A systematic review on resource allocation in public health

Background

Research in resource allocation is a need arising from State interference by the allocative function, which seeks to promote resource adjustments with the provision of certain goods and public services (Musgrave, 1974; Musgrave & Musgrave, 1980, Longo & Troster, 1993). In this perspective, a research question arises: how has international literature on the field of Business, Management and Accounting been approaching resource allocation in public health?

Methods

Systematic Literature Review through the Scopus Database. keywords: “public health” and “resource allocation”. The types were Article and Review. Language: English, since it is internationally accepted in scientific articles, and Portuguese, in order to include Brazilian research. Search period: from 1976 to 2017. Areas: “Business, Management and Accounting”. The performed analysis technique was qualitative meta-synthesis and by using the MAXQDA Analytics Pro 18 software.

Results

The first identified study was in 2000 Sweden, pulished in Health Care Management Science. The most recente in 2017 Brazil, published in Evaluation and Program Planning. Among the countries that presented the largest production, the United States is highlighted (4). Dispersion of publication among reviews was noted. Generally, publications are grouped in four perspectives: adequate allocation, resource management and effective cost; resource allocation for treating specific diseases; resource allocation for decision-making; and health evaluation and the need of informing resource allocation. The prevailing lack of theoretical grounding must be highlighted.

Conclusions

Can be inferred that this production is recent, that it does not possess a specific focus or outline, as there is a variety of approaches, most of them being geared towards healthcare and disease control, such as cancer, diabetes, overweight, rabies, malaria and infectious diseases.

Key messages

International literature indicates that the theme is yet unexplored in the field of Business, Management e Accounting and most studies are geared towards healthcare and disease control. Allocation in the public-health policy as a function of the role of the State in providing the necessary budget for financial availability and not cost-wise, suggests lack of research.

Abstract CT165: An open label, multi-cohort, phase Ib study of xentuzumab and abemaciclib: Preliminary results from the advanced non-small cell lung cancer (NSCLC) cohort

Introduction: Insulin-like growth factor (IGF) signaling and the cyclin D-cyclin-dependent kinase (CDK) 4 & 6-retinoblastoma pathway are implicated in cancer progression and treatment resistance. Activation of the IGF receptor results in upregulation of cyclin D1 and progression through the cell cycle. Dual inhibition of IGF and CDK 4 & 6 should lead to decreased cell proliferation through disruption of cell-cycle progression. This phase Ib trial assessed safety and preliminary efficacy of xentuzumab, an IGF-ligand neutralizing antibody, in combination with abemaciclib, a CDK 4 & 6 inhibitor. In a dose-finding cohort in patients (pts) with solid tumors, the recommended phase II dose was determined as xentuzumab 1000 mg weekly intravenously plus abemaciclib 150 mg every 12 hours (Q12h) orally. Here, we present data from an expansion cohort in pts with NSCLC. Methods: Eligible pts had stage IV NSCLC with measurable disease which had progressed after platinum-based chemotherapy and immunotherapy, and had either received 1-2 prior chemotherapies for advanced/metastatic disease or were judged ineligible for further standard second-line chemotherapy. Prior CDK 4 & 6 inhibitor therapy was not permitted. Pts received xentuzumab 1000 mg weekly plus abemaciclib 150 mg Q12h until disease progression or intolerability of study medication. The primary endpoint was objective response defined as best overall response of complete response or partial response (PR) per RECIST 1.1. Secondary endpoints included progression-free survival (PFS). Results: 25 pts with NSCLC were treated (17 male [68%], median age 64 years [range 53-76]). 4 pts remained on treatment at time of analysis. Median treatment exposure was 1.6 months (range 0.5-19.7). Of 19 pts evaluable for response, 1 had a best overall response of PR (65% target lesion shrinkage), 9 had stable disease (duration ≥24 weeks in 3 pts) and 9 had progressive disease. Median PFS was 2.1 months (95% CI 1.2-5.3). All pts experienced adverse events (AEs) and 23 experienced treatment-related AEs (TRAEs), most commonly diarrhea (n=15; 60%), nausea (n=10; 40%) and platelet count decreased (n=8; 32%). The most common grade ≥3 TRAEs were thrombocytopenia (n=4; 16%) and neutropenia (n=3; 12%). No AEs of hyperglycemia or blood glucose increased were reported. Serious AEs were experienced by 13 pts (52%). 2 pts had fatal serious AEs due to disease progression and respiratory failure. Conclusion: The combination of xentuzumab and abemaciclib showed preliminary efficacy in pts with NSCLC who had progressed on chemotherapy and an immune checkpoint inhibitor. One PR was reported. The combination had a manageable safety profile.

Citation Format: Patricia LoRusso, Javier García-Corbacho, Fadi S. Braiteh, Anthony Gonçalves, Francesco Ricci, Hiroji Iwata, Marta Capelán, Marie Paule Sablin, Aleix Prat, Molly Catherine Hardebeck, Marta Puig, Dennis Chin-Lun Huang, Mingchi Hsu, Douglas Yee. An open label, multi-cohort, phase Ib study of xentuzumab and abemaciclib: Preliminary results from the advanced non-small cell lung cancer (NSCLC) cohort [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 CT165.

New Therapeutics in HER2-Positive Advanced Breast Cancer: Towards a Change in Clinical Practices?pi

Over the last few decades, improved knowledge of oncogenic activation mechanisms of HER2 protein has led to the development of HER2 targeted therapies that are currently commonly used in HER2-positive advanced breast cancer, such as trastuzumab, lapatinib, pertuzumab, and ado-trastuzumab emtansine. The management of this breast cancer subgroup has thus been revolutionized and its prognosis has changed dramatically. Nevertheless, HER2-positive advanced breast cancer remains an incurable disease and resistance to conventional anti-HER2 drugs is almost unavoidable. Nowadays, biochemical and pharmaceutical advances are meeting the challenge of developing increasingly sophisticated therapies directed against HER2, including novel anti HER2 antibodies with increased affinity. New antibody-drug conjugates (ADC) with more advanced pharmacological properties, and dual targeting of epitopes via bispecific monoclonal antibodies are also emerging. In addition, more potent and more specific HER2 tyrosine kinase inhibitors have shown interesting outcomes and are under development. Finally, researchers' interest in tumor microenvironment, particularly tumor-infiltrating lymphocytes, and the major role that signaling pathways, such as the PI3K/AKT/mTOR pathway, play in the development of resistance to anti-HER2 therapies have spurred the development of clinical trials evaluating innovative combinations of anti-HER2 with PD-1/PDL-1, CDK4/6 and PI3K inhibitors. However, several questions remain unresolved, like the optimal management of HER2-positive/HR-positive advanced breast cancer and the identification of predictive biomarkers to better define populations that can benefit most from these new therapies and approaches.

Quality of Life During Chemotherapy for Breast Cancer in a West African Population in Dakar, Senegal: A Prospective Study

PURPOSE

The prevalence of breast cancer is increasing in low- to middle-income countries such as Senegal. Our prospective study assessed the quality of life (QoL) of patients with breast cancer undergoing chemotherapy in Senegal.

PATIENTS AND METHODS

Our study included women with breast cancer undergoing chemotherapy as initial treatment at the Center Aristide Le Dantec University Hospital in Dakar. Clinical, sociodemographic, and QoL data were collected and analyzed at three different times: baseline, 3 months, and 6 months after the start of systemic therapy. Health-related QoL was assessed using a Functional Assessment of Cancer Therapies-Breast (FACT-B) questionnaire after translation into the Wolof language. Linear mixed-effects models were performed to assess the changes in QoL scores.

RESULTS

Between July 2017 and February 2018, 120 patients were included in the study. Their median age was 45 years. Most patients (n = 105; 92%) had locally advanced disease (T3 to T4 stage) and lymph node involvement (n = 103; 88%), and half had metastatic disease. The FACT-B total scores significantly improved over time (β = 1.58; 95% CI, 0.50 to 2.67; P < .01). Nausea and vomiting were significantly associated with a decrease in FACT-B total scores (β = −16.89, 95% CI, −29.58 to −4.24, P = .012; and β = −13.44, 95% CI, −25.15 to −1.72, P = .028, respectively).

CONCLUSION

Our study confirmed the feasibility of standardized QoL assessment in Senegalese patients with breast cancer. Our results indicated a potential improvement of QoL over the course of chemotherapy. Optimizing nausea and vomiting prevention may improve QoL.

PARP Inhibitors in the Treatment of Early Breast Cancer: The Step Beyond?

Exquisitely exploiting defects in homologous recombination process, poly(ADP-ribose) polymerase (PARP) inhibitors have recently emerged as a promising class of therapeutics in human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer with germline breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) mutations (gBRCA1/2m). In this setting, PARP inhibitors, either as single agent or in combination with platinum-based chemotherapy, significantly increased progression-free survival, as compared to conventional chemotherapy. Accordingly, further therapeutic advances are expected at an earlier stage of the disease. In the neoadjuvant setting, veliparib failed to increase the pathological complete response rate when added to a carboplatin-based regimen, in unselected triple-negative breast cancer patients. Similarly, when administered before anthracycline-cyclophosphamide, the neoadjuvant olaparib-paclitaxel combination was not superior to carboplatin–paclitaxel, in patients with HER2-negative breast cancer and BRCA1/2 mutation, or homologous recombination defect. Yet, neoadjuvant talazoparib, administered as a single-agent in patients with HER2-negative breast cancer and germline BRCA1/2 mutation, achieved an impressive pathological complete response rate of nearly 50%. In the adjuvant setting, the results from the OlympiA phase III study, evaluating adjuvant olaparib in HER2-negative early breast cancer and germline BRCA1/2 mutations, are eagerly awaited. Ongoing trials should clarify whether PARP inhibitors might improve outcome when administered in the adjuvant or neoadjuvant setting in early breast cancer patients with BRCA1/2 mutation or homologous recombination defect.

Impact of age at diagnosis of metastatic breast cancer on overall survival in the real-life ESME metastatic breast cancer cohort

BACKGROUND

Young age is a poor prognostic factor in early stage breast cancer (BC) but its value is less established in metastatic BC (MBC). We evaluated the impact of age at MBC diagnosis on overall survival (OS) across three age groups (<40, 40 to 60 and > 60 years(y)).

METHODS

ESME MBC database is a national cohort, collecting retrospective data from 18 participating French cancer centers between January 01, 2008 and December 31, 2014.

RESULTS

Among 14 403 women included, 1077 (7.5%), 6436 (44.7%) and 6890 (47.8%) pts were <40, 40-60 and > 60 y respectively. Pts <40 had significantly more aggressive presentations than other age groups: more frequent HER2+ (25.7 vs 15.3% in >60y) and triple negative subtypes (27.4 vs 14.6% in >60y), and more frequent visceral involvement (36.3 vs 29.8% in >60y). At a median follow-up of 48 months, median OS differed across age groups: 38.8, 38.4 and 35.6 months for pts <40, 40-60 and > 60y, respectively (p < 0.0001). Compared to pts <40y, older pts had a statistically significant higher risk of death (all causes of death included), although of limited clinical value (HR = 1.1, IC 95%:1.01-1.20). There was a significant trend for better OS in pts <40y with HER2+ and luminal diseases. A possible explanation is a greater use of anti-Her2 therapies as first-line treatments: 86.6, 81.9 and 74.9% for pts <40, 40-60 and > 60y, respectively (p < 0.0001).

CONCLUSION

Although young age seems associated with more aggressive presentations at diagnosis of MBC, it has no deleterious effect on OS in this large series.

Abstract OT2-04-01: A prospective, multicentre, open-label, randomized phase II study of PEmbroLizumab in combination with neo-adjuvant (F)EC-paclitaxel regimen in HER2-negative Inflammatory breast CANcer

Background: Inflammatory breast cancer (IBC) represents a rare but aggressive form of locally advanced BC. In spite of multimodality therapy including neoadjuvant chemotherapy (NAC), radical surgery and radiotherapy, prognosis remains poor, notably in HER2-negative subtypes. Whole-genome and gene expression profiling studies in IBC have identified an immune-enriched signature predicting for pathological complete response (pCR), suggesting a critical role for T-cell cytotoxicity in reaching complete tumor cell elimination after NAC. In addition, overexpression of programmed cell death ligand 1 (PD-L1) mRNA in IBC is more frequent than in non-IBC and has significant correlation with pCR. Pembrolizumab (PEM), an anti- programmed cell death 1 (PD 1) receptor antibody, inhibiting its interaction with PD-L1, is registered or in development across a large range of malignancies. PEM may boost anti-tumor immunity, eradicating residual tumor cells and thus improving pCR and outcome in HER2-negative IBC.

Trial design: PELICAN-IPC 2015-016 trial (NCT03515798), sponsored by Institut Paoli-Calmettes with financial support of MSD, is a multicenter, randomized phase II, non-comparative study evaluating the addition of PEM to anthracyclines/taxanes NAC in non-metastatic HER2-negative IBC. Patients will receive 4 cycles of Q3W FEC100 (5FU 500 mg/m², Epirubicin 100 mg/m², Cyclophosphamide 500 mg/m²; non-triple negative) or 4 cycles of Q2W EC (Epirubicin 90 mg/m², Cyclophosphamide 600 mg/m²; triple-negative) followed by Q1W paclitaxel 80 mg/m² x 12, with (arm B) or without (arm A) Q3W IV PEM 200 mg started with C2 FEC/EC. The primary endpoint will be pCR in the experimental arm. The study also includes a run-in safety phase. Secondary endpoints include tolerance, invasive disease-free, event-free and overall survivals in each arms and collection of pre- and post-treatment tissue and blood samples for pharmacodynamics measurements and biological correlates. Following Simon’s 2-stage optimal procedure a total of 54 patients in arm B is required to reject the null hypothesis of a truly ineffective experimental arm (H0: p&lt;= 20%) with 5% error risk and 90% power assuming a true pCR rate of 40%. 27 additional patients will be enrolled in the control arm A. Since June 2018, 7 patients have been enrolled in a single center and 13 additional centers are expected to open before the end of 2019.

Citation Format: Anthony Gonçalves. A prospective, multicentre, open-label, randomized phase II study of PEmbroLizumab in combination with neo-adjuvant (F)EC-paclitaxel regimen in HER2-negative Inflammatory breast CANcer [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 OT2-04-01.

Abstract P3-11-05: A phase Ib multi-cohort study of xentuzumab and abemaciclib in patients (pts) with solid tumors and breast cancer (BC) - Initial report of four dose-finding cohorts

Background: Insulin-like growth factor receptor-1 (IGF-1R) signaling is implicated in cancer progression, prognosis, and treatment resistance. Cross-talk between IGF-1R signaling and cyclin-dependent kinase (CDK) 4 & 6 was reported in preclinical studies, and synergy was shown with concurrent inhibition of IGF-1R signaling and CDK 4 & 6. The CDK 4 & 6 inhibitor, abemaciclib, is FDA approved for hormone receptor-positive [HR+], HER2- advanced BC (ABC) in combination with an aromatase inhibitor as initial endocrine-based therapy, with fulvestrant for progression following endocrine therapy (ET), and as monotherapy for progression following ET and prior chemotherapy in the metastatic setting. NCT03099174 is a prospective, open-label study investigating the safety and tolerability of concurrent inhibition of IGF/IGF-1R signaling with the IGF-1/2-neutralizing monoclonal antibody, xentuzumab, plus abemaciclib (provided by Eli Lilly), with or without ET. Methods: 4 dose-finding cohorts were evaluated in 2 parts using a Bayesian Logistic Regression Model with overdose control, fitted to toxicity outcomes. Part 1 (Cohort A) included pts with solid tumors who had failed/were intolerant of prior treatments, or had no other option available. The starting dose was xentuzumab 1000 mg i.v. weekly plus abemaciclib 150 mg orally (p.o.) every 12 h (Q12h). Part 1 determined the maximum tolerated dose (MTD) and/or recommended phase II dose (RP2D) prior to starting Part 2. Part 2 included postmenopausal women with HR+, HER2- BC who had received 0-2 prior lines of chemotherapy in the metastatic setting and were eligible for ET. One of 3 ETs was combined with xentuzumab plus abemaciclib (doses determined in Part 1): Cohort B, letrozole; Cohort C, anastrozole; Cohort D, fulvestrant. Previous CDK 4 & 6 inhibitor therapy was not permitted. Treatment was given until progression, lack of tolerability, or withdrawal. Primary endpoints were MTD and dose-limiting toxicities (DLTs) during the first 28-day cycle. Tumor response and progression-free survival (PFS) were also assessed. Results: 27 pts were treated (26 female [96.3%]; median age, 58 years [range 34-70]); 9 pts remained on treatment at the time of analysis. Cohorts A/B/C/D included 6/7/6/8 pts. Cohort A included pts with ABC (n=3), and lung cancer, sarcoma, and colorectal cancer (n=1 each). In total, 23 pts were evaluable for MTD. MTD was xentuzumab 1000 mg i.v. weekly plus abemaciclib 150 mg p.o. Q12h in Cohorts A, B, and D (Cohort C is ongoing). During Cycle 1, 4 DLTs were reported (Cohort A: grade 3 neutrophil count decrease, n=1; Cohort B: grade 3 neutrophil count decrease, n=1; Cohort C: grade 4 thrombocytopenia, n=1; Cohort D: grade 3 neutropenia, n=1). The most common drug-related AEs (DRAEs) in Cohort A were diarrhea and decreased appetite (66.7% each), and nausea, vomiting, and asthenia (50% each). The most common DRAEs in Cohorts B/C/D were diarrhea (90.5%), asthenia (66.7%), anemia (61.9%), neutropenia (57.1%), and nausea (52.4%). Most were reversible and grade 1/2. The most common grade 3/4 DRAEs were diarrhea (16.7/0%) in Cohort A, and neutropenia (19.0/14.3%) and diarrhea (14.3/0%) in Cohorts B/C/D. 4 pts had a best overall response of partial response (Cohorts A and B, n=1; Cohort D, n=2) and 10 pts had stable disease (Cohort A/B/C/D, n=1/3/1/5; duration currently &lt;24 weeks). Median PFS (95% CI) was 1.7 (1-7.3) months in Cohort A and 12.4 (3.5-not calculable) months in Cohorts B/C/D. Conclusions: The MTD and RP2D of xentuzumab was 1000 mg i.v. weekly plus abemaciclib 150 mg p.o. Q12h with or without ET. The safety profile of xentuzumab in combination with abemaciclib, with or without ET, was tolerable and manageable, with no new safety signals. Expansion cohorts for xentuzumab plus abemaciclib and fulvestrant in HR+ HER2- BC are ongoing.

Citation Format: Douglas Yee, Mafalda Oliveira, Hiroji Iwata, Anthony Gonçalves, Javier García-Corbacho, Marie Paule Sablin, Aleix Prat, Molly Catherine Hardebeck, Marta Puig, Dennis Chin-Lun Huang, Mingchi Hsu, Patricia LoRusso. A phase Ib multi-cohort study of xentuzumab and abemaciclib in patients (pts) with solid tumors and breast cancer (BC) - Initial report of four dose-finding cohorts [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 P3-11-05.

Abstract PD10-01: Patient-reported outcomes in patients with HER2- advanced breast cancer and a germline BRCA1/2 mutation receiving talazoparib vs physician’s choice of chemotherapy: A focus on EMBRACA ECOG performance status subgroups

Background EMBRACA was a randomized 2:1 open-label Phase 3 study (NCT01945775). As part of key subgroup analyses of EMBRACA, significant improvements in progression-free survival with talazoparib (TALA) vs physician’s choice of chemotherapy (PCT) were observed in HER2- germline BRCA1/2 mutated (gBRCA1/2mut) advanced breast cancer (ABC) in patient (pt) subgroups with an Eastern Cooperative Oncology Group (ECOG) performance status of grade 0 and grade &gt;0. These post hoc analyses evaluated pt-reported outcomes (PROs) in both ECOG subgroups. Methods PRO was assessed at baseline (Day 1), start of each treatment cycle (every 3 weeks), and end of treatment, using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and breast cancer module QLQ-BR23. Higher scores in global health status (GHS)/quality of life (QoL) and functional scales indicate better GHS/QoL and functioning, respectively; higher scores in symptom scales indicate worse symptom severity. PRO analyses, performed separately in ECOG performance status grade 0 and &gt;0 subgroups, for GHS/QoL, functional, and symptom scales include overall mean change from baseline (per longitudinal repeated measures mixed-effects model) and time to definitive clinically meaningful deterioration (TTD; per survival analysis methods). Between-arm comparisons of TTD were made using stratified log-rank test and Cox proportional hazards model. Results Baseline scores were similar between arms. A statistically significant estimated overall change from baseline in GHS/QoL favored TALA vs PCT for both ECOG performance status grade 0 (8.1 [95%CI: (3.3, 13.0)] P&lt;0.001) and grade &gt;0 (9.4 [95%CI: (2.8, 16.0)] P=0.005) subgroups. A statistically significant estimated overall change from baseline in pt-reported pain symptoms favored TALA vs PCT for both ECOG performance status grade 0 (-13.3 [95%CI: -18.9, -7.8]; P&lt;0.001) and grade &gt;0 (-16.4 [95%CI: -25.3, -7.5]; P&lt;0.001) subgroups. A statistically significant estimated overall change from baseline in pt-reported fatigue favored TALA vs PCT for both ECOG performance status grade 0 (-9.5 [95%CI: -15.4, -3.6]; P=0.002) and grade &gt;0 (-19.4 [95%CI: -28.8, -10.1]; P&lt;0.001) subgroups. A statistically significant delay in TTD favoring TALA was observed in GHS/QoL for both ECOG performance status grade 0 (median: 24.3 vs 10.3 mos, HR=0.40 [95%CI: 0.24, 0.67]; P&lt;0.001) and grade &gt;0 (median: 21.1 vs 6.0 mos, HR=0.34 [95%CI: 0.19, 0.61]; P&lt;0.001) subgroups. A statistically significant delay in TTD favoring TALA was observed in pt-reported pain symptoms for both ECOG performance status grade 0 (median: 21.5 vs 5.9 mos, HR=0.29 [95%CI: 0.17, 0.49]; P&lt;0.001) and grade &gt;0 (median: not reached vs 7.5 mos, HR=0.36 [95%CI: 0.19, 0.68]; P=0.001) subgroups. A statistically significant delay in TTD favoring TALA was observed in pt-reported fatigue for both ECOG performance status grade 0 (median: 17.1 vs 6.1 mos, HR=0.40 [95%CI: 0.25, 0.65]; P&lt;0.001) and grade &gt;0 (median: 16.9 vs 7.1 mos, HR=0.41 [95%CI: 0.24, 0.69]; P&lt;0.001) subgroups. When comparing between arms, none of the analyses in either the ECOG performance status grade 0 or &gt;0 subgroup yielded statistically significant PRO results favoring PCT. Conclusions In pts with HER2- ABC, TALA (vs PCT) resulted in significantly better change from baseline and significantly delayed TTD in GHS/QoL, pt-reported pain symptoms and fatigue in both ECOG performance status grade 0 and &gt;0 subgroups; none of the analyses significantly favored PCT. These results further support the positive risk-benefit profile of TALA vs PCT in pts with HER2- gBRCA1/2mut ABC in both ECOG performance status subgroups of grade 0 and &gt;0. Funding: Pfizer Inc.

Citation Format: Hope S Rugo, Ruben G. W. Quek, Helen Bhattacharyya, Anthony Gonçalves, Johannes Ettl, Sara A. Hurvitz. Patient-reported outcomes in patients with HER2- advanced breast cancer and a germline BRCA1/2 mutation receiving talazoparib vs physician’s choice of chemotherapy: A focus on EMBRACA ECOG performance status subgroups [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 PD10-01.

NOTCH and DNA repair pathways are more frequently targeted by genomic alterations in inflammatory than in non-inflammatory breast cancers

Inflammatory breast cancer (IBC) is the most pro‐metastatic form of breast cancer. Better understanding of its pathophysiology and identification of actionable genetic alterations (AGAs) are crucial to improve systemic treatment. We aimed to define the DNA profiles of IBC vs noninflammatory breast cancer (non‐IBC) clinical samples in terms of copy number alterations (CNAs), mutations, and AGAs. We applied targeted next‐generation sequencing (tNGS) and array‐comparative genomic hybridization (aCGH) to 57 IBC and 50 non‐IBC samples and pooled these data with four public datasets profiled using NGS and aCGH, leading to a total of 101 IBC and 2351 non‐IBC untreated primary tumors. The respective percentages of each molecular subtype [hormone receptor‐positive (HR+)/HER2−, HER2+, and triple‐negative] were 68%, 15%, and 17% in non‐IBC vs 25%, 35%, and 40% in IBC. The comparisons were adjusted for both the molecular subtypes and the American Joint Committee on Cancer (AJCC) stage. The 10 most frequently altered genes in IBCs were TP53 (63%), HER2/ERBB2 (30%), MYC (27%), PIK3CA (21%), BRCA2 (14%), CCND1 (13%), GATA3 (13%), NOTCH1 (12%), FGFR1 (11%), and ARID1A (10%). The tumor mutational burden was higher in IBC than in non‐IBC. We identified 96 genes with an alteration frequency (p < 5% and q < 20%) different between IBC and non‐IBC, independently from the molecular subtypes and AJCC stage; 95 were more frequently altered in IBC, including TP53, genes involved in the DNA repair (BRCA2) and NOTCH pathways, and one (PIK3CA) was more frequently altered in non‐IBC. Ninety‐seven percent of IBCs displayed at least one AGA. This percentage was higher than in non‐IBC (87%), notably for drugs targeting DNA repair, NOTCH signaling, and CDK4/6, whose pathways were more frequently altered (DNA repair) or activated (NOTCH and CDK4/6) in IBC than in non‐IBC. The genomic landscape of IBC is different from that of non‐IBC. Enriched AGAs in IBC may explain its aggressiveness and provide clinically relevant targets.

Talazoparib in Patients with a Germline BRCA-Mutated Advanced Breast Cancer: Detailed Safety Analyses from the Phase III EMBRACA Trial

Background

In the EMBRACA phase III study (NCT01945775), talazoparib was associated with a significantly prolonged progression‐free survival (PFS) compared with physician's choice of chemotherapy (PCT) in germline BRCA1/2‐mutated HER2‐negative advanced breast cancer (ABC). Herein, the safety profile of talazoparib is explored in detail.

Materials and Methods

Overall, 412 patients received ≥1 dose of talazoparib (n = 286) or PCT (n = 126). Adverse events (AEs) were evaluated, including timing, duration, and potential overlap of selected AEs. The relationship between talazoparib plasma exposure and grade ≥3 anemia was analyzed. Time‐varying Cox proportional hazard models assessed the impact of dose reductions on PFS. Patient‐reported outcomes (PROs) in patients with common AEs and health resource utilization (HRU) were assessed in both treatment arms.

Results

The most common AEs with talazoparib were hematologic (195 [68.2%] patients) and typically occurred within the first 3–4 months of receiving talazoparib. Grade 3‐4 anemia lasted approximately 7 days for both arms. Overlapping grade 3‐4 hematologic AEs were infrequent with talazoparib. Higher talazoparib exposure was associated with grade ≥3 anemia. Permanent discontinuation of talazoparib due to hematologic AEs was low (<2%). A total of 150 (52.4%) patients receiving talazoparib had AEs associated with dose reduction. Hematologic toxicities were managed by supportive care medication (including transfusion) and dose modifications. Among patients with anemia or nausea and/or vomiting AEs, PROs favored talazoparib. After accounting for the treatment‐emergent period, talazoparib was generally associated with a lower rate of hospitalization and supportive care medication use compared with chemotherapy.

Conclusion

Talazoparib was associated with superior efficacy, favorable PROs, and lower HRU rate versus chemotherapy in gBRCA‐mutated ABC. Toxicities were manageable with talazoparib dose modification and supportive care.

Implications for Practice

Talazoparib was generally well tolerated in patients with germline BRCA‐mutated HER2‐negative advanced breast cancer in the EMBRACA trial. Common toxicities with talazoparib were primarily hematologic and infrequently resulted in permanent drug discontinuation (<2% of patients discontinued talazoparib due to hematologic toxicity). Hematologic toxicities typically occurred during the first 3–4 months of treatment and were managed by dose modifications and supportive care measures. A significant efficacy benefit, improved patient‐reported outcomes, lower rate of health resource utilization and a tolerable safety profile support incorporating talazoparib into routine management of germline BRCA‐mutated locally advanced/metastatic breast cancer.

Talazoparib is a viable option for patients with germline BRCA‐mutated advanced breast cancer. This article presents detailed safety analyses for talazoparib, as a follow‐up to reported results from the EMBRACA trial, to highlight patterns of toxicity compared with chemotherapy and to outline guidelines for management of talazoparib toxicity in clinical practice via dose modifications and/or standard supportive care.

Paclitaxel Response Can Be Predicted With Interpretable Multi-Variate Classifiers Exploiting DNA-Methylation and miRNA Data

To address the problem of resistance to paclitaxel treatment, we have investigated to which extent is possible to predict Breast Cancer (BC) patient response to this drug. We carried out a large-scale tumor-based prediction analysis using data from the US National Cancer Institute’s Genomic Data Commons. These data sets comprise the responses of BC patients to paclitaxel along with six molecular profiles of their tumors. We assessed 10 Machine Learning (ML) algorithms on each of these profiles and evaluated the resulting 60 classifiers on the same BC patients. DNA methylation and miRNA profiles were the most informative overall. In combination with these two profiles, ML algorithms selecting the smallest subset of molecular features generated the most predictive classifiers: a complexity-optimized XGBoost classifier based on CpG island methylation extracted a subset of molecular factors relevant to predict paclitaxel response (AUC = 0.74). A CpG site methylation-based Decision Tree (DT) combining only 2 of the 22,941 considered CpG sites (AUC = 0.89) and a miRNA expression-based DT employing just 4 of the 337 analyzed mature miRNAs (AUC = 0.72) reveal the molecular types associated to paclitaxel-sensitive and resistant BC tumors. A literature review shows that features selected by these three classifiers have been individually linked to the cytotoxic-drug sensitivities and prognosis of BC patients. Our work leads to several molecular signatures, unearthed from methylome and miRNome, able to anticipate to some extent which BC tumors respond or not to paclitaxel. These results may provide insights to optimize paclitaxel-therapies in clinical practice.

Outcomes in Clinically Relevant Patient Subgroups From the EMBRACA Study: Talazoparib vs Physician's Choice Standard-of-Care Chemotherapy

Background

Talazoparib is a poly(adenosine diphosphate-ribose) polymerase inhibitor that causes death in cells with breast cancer susceptibility gene 1 or 2 (BRCA1/2) mutations.

Methods

EMBRACA (NCT01945775) was a randomized phase III study comparing efficacy, safety, and patient-reported outcomes (PROs) of talazoparib (1 mg) with physician’s choice of chemotherapy (PCT: capecitabine, eribulin, gemcitabine, vinorelbine) in locally advanced or metastatic breast cancer with a germline BRCA1/2 (gBRCA1/2) mutation. Prespecified patient subgroups were analyzed for progression-free survival, objective response, clinical benefit, duration of response, and safety. PROs were evaluated in hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2−) or triple-negative breast cancer (TNBC) subgroups.

Results

Of 431 patients, 287 were randomly assigned to talazoparib and 144 to PCT. Prespecified subgroup analyses showed prolonged progression-free survival with talazoparib (HR+/HER2−: hazard ratio = 0.47, 95% confidence interval = 0.32 to 0.71; TNBC: hazard ratio = 0.60, 95% confidence interval = 0.41 to 0.87) and greater objective response rate (odds ratio = 1.97 to 11.89), clinical benefit rate (odds ratio = 2.05 to 7.77), and duration of response with talazoparib in all subgroups. PROs in HR+/HER2− and TNBC subgroups showed consistent overall improvement and delay in time to definitive clinically meaningful deterioration with talazoparib vs PCT. Across subgroups, common adverse events included anemia, fatigue, and nausea with talazoparib and neutropenia, fatigue, and nausea with PCT. Seven patients (2.4%) receiving talazoparib had grade II alopecia and 22.7% had grade I alopecia.

Conclusions

Across all patient subgroups with gBRCA-mutated advanced breast cancer, talazoparib demonstrated clinically significant superiority in outcomes compared with PCT.

CinéBreast-factors influencing the time to first metastatic recurrence in breast cancer: Analysis of real-life data from the French ESME MBC database

Purpose

The Time to First Metastatic Recurrence (TFMR) could be considered as an indirect reflection of the tumour growth kinetics which plays an important role in cancer. Molecular subtypes such as expression of estrogen receptor are known predictive factors of TFMR. The CinéBreast study aimed to identify predictive factors of the time to TFMR.

Methods

The French Epidemiological Strategy and Medical Economics (ESME) Metastatic Breast Cancer (MBC) Database (NCT03275311) was used, which contains data from a cohort of metastatic breast cancer patients from 2008 to 2016 using retrospective data collection. It is a national multi-centre database. The impact of TFMR on overall survival (OS) since first metastasis was also evaluated.

Results

Among 16 702 patients recorded in the ESME MBC database, 10 595 had an initially localised breast cancer with hormone receptor (HR) and HER2 status available, with a metastatic recurrence. Median follow up was 56 months. Median TFMR was 59 months (<24: 20%, 24–60: 31%, 60–120: 25%, >120: 24%). HER2+ and TNBC were respectively 4 times and 12 times (p < 0.0001) more likely to have a recurrence within 2 years when compared to the luminal subgroup. Short TFMR and HR-/HER2-subtype significantly correlated with a poor OS in multivariate analysis.

Some patients with MBC (20% in HER2+, 10% in ER+/HER2-and <5% in the ER-/HER2-) were long-term survivors in all 3 subgroups.

Conclusions

In this large-scale real-life data study, patients with a TNBC metastatic recurrence had a shorter TFMR. Short TFMR significantly correlated with worse overall survival.

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ESME is a large-scale real-life database of 16 702 metastatic breast cancer patients.

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A short time to first metastatic recurrence is associated with poor overall survival.

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Triple-negative tumours were more likely to recur early than HR+ and HER2+ tumours.