Final results of the TANIA randomised phase III trial of bevacizumab after progression on first-line bevacizumab therapy for HER2-negative locally recurrent/metastatic breast cancer

BACKGROUND

The randomised phase III TANIA trial demonstrated that continuing bevacizumab with second-line chemotherapy for locally recurrent/metastatic breast cancer (LR/mBC) after progression on first-line bevacizumab-containing therapy significantly improved progression-free survival (PFS) compared with chemotherapy alone [hazard ratio (HR) = 0.75, 95% confidence interval (CI) 0.61-0.93]. We report final results from the TANIA trial, including overall survival (OS) and health-related quality of life (HRQoL).

PATIENTS AND METHODS

Patients with HER2-negative LR/mBC that had progressed on or after first-line bevacizumab plus chemotherapy were randomised to receive standard second-line chemotherapy either alone or with bevacizumab. At second progression, patients initially randomised to bevacizumab continued bevacizumab with their third-line chemotherapy, but those randomised to chemotherapy alone were not allowed to cross over to receive third-line bevacizumab. The primary end point was second-line PFS; secondary end points included third-line PFS, combined second- and third-line PFS, OS, HRQoL and safety.

RESULTS

Of the 494 patients randomised, 483 received second-line therapy; 234 patients (47% of the randomised population) continued to third-line study treatment. The median duration of follow-up at the final analysis was 32.1 months in the chemotherapy-alone arm and 30.9 months in the bevacizumab plus chemotherapy arm. There was no statistically significant difference between treatment arms in third-line PFS (HR = 0.79, 95% CI 0.59-1.06), combined second- and third-line PFS (HR = 0.85, 95% CI 0.68-1.05) or OS (HR = 0.96, 95% CI 0.76-1.21). Third-line safety results showed increased incidences of proteinuria and hypertension with bevacizumab, consistent with safety results for the second-line treatment phase. No differences in HRQoL were detected.

CONCLUSIONS

In this trial, continuing bevacizumab beyond first and second progression of LR/mBC improved second-line PFS, but no improvement in longer term efficacy was observed. The second-line PFS benefit appears to be achieved without detrimentally affecting quality of life.

CLINICALTRIALSGOV

NCT01250379.

Do platinum salts fit all triple negative breast cancers?

Triple-negative breast cancer (TNBC) is an aggressive disease with limited treatment options and poor prognosis once metastatic. Pre-clinical and clinical data suggest that TNBC could be more sensitive to platinum-based chemotherapy, especially among BRCA1/2-mutated patients. In recent years, several randomised trials have been conducted to evaluate platinum efficacy in both early-stage and advanced TNBC, with conflicting results especially for long-term outcomes. Experimental studies are now focusing on identifying biomarkers of response to help selecting patients who may benefit most from platinum-based therapies, including BRCA1/2 mutational status and genomic instability signatures (such as HRD-LOH or HRD-LST scores). A standard therapy for TNBC is still missing and platinum-based regimens represent an emerging therapeutic option for selected patients with a defect in the homologous recombination repair system. The identification of these patients through validated biomarker assays will be crucial to optimize the use of currently approved agents in TNBC.

Long-acting insulin analog detemir displays reduced effects on adipocyte differentiation of human subcutaneous and visceral adipose stem cells

BACKGROUND AND AIMS

Since treatment with insulin detemir results in a lower weight gain compared to human insulin, we investigated whether detemir is associated with lower ability to promote adipogenesis and/or lipogenesis in human adipose stem cells (ASC).

METHODS AND RESULTS

Human ASC isolated from both the subcutaneous and visceral adipose tissues were differentiated for 30 days in the presence of human insulin or insulin detemir. Nile Red and Oil-Red-O staining were used to quantify the rate of ASC conversion to adipocytes and lipid accumulation, respectively. mRNA expression levels of early genes, including Fos and Cebpb, as well as of lipogenic and adipogenic genes, were measured at various phases of differentiation by qRT-PCR. Activation of insulin signaling was assessed by immunoblotting. ASC isolated from subcutaneous and visceral adipose tissue were less differentiated when exposed to insulin detemir compared to human insulin, showing lower rates of adipocyte conversion, reduced triglyceride accumulation, and impaired expression of late-phase adipocyte marker genes, such as Pparg2, Slc2a4, Adipoq, and Cidec. However, no differences in activation of insulin receptor, Akt and Erk and induction of the early genes Fos and Cebpb were observed between insulin detemir and human insulin.

CONCLUSION

Insulin detemir displays reduced induction of the Pparg2 adipocyte master gene and diminished effects on adipocyte differentiation and lipogenesis in human subcutaneous and visceral ASC, in spite of normal activation of proximal insulin signaling reactions. These characteristics of insulin detemir may be of potential relevance to its weight-sparing effects observed in the clinical setting.

Abstract P6-14-01: Final results of the TANIA randomized phase III trial of bevacizumab (BEV) after progression on 1st-line BEV therapy for HER2-negative locally recurrent/metastatic breast cancer (LR/mBC)

BACKGROUND: The open-label randomized phase III TANIA trial (NCT01250379) evaluated 2nd-line BEV-containing therapy in BEV-pretreated LR/mBC. The primary objective was met: 2nd-line PFS was statistically significantly improved in patients (pts) receiving further BEV (hazard ratio [HR] 0.75, 95% CI 0.61–0.93; p=0.0068) [von Minckwitz, Lancet Oncol 2014]. We report final efficacy, safety, and health-related quality of life (HRQoL) results.

METHODS: Eligible pts had HER2-negative LR/mBC that had progressed on/after 1st-line BEV plus chemotherapy (CT). Pts were randomized to receive 2nd-line CT (investigator's choice) either alone or combined with BEV (15 mg/kg q3w or 10 mg/kg q2w) until disease progression (PD), unacceptable toxicity, or consent withdrawal. At 2nd PD, pts in the CT arm received 3rd-line CT without BEV (no crossover); pts initially randomized to BEV–CT received 3rd-line BEV–CT. Secondary endpoints included 3rd-line PFS, 2nd- and 3rd-line PFS (from randomization to 3rd PD/death), overall survival (OS), HRQoL, and safety. HRQoL was assessed using FACT-B at baseline, every 8/9 weeks (depending on treatment schedule) during 2nd-line therapy, and at the time of 2nd PD. Prespecified HRQoL analyses included differences between treatment arms in mean change from baseline for each FACT-B subscale.

RESULTS: At the time of data cut-off for the prespecified final analysis (April 30, 2015, 24 months after the last pt was randomized), median follow-up was 32.1 vs 30.9 months in the CT vs BEV–CT arms, respectively. All pts had stopped study treatment. Of the 494 pts randomized to 2nd-line therapy, 234 began 3rd-line therapy (105 initially randomized to CT; 129 from the BEV–CT arm, of whom 17 received CT without BEV). The most commonly selected 3rd-line CT was vinorelbine (33% of CT pts vs 31% of BEV–CT pts).

EndpointNo. of events/pts (%)Median, months (95% CI)Stratified HR (95% CI)p-value CTBEV–CTCTBEV–CT  3rd-line PFS99/105 (94)124/129 (96)2.9 (2.2-3.9)3.8 (2.4-5.1)0.79 (0.59-1.06)0.10802nd- and 3rd-line PFS177/247 (72)206/247 (83)10.7 (9.2-12.5)12.8 (10.7-14.5)0.85 (0.68-1.05)0.1349OS156/247 (63)163/247 (66)18.7 (15.4-21.2)19.7 (17.6-21.0)0.96 (0.76-1.21)0.7253

Subgroup analyses of 3rd-line PFS and OS according to stratification factors were consistent with the overall ITT result. Before study closure, 68% and 61% of pts in the 3rd-line ITT population CT and BEV–CT arms, respectively, received further CT. 3rd-line safety results showed no new safety signals. At week 8/9, mean change from baseline for all FACT-B subscales was <1.5 points in either direction in both treatment arms, representing no significant difference. Similarly, exploratory HRQoL analyses of the physical and functional wellbeing subscales using mixed-model repeated measures and responder analyses revealed no meaningful significant differences between treatment arms.

CONCLUSIONS: Although BEV given after PD on 1st-line BEV-containing therapy showed improvement in 2nd-line PFS, no OS benefit was demonstrated. No new safety signals were observed. There were no differences in HRQoL between treatment arms, suggesting that the PFS benefit with BEV is achieved with maintained HRQoL.

Citation Format: Vrdoljak E, Marschner N, Zielinski C, Gligorov J, Cortes J, Puglisi F, Aapro M, Fallowfield L, Fontana A, Inbar M, Kahan Z, Welt A, Lévy C, Brain E, Pivot X, Putzu C, Gonzalez-Martin A, Ebel K, Easton V, von Minckwitz G. Final results of the TANIA randomized phase III trial of bevacizumab (BEV) after progression on 1st-line BEV therapy for HER2-negative locally recurrent/metastatic breast cancer (LR/mBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-14-01.

Abstract P3-07-55: Predictive value of O6-methylguanine-DNA methyltransferase (MGMT) promoter gene methylation in triple-negative breast cancer patients receiving carboplatin

Background: The epigenetic profile of triple-negative breast cancer (TNBC) showed a wide prevalence of MGMT promoter methylation.Aberrant methylation of MGMT seems to be an independent predictor of poor survival in patients with basal-like breast cancer. Moreover, patients with MGMT-negative basal-like tumors who received cyclophosphamide had asignificantly improved DFS and OS compared with MGMT-positive tumors.However, the impact of MGMT methylation in the context of modern therapy concepts is not clear.

Methods: We retrospectively evaluated 174 TNBC tumors of patients enrolled into the neoadjuvantGeparSixtotrial from 08/2011 to 12/2012. Patients were randomized to receive 18 weeks of neoadjuvant treatment with paclitaxel (80mg/m2/week) and non-pegylated liposomal doxorubicin (20mg/m2/week) with or without addition of carboplatin (AUC 2.0-1.5/week).Hormone-receptor status, HER2status, and Ki67 were centrally confirmed prior to randomization. We defined pathological complete response (pCR)as ypT0/is ypN0. MGMT promoter methylation status was determined by PCR using EZ DNA Methylation Kit™ (Zymo Research); TNBCtumors were considered to be methylated if they had an average methylation ≥10%, some tumors were considered borderline due to high heterogeneity among GpC islands.We investigated the effect of MGMT methylation on pCR and its correlation with baseline characteristics.

Results: A total of210 tumors from the TNBC cohort of the GeparSixtotrial(n=315) were available with a tumor content >20%. In 174 tumors the methylation assay was performed successfully. The number of tumorswith methylated MGMT was similar in carboplatin vs. non-carboplatin treated cohorts. In the carboplatin group 19.3% (17/88) of TNBC were methylated, 65.5% (58/88)unmethylated, and 14.8% (13/88) borderline.In the non-carboplatin group 20.9% (18/86) of TNBC were methylated, 62.8% (54/86)unmethylated, and 16.3% (14/86) borderline.In the entire cohort,there was no association between MGMT methylation status and pCR (p=0.522).Non-carboplatin cohort: 33.3% (6/18) of patients with methylated MGMT achieved pCR vs. 51.9% (28/54) of unmethylatedand 21.4% (3/14) of borderline (p=0.079).Carboplatin cohort: 52.9% (9/17) of patients with methylated MGMT achieved pCR vs. 55.2% (32/58) of unmethylatedand 76.9% (10/13) of borderline (p=0.320). In TNBC patients with methylated MGMT, the addition of carboplatin resulted in a 20% increased pCR rate (p=0.241).

Conclusion: In this study no statistically significant association between MGMT methylation andpCR was found.Patients with MGMT methylation seemed to have a lower possibility to achieve a pCR and the addition of carboplatin seemed to reverse this effect. However, a clear classification of the borderline MGMT samples and further studies in larger series of TNBC are warranted.

Citation Format: Fontanella C, Gehlhaar C, Denkert C, Schneeweiss A, Heppner B-I, Koch I, Blohmer J-U, Jackisch C, Lederer B, Fasching PA, Müller V, Untch M, Aprile G, Puglisi F, Nekljudova V, Heppner F, von Minckwitz G, Loibl S. Predictive value of O6-methylguanine-DNA methyltransferase (MGMT) promoter gene methylation in triple-negative breast cancer patients receiving carboplatin. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-55.

Abstract P2-08-06: Usefulness of the pre-treatment neutrophil-to-lymphocyte ratio in predicting first-line progression free-survival in triple-negative breast cancer patients

Background: The neutrophil-to-lymphocyte ratio (NLR) is an independent predictor of poor prognosis inunselected breast cancer patients with NLR >3.3. Moreover, pre-treatment NLR has been associated with disease-free and overal survival (OS) in patients with early triple-negative breast cancer (TNBC). We aimed to determine whether the NLR is predictive of progression-free survival (PFS) in metastatic TNBC.

Methods: We reviewed the records of 48 TNBC patients who received at least one administration of first-line (1°L) chemotherapy for advanced disease from October 2004 to April 2014. The NLR (absolute neutrophil count/absolute lymphocyte count) was calculated from the full blood count routinely performed immediately before the initiation of first-line treatment. The association between categorical variables was calculated by X2 test. PFS (from start of 1°L treatment to disease progression or death) and OS (from start of 1°L treatment to death) were estimated using Kaplan Meier method. Multivariable Cox regression was used to determine the independent prognostic significances of the NLR (co-variables stage at diagnosis, histology, and tumor grade).

Results: NLR was not associated with stage at diagnosis (p=0.214), histology (p=0.597), or tumor grade (p=0.775). After a median follow-up of 10.9 months (range 1.3-54.9), 88.6% of TNBC patients with NLR≤3.3 versus 0.0% of patients with NLR>3.3 had a 1°L PFS>3 months (p<0.001). Similarly, 62.9% of TNBC patients with NLR≤3.3 versus 30.8% of patients with NLR>3.3 had an OS>10 months (p=0.047). Metastatic TNBC patients with NLR≤3.3 had a longer median 1°L PFS (5.2 months) and median OS (13.5 months) compared with patients with NLR>3.3 (1°L PFS 2.1 months, p<0.001; OS 7.7 months, p=0.018). In multivariable analysis, NLR>3.3 is associated with a shorter PFS (hazard ratio [HR] 22.4; 95% confidence interval [CI] 6.7-75.1, p<0.001) and higher risk of death (HR 3.2, 95%CI 1.4-7.4, p=0.005).

Conclusion: Our study showed that pre-treatment NLR is associated with 1°L PFS and OS in patients with metastatic TNBC. However, further investigation in larger series of metastatic TNBC is warranted.

Citation Format: Fontanella C, Fanotto V, Gerratana L, Bonotto M, Cinausero M, Bozza C, Iacono D, Russo S, Andreetta C, Minisini AM, Moroso S, Mansutti M, Fasola G, Puglisi F. Usefulness of the pre-treatment neutrophil-to-lymphocyte ratio in predicting first-line progression free-survival in triple-negative breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-08-06.

The p66Shc protein controls redox signaling and oxidation-dependent DNA damage in human liver cells

The p66Shc protein mediates oxidative stress-related injury in multiple tissues. Steatohepatitis is characterized by enhanced oxidative stress-mediated cell damage. The role of p66Shc in redox signaling was investigated in human liver cells and alcoholic steatohepatitis. HepG2 cells with overexpression of wild-type or mutant p66Shc, with Ser36 replacement by Ala, were obtained through infection with recombinant adenoviruses. Reactive oxygen species and oxidation-dependent DNA damage were assessed by measuring dihydroethidium oxidation and 8-hydroxy-2'-deoxyguanosine accumulation into DNA, respectively. mRNA and protein levels of signaling intermediates were evaluated in HepG2 cells and liver biopsies from control and alcoholic steatohepatitis subjects. Exposure to H2O2 increased reactive oxygen species and phosphorylation of p66Shc on Ser36 in HepG2 cells. Overexpression of p66Shc promoted reactive oxygen species synthesis and oxidation-dependent DNA damage, which were further enhanced by H2O2. p66Shc activation also resulted in increased Erk-1/2, Akt, and FoxO3a phosphorylation. Blocking of Erk-1/2 activation inhibited p66Shc phosphorylation on Ser36. Increased p66Shc expression was associated with reduced mRNA levels of antioxidant molecules, such as NF-E2-related factor 2 and its target genes. In contrast, overexpression of the phosphorylation defective p66Shc Ala36 mutant inhibited p66Shc signaling, enhanced antioxidant genes, and suppressed reactive oxygen species and oxidation-dependent DNA damage. Increased p66Shc protein levels and Akt phosphorylation were observed in liver biopsies from alcoholic steatohepatitis compared with control subjects. In human alcoholic steatohepatitis, increased hepatocyte p66Shc protein levels may enhance susceptibility to DNA damage by oxidative stress by promoting reactive oxygen species synthesis and repressing antioxidant pathways.