnaire. Adverse events will be graded/recorded as per National Cancer Institute CTCAE v5.0. An estimated 668 subjects will be enrolled, treated for up to 2 years and followed until occurrence of 187 events (invasive disease recurrence or death) or 3 years from last subject randomized. Survival follow-up is for 5 years from randomization of last subject. Clinical trial information: NTC03562637 .

Patient-reported outcomes from KATHERINE: A phase 3 study of adjuvant trastuzumab emtansine versus trastuzumab in patients with residual invasive disease after neoadjuvant therapy for human epidermal growth factor receptor 2-positive breast cancer

Background

The phase 3 KATHERINE trial demonstrated significantly improved invasive disease–free survival with adjuvant trastuzumab emtansine (T‐DM1) versus trastuzumab in patients with HER2‐positive early breast cancer and residual invasive disease after neoadjuvant chemotherapy plus HER2‐targeted therapy.

Methods

Patients who received taxane‐ and trastuzumab‐containing neoadjuvant therapy (with/without anthracyclines) and had residual invasive disease (breast and/or axillary nodes) at surgery were randomly assigned to 14 cycles of adjuvant T‐DM1 (3.6 mg/kg intravenously every 3 weeks) or trastuzumab (6 mg/kg intravenously every 3 weeks). The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire–Core 30 (QLQ‐C30) and breast cancer module (QLQ‐BR23) were completed at screening, at day 1 of cycles 5 and 11, within 30 days after study drug completion, and at 6‐ and 12‐month follow‐up visits.

Results

Of patients who were randomly assigned to T‐DM1 (n = 743) and trastuzumab (n = 743), 612 (82%) and 640 (86%), respectively, had valid baseline and ≥1 postbaseline assessments. No clinically meaningful changes (≥10 points) from baseline in mean QLQ‐C30 and QLQ‐BR23 scores occurred in either arm. More patients receiving T‐DM1 reported clinically meaningful deterioration at any assessment point in role functioning (49% vs 41%), appetite loss (38% vs 28%), constipation (47% vs 38%), fatigue (66% vs 60%), nausea/vomiting (39% vs 30%), and systemic therapy side effects (49% vs 36%). These differences were no longer apparent at the 6‐month follow‐up assessment, except for role functioning (23% vs 16%).

Conclusion

These data suggest that health‐related quality of life was generally maintained in both study arms over the course of treatment.

Patient‐reported outcomes are reported from the randomized, phase 3 KATHERINE trial, which demonstrated significantly improved invasive disease–free survival with adjuvant T‐DM1 compared with trastuzumab in patients who had residual invasive disease following neoadjuvant chemotherapy plus HER2‐targeted therapy. Patients who are treated with T‐DM1 have a greater incidence of any grade and grade ≥3 adverse events compared with trastuzumab‐treated patients; however, these adverse events appear to have a minimal impact on patient‐reported quality of life.

A preliminary report of head-to-head comparison of 18-gene-based clinical-genomic model and oncotype DX 21-gene assay for predicting recurrence of early-stage breast cancer

Background

The information of Oncotype DX applied in Asian breast cancer patients is limited. A recurrence index for distant recurrence (RI-DR) has been developed for early-stage breast cancer (EBC) from tumor samples in Chinese patients. In this study, we compared the prognostic performance of the Oncotype DX (ODx) recurrence score (RS) with the RI-DR for any recurrence risk type.

Materials and methods

One hundred thirty-eight (138) patients with hormone receptor-positive and human epidermal growth factor receptor 2-negative EBC who were previously tested with ODx were included for testing with the RI-DR. The cutoff score to partition the low- and high-risk patients was 26 for RS and 36 for RI-DR. The primary endpoint was recurrence-free survival (RFS).

Results

The concordance between the RI-DR and RS was 83% in N0 patients and 81% in node-positive patients when the RS score cutoff was set at 26. With a median follow-up interval of 36.8 months, the 4-year RFS for the high- and low-risk groups categorized by the RS were 61.9% and 95.0%, respectively (hazard ratio: 10.6, 95.0% confidence interval [CI]: 1.8–62.9). The 4-year RFS in the high- and low-risk groups categorized by the RI-DR were 72.6% and 98.5%, respectively (hazard ratio: 18.9, 95% CI: 1.8–138.8).

Conclusion

This paper illustrated the performance of RI-DR and ODx RS in breast cancer women in Taiwan. There was high concordance between the RI-DR and RS. The RI-DR is not inferior to the RS in predicting RFS in EBC patients. This study will fill the gap between the current and best practice in Chinese patients.

Using next-generation sequencing to redefine BRCAness in triple-negative breast cancer

BRCAness is considered a predictive biomarker to platinum and poly(ADP‐ribose) polymerase (PARP) inhibitors. However, recent trials showed that its predictive value was limited in triple‐negative breast cancer (TNBC) treated with platinum. Moreover, tumors with mutations of DNA damage response (DDR) genes, such as homologous recombination (HR) genes, could be sensitive to platinum and PARP inhibitors. Thus, we aim to explore the relationship between mutation status of DDR genes and BRCAness in TNBC. We sequenced 56 DDR genes in 120 TNBC and identified BRCAness by array comparative genomic hybridization. The sequencing results showed that 13, 14, and 14 patients had BRCA, non‐BRCA HR, and non‐HR DDR gene mutations, respectively. Array comparative genomic hybridization revealed that BRCA‐mutated and HR gene‐mutated TNBC shared similar BRCAness features, both having higher numbers and longer length of large‐scale structural aberration (LSA, >10 Mb) and similar altered chromosomal regions of LSA. These suggested non‐BRCA HR gene‐mutated TNBC shared similar characteristics with BRCA‐mutated TNBC, indicating non‐BRCA HR gene‐mutated TNBC sensitive to platinum and PARP inhibitors. Among tumors with mutation of non‐HR DDR genes, 3 PTEN and 1 MSH6 mutation also contained significant LSAs (BRCAness); however, they had different regions of genomic alteration to BRCA and HR gene‐mutated tumors, might explain prior findings that PTEN‐ and MSH6‐mutated cancer cells not sensitive to PARP inhibitors. Therefore, we hypothesize that the heterogeneous genomic background of BRCAness indicates different responsiveness to platinum and PARP inhibitors. Direct sequencing DDR genes in TNBC should be applied to predict their sensitivity toward platinum and PARP inhibitors.

Abstract P5-06-30: Identification of novel single nucleotide polymorphisms located in MAP3K1 and ABCB1 genes as markers for poor overall survival in early-stage hormone receptor-positive breast cancer using next-generation sequencing

Background: We previously revealed that single nucleotide polymorphisms (SNPs) of CYP19A1, MAP3K1 rs889312, and ABCB1 rs2032582 were associated with overall survival (OS) in early-stage hormone receptor (HR)-positive breast cancer patients. Previous studies also showed that FGFR2 rs1219468 and TOX3 rs8051542 influenced OS in early-stage breast cancer patients. In this study, we assessed whether undiscovered SNPs of CYP19A1, MAP3K1, ABCB1, FGFR2, and TOX3 are associated with clinical outcome of patients with early-stage HR-positive breast cancer.

Patients and Methods: We used next-generation sequencing (NGS) methods to explore unidentified SNPs of CYP19A1, MAP3K1, ABCB1, FGFR2, and TOX3 in 80 patients who had HR+, T1 to T2, and N0 to N1 breast cancer and had matched clinicopathological features and clinical outcomes (experimental cohort). The mapping selected SNPs identified from NGS were located in different chromosomes, such as chromosome 5 (MAP3K), 7 (ABCB1), 10 (FGFR2), 15 (CYP19A1), and 16 (TOX3), were analyzed. The multivariate-adjusted hazard ratio (aHR) of OS associated with the individual genotypes of the experimental cohort was assessed after adjusting for age, tumor size, tumor grade, HER2 status, menopausal status, and chemotherapy using Cox regression analyses. We further correlated identified significant novel SNPs with disease-free survival (DFS) and OS in 195 patients with HR-positive, T1-T2, and N0-1 breast cancer (validation cohort) using stepwise selection multiple Cox model analyses.

Results: Through target region re-sequencing, we identified 69 novel SNPs, including 18 CYP19A1 SNPs, 16 MAP3K SNPs, 18 ABCB1 SNPs, 12 FGFR2 SNPs, and 5 TOX3 SNPs in the experimental cohort (n = 80). After multivariate-adjusted analyzing, FGFR2 rs2981460(C/C) (p = 0.0115), and MAP3K1 rs3822625 (A/A) (p = 0.0475), rs702689

(G/G) (p = 0.0312), rs832567 (C/C) (p = 0.0312), and rs9687226 (C/C) (p = 0.0475), and ABCB1 rs2032582 (T/T+T/C) (p = 0.0061) were significantly associated with the poorer OS of the experimental cohort. In a validated cohort (n =195) (Table 1), we found that MAP3K1 rs702689 (G/G) was significantly associated with poorer DFS (aHR = 2.3; 95% confidence interval [CI] = 1.1 to 5.1; p = 0.03) and OS (aHR = 4.9; 95% CI = 1.3 to 18.7; p = 0.02). In addition, MAP3K1 rs832567 (C/C) was significantly associated with poorer DFS (aHR = 2.5; 95% CI = 1.1 to 5.5; p = 0.02) and OS (aHR = 5.4; 95% CI = 1.4 to 21.6; p = 0.02). In premenopausal women of validation cohort (n = 108), ABCB1 rs2032582 (T/T+T/C) was significantly associated with a poor OS (aHR = 62.3; 95% CI = 2.0 to 1911.7; p = 0.02).

Conclusions: Our results indicate that 3 novel SNPs, MAP3K1 rs702689, MAP3K1 rs832567, and ABCB1 rs2032582, may affect the prognosis of early-stage HR-positive breast cancer. Further validation of these SNPs in a large series of patients with early-stage HR-positive breast cancer who received adjuvant endocrine therapy alone is warranted.

Table 1. The Associations of Hormone Receptor-Positive Breast Cancer Patients with Various Genotypes in multiple Cox model (validation cohort)Disease-free survivalOverall survivalGenotypeaHR (95%CI)PaHR (95%CI)PTotal (n = 195)FGFR2_ rs2981460 (C/C vs.C/T+T/T)0.4 (0.1-1.8)0.220.6 (0.1-5.4)0.68MAP3K1_ rs3822625 (A/A vs. G/A+GG)2.0 (0.7-5.3)0.192.7 (0.6-12.9)0.20MAP3K1_ rs702689 (G/G vs. A/A+A/G)2.3 (1.1-5.1)0.034.9 (1.3-18.7)0.02MAP3K1_rs832567 (C/C vs. A/A+A/C)2.5 (1.1-5.5)0.025.4 (1.4-21.6)0.02MAP3K1_rs9687226 (C/C vs. T/T+T/C)2.0 (0.7-5.3)0.192.7 (0.6-12.9)0.20Premenopausal (n=108)ABCB1_rs2032582 (T/T+T/C vs. C/C)2.0 (0.8-5.0)0.1562.3 (2.0-1911.7)0.02aHR: adjusted by age, estrogen receptor and progesterone receptor status, number of lymph nodes, menopausal status, adjuvant chemotherapy, lymphovascular invasion, and tumor size.

Citation Format: Sung-Hsin Kuo, Shi-Yi Yang, Po-Han Lin, Chen-Hsin Chen, Hsin-Chou Yang, Chih-Yuan Hsu, Chiun-Sheng Huang. Identification of novel single nucleotide polymorphisms located in MAP3K1 and ABCB1 genes as markers for poor overall survival in early-stage hormone receptor-positive breast cancer using next-generation sequencing [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-06-30.

Abstract P3-14-01: Adjuvant trastuzumab emtansine (T-DM1) vs trastuzumab (H) in patients with residual invasive disease after neoadjuvant therapy for HER2-positive breast cancer: KATHERINE subgroup analysis

Background: Patients with HER2-positive early breast cancer with residual invasive disease after neoadjuvant chemotherapy (NACT) + HER2-targeted therapy have a higher risk of recurrence and death than those with pathologic complete response. In the phase III KATHERINE study, adjuvant T-DM1 reduced the risk of recurrence or death by 50% vs H in this population. Data from KATHERINE subgroups are reported here, including patients treated with non-anthracycline (AC) vs AC based NACT, patients with small tumors (cT1cN0) who typically do not receive neoadjuvant treatment, and patients with particularly higher-risk tumors defined by nodal involvement and hormone-receptor status. Methods: Eligible patients had HER2-positive early breast cancer, received taxane- and H-containing neoadjuvant therapy ± AC followed by surgery, and had residual invasive disease in the breast and/or axillary nodes. Patients received 14 cycles of adjuvant T-DM1 (3.6 mg/kg IV q3w) or H (6 mg/kg IV q3w) and endocrine and/or radiation therapy per local standards. The primary endpoint was invasive disease-free survival (IDFS), defined as time from randomization to the first occurrence of ipsilateral locoregional or contralateral invasive breast cancer recurrence, distant recurrence, or death from any cause. In this exploratory analysis, efficacy subpopulations were derived from the intent-to-treat population and safety data were reported for patients who received ≥1 dose of study treatment. Results: In the non-AC v AC based NACT analysis (N=1486), some patient characteristics were imbalanced. For non-AC/AC based NACT, respectively, these included: region (North America; 60.6% v 11.0%), race (Asian; 12.8% v 7.4%), ECOG PS 1 (28.0% v 15.7%); neoadjuvant HER2-based therapy (H + pertuzumab; 46.6% v 9.8%), and neoadjuvant carboplatin/cisplatin (78.7 v 2.3%). Benefit was observed with T-DM1 regardless of neoadjuvant AC use (Table). The all-grade incidence of selected AEs with T-DM1 including hepatotoxicity, peripheral neuropathy, hemorrhage, IRR/hypersensitivity, and cardiac dysfunction was similar between non-AC and AC NACT groups. There was a small increase in the non-AC group in all-grade thrombocytopenia (32.5% v 27.4%) and pulmonary toxicity (6.7% vs 1.7%). There was an increased incidence of grade ≥3 AEs (39.9% vs 21.7%) in the non-AC vs the AC group with T-DM1 which was likely driven by an increase in thrombocytopenia (10.4% v 4.3%) and peripheral sensory neuropathy (4.3% vs 0.5%). However, the percentage of patients with AEs leading to T-DM1 withdrawal in the non-AC vs AC groups (19.6% v 17.5%) was similar, as was the percentage with AEs leading to T-DM1 dose reduction (14.1% v 11.6%). In patients with cT1N0 tumors (n=77), baseline characteristics were well-balanced for H v T-DM1. There were only 6 IDFS events in this subgroup overall; none were observed with T-DM1 (Table). In the analysis of particularly higher-risk tumors, all subgroups showed a benefit with T-DM1; the number of patients was small in some subgroups (Table). Conclusions: T-DM1 provides clinical benefit regardless of prior non-AC vs AC based NACT, and in subgroups with small or particularly higher-risk tumors. There was an increased incidence of grade ≥3 AEs with T-DM1 in the non-AC vs the AC group but these did not result in increased treatment discontinuation and were likely driven by the imbalance in prior therapy.

Table 1. Risk of IDFS event in patients treated with non-AC versus AC based NACT, patients with small tumors, and patients with particularly higher-risk tumors.Unstratified hazard ratio of IDFS (95% confidence interval [CI])Patients treated with non-AC vs AC based NACT (N=1,486)Non-AC-based NACT: H (n=179) vs T-DM1 (n=164)0.43 (0.22–0.82)AC-based NACT: H (n=564) vs T-DM1 (n=579)0.51 (0.38–0.67)Patients with small (cT1cN0) tumors (N=77)H (n=32) vs T-DM1 (n=45)6 events with H; 0 events with T-DM1(hazard ratio not applicable due to zero events in T-DM1 arm)Tumor subgroups defined by nodal and HR status (N=957)Inoperable; any HR or ypN statusH (n=190)T-DM1 (n=185)3-year IDFS event-free rate, % (95% CI)60.2 (52.7–67.8)76.0 (70.0–82.4)Unstratified hazard ratio (95% CI)0.54 (0.37–0.80)Operable; ypN positive and HR negativeH (n=52)T-DM1 (n=58)3-year IDFS event-free rate, % (95% CI)69.5 (56.1–82.9)76.0 (64.5–87.5)Unstratified hazard ratio (95% CI)0.72 (0.35–1.50)Operable; ypN positive and HR positiveH (n=167)T-DM1 (n=168)3-year IDFS event-free rate, % (95% CI)77.2 (70.2–84.1)91.4 (86.6–96.2)Unstratified hazard ratio (95% CI)0.43 (0.25–0.75)Operable; ypN0 and HR negativeH (n=68)T-DM1 (n=69)3-year IDFS event-free rate, % (95% CI)77.2 (66.5–87.9)91.1 (84.3–97.9)Unstratified hazard ratio (95% CI)0.43 (0.17–1.06)

Citation Format: Max S Mano, Sibylle Loibl, Eleftherios P. Mamounas, Gunter von Minckwitz, Chiun-Sheng Huang, Michael Untch, Norman Wolmark, Irene L. Wapnir, Youngsen Yang, Alison K. Conlin, Sherko Kümmel, Mahasti Saghatchian, Michael P. DiGiovanna, Claudia Strunk, Martina Zimovjanova, Chunyan Song, Haying Liu, David Tesarowski, Steven Blotner, Lisa H. Lam, Melanie Smitt, Charles E. Geyer Jr. Adjuvant trastuzumab emtansine (T-DM1) vs trastuzumab (H) in patients with residual invasive disease after neoadjuvant therapy for HER2-positive breast cancer: KATHERINE subgroup analysis [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-14-01.

Potent Cell-Cycle Inhibition and Upregulation of Immune Response with Abemaciclib and Anastrozole in neoMONARCH, Phase II Neoadjuvant Study in HR+/HER2- Breast Cancer

PURPOSE

neoMONARCH assessed the biological effects of abemaciclib in combination with anastrozole in the neoadjuvant setting.

PATIENTS AND METHODS

Postmenopausal women with stage I-IIIB HR⁺/HER2^- breast cancer were randomized to a 2-week lead-in of abemaciclib, anastrozole, or abemaciclib plus anastrozole followed by 14 weeks of the combination. The primary objective evaluated change in Ki67 from baseline to 2 weeks of treatment. Additional objectives included clinical, radiologic, and pathologic responses, safety, as well as gene expression changes related to cell proliferation and immune response.

RESULTS

Abemaciclib, alone or in combination with anastrozole, achieved a significant decrease in Ki67 expression and led to potent cell-cycle arrest after 2 weeks of treatment compared with anastrozole alone. More patients in the abemaciclib-containing arms versus anastrozole alone achieved complete cell-cycle arrest (58%/68% vs. 14%, P < 0.001). At the end of treatment, following 2 weeks lead-in and 14 weeks of combination therapy, 46% of intent-to-treat patients achieved a radiologic response, with pathologic complete response observed in 4%. The most common all-grade adverse events were diarrhea (62%), constipation (44%), and nausea (42%). Abemaciclib, anastrozole, and the combination inhibited cell-cycle processes and estrogen signaling; however, combination therapy resulted in increased cytokine signaling and adaptive immune response indicative of enhanced antigen presentation and activated T-cell phenotypes.

CONCLUSIONS

Abemaciclib plus anastrozole demonstrated biological and clinical activity with generally manageable toxicities in patients with HR⁺/HER2^- early breast cancer. Abemaciclib led to potent cell-cycle arrest, and in combination with anastrozole, enhanced immune activation.

A network analysis to identify mediators of germline-driven differences in breast cancer prognosis

Identifying the underlying genetic drivers of the heritability of breast cancer prognosis remains elusive. We adapt a network-based approach to handle underpowered complex datasets to provide new insights into the potential function of germline variants in breast cancer prognosis. This network-based analysis studies ~7.3 million variants in 84,457 breast cancer patients in relation to breast cancer survival and confirms the results on 12,381 independent patients. Aggregating the prognostic effects of genetic variants across multiple genes, we identify four gene modules associated with survival in estrogen receptor (ER)-negative and one in ER-positive disease. The modules show biological enrichment for cancer-related processes such as G-alpha signaling, circadian clock, angiogenesis, and Rho-GTPases in apoptosis.

Neoadjuvant Trastuzumab Emtansine and Pertuzumab in Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer: Three-Year Outcomes From the Phase III KRISTINE Study

PURPOSE

The KRISTINE study compared neoadjuvant trastuzumab emtansine plus pertuzumab (T-DM1+P) with docetaxel, carboplatin, trastuzumab plus P (TCH+P) for the treatment human epidermal growth factor receptor 2–positive stage II to III breast cancer. T-DM1+P led to a lower pathologic complete response rate (44.4% v 55.7%; P = .016), but fewer grade 3 or greater and serious adverse events (AEs). Here, we present 3-year outcomes from KRISTINE.

METHODS

Patients were randomly assigned to neoadjuvant T-DM1+P or TCH+P every 3 weeks for six cycles. Patients who received T-DM1+P continued adjuvant T-DM1+P, and patients who received TCH+P received adjuvant trastuzumab plus pertuzumab. Secondary end points included event-free survival (EFS), overall survival, patient-reported outcomes (measured from random assignment), and invasive disease-free survival (IDFS; measured from surgery).

RESULTS

Of patients, 444 were randomly assigned (T-DM1+P, n = 223; TCH+P, n = 221). Median follow-up was 37 months. Risk of an EFS event was higher with TDM-1+P (hazard ratio [HR], 2.61 [95% CI, 1.36 to 4.98]) with more locoregional progression events before surgery (15 [6.7%] v 0). Risk of an IDFS event after surgery was similar between arms (HR, 1.11 [95% CI, 0.52 to 2.40]). Pathologic complete response was associated with a reduced risk of an IDFS event (HR, 0.24 [95% CI, 0.09 to 0.60]) regardless of treatment arm. Overall, grade 3 or greater AEs (31.8% v 67.7%) were less common with T-DM1+P. During adjuvant treatment, grade 3 or greater AEs (24.5% v 9.9%) and AEs leading to treatment discontinuation (18.4% v 3.8%) were more common with T-DM1+P. Patient-reported outcomes favored T-DM1+P during neoadjuvant treatment and were similar to trastuzumab plus pertuzumab during adjuvant treatment.

CONCLUSION

Compared with TCH+P, T-DM1+P resulted in a higher risk of an EFS event owing to locoregional progression events before surgery, a similar risk of an IDFS event, fewer grade 3 or greater AEs during neoadjuvant treatment, and more AEs leading to treatment discontinuation during adjuvant treatment.