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Ciruelos E, García-Sáenz JÁ, Gavilá J, Martín M, Rodríguez CA, Rodríguez-Lescure Á. Safety profile of trastuzumab deruxtecan in advanced breast cancer: Expert opinion on adverse event management. Clin Transl Oncol 2024; 26:1539-1548. [PMID: 38336982 PMCID: PMC11178646 DOI: 10.1007/s12094-024-03383-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/04/2024] [Indexed: 02/12/2024]
Abstract
Trastuzumab deruxtecan (T-DXd) is an antibody-drug conjugate that targets human epidermal growth factor receptor 2 (HER2) and has shown promising results in the treatment of advanced/metastatic breast cancer. The objective of this report is to provide guidance on the prophylaxis, monitoring, and management of adverse events (AEs) in patients with breast cancer treated with T-DXd, and to emphasize that proper management of AEs is needed to optimize the effectiveness of T-DXd treatment and reduce the number of discontinuations. The article covers various aspects of T-DXd treatment, including its clinical efficacy, safety profile, and dosing considerations, and provides practical recommendations for managing AEs, such as nausea/vomiting, interstitial lung disease, and hematologic toxicity. Although there are still many knowledge gaps about the cause and incidence of AEs in real-world patients, this document may serve as a valuable resource for clinicians who are involved in the care of breast cancer patients receiving T-DXd treatment.
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Affiliation(s)
- Eva Ciruelos
- Medical Oncology Unit, Hospital 12 de Octubre, Madrid, Spain
| | | | - Joaquín Gavilá
- Medical Oncology Unit, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Miguel Martín
- Medical Oncology Unit, Hospital Gregorio Marañón, Madrid, Spain
| | - César A Rodríguez
- Medical Oncology Unit, Hospital Universitario de Salamanca-IBSAL, Salamanca, Spain
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Vidula N, Rodriguez K, Wong AK, Boyraz B. Case 17-2024: A 45-Year-Old Woman with Metastatic Breast Cancer. N Engl J Med 2024; 390:2011-2022. [PMID: 38838315 DOI: 10.1056/nejmcpc2309499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Affiliation(s)
- Neelima Vidula
- From the Departments of Medicine (N.V., A.K.W.), Radiology (K.R.), and Pathology (B.B.), Massachusetts General Hospital, and the Departments of Medicine (N.V., A.K.W.), Radiology (K.R.), and Pathology (B.B.), Harvard Medical School - both in Boston
| | - Karen Rodriguez
- From the Departments of Medicine (N.V., A.K.W.), Radiology (K.R.), and Pathology (B.B.), Massachusetts General Hospital, and the Departments of Medicine (N.V., A.K.W.), Radiology (K.R.), and Pathology (B.B.), Harvard Medical School - both in Boston
| | - Alexandra K Wong
- From the Departments of Medicine (N.V., A.K.W.), Radiology (K.R.), and Pathology (B.B.), Massachusetts General Hospital, and the Departments of Medicine (N.V., A.K.W.), Radiology (K.R.), and Pathology (B.B.), Harvard Medical School - both in Boston
| | - Baris Boyraz
- From the Departments of Medicine (N.V., A.K.W.), Radiology (K.R.), and Pathology (B.B.), Massachusetts General Hospital, and the Departments of Medicine (N.V., A.K.W.), Radiology (K.R.), and Pathology (B.B.), Harvard Medical School - both in Boston
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3
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Li BT, Meric-Bernstam F, Bardia A, Naito Y, Siena S, Aftimos P, Anderson I, Curigliano G, de Miguel M, Kalra M, Oh DY, Park JO, Postel-Vinay S, Rha SY, Satoh T, Spanggaard I, Michelini F, Smith A, Machado KK, Saura C. Trastuzumab deruxtecan in patients with solid tumours harbouring specific activating HER2 mutations (DESTINY-PanTumor01): an international, phase 2 study. Lancet Oncol 2024; 25:707-719. [PMID: 38710187 DOI: 10.1016/s1470-2045(24)00140-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Trastuzumab deruxtecan is a HER2-directed antibody-drug conjugate approved by the US Food and Drug Administration and the European Medicines Agency for HER2-mutant non-small-cell lung cancer. Few treatment options exist for patients with HER2-mutant solid tumours beyond lung cancers. We investigated trastuzumab deruxtecan in metastatic solid tumours with specific activating HER2 mutations. METHODS In this open-label, phase 2, basket study done in 29 centres in Asia, Europe, and North America, we investigated trastuzumab deruxtecan (5·4 mg/kg every 3 weeks by intravenous infusion) in patients aged 18 years or older with unresectable or metastatic solid tumours with specific activating HER2 mutations, an Eastern Cooperative Oncology Group performance status of 0 or 1, and disease progression following previous treatment (previous HER2-targeted therapy was permitted) or with no satisfactory alternative treatment options. The primary endpoint was confirmed objective response rate by independent central review. Anti-tumour activity and safety were analysed in all patients who received at least one dose of trastuzumab deruxtecan. This trial is registered with ClinicalTrials.gov, NCT04639219, and is active but no longer recruiting. FINDINGS Between Dec 30, 2020, and Jan 25, 2023, 102 patients (62 [61%] female and 40 [39%] male; median age 66·5 years [IQR 58-72]; 51 [50%] White, two [2%] Black or African American, 38 [37%] Asian, and 11 [11%] did not have race information reported) with solid tumours with activating HER2 mutations received trastuzumab deruxtecan and were included in the anti-tumour activity and safety analyses sets. Patients had a median of three (IQR 2-4) previous treatment regimens. The median duration of follow-up was 8·61 months (IQR 3·71-12·68). The objective response rate by independent central review was 29·4% (95% CI 20·8-39·3; 30 of 102 patients). 52 (51%) patients had a treatment-emergent adverse event of grade 3 or worse; the most common events (in ≥5% of patients) were anaemia (16 [16%]) and neutrophil count decreased (eight [8%]). Drug-related treatment-emergent serious adverse events occurred in ten (10%) patients. Adjudicated drug-related interstitial lung disease or pneumonitis of any grade occurred in 11 patients (11%; three grade 1, five grade 2, one grade 3, and two grade 5); there were two (2%) cases of fatal adjudicated drug-related interstitial lung disease or pneumonitis. INTERPRETATION Trastuzumab deruxtecan showed anti-tumour activity and durable responses in heavily pretreated patients across multiple tumour types with activating HER2 mutations, with no new safety signals. Prespecified HER2 mutations might be targeted by HER2-directed antibody-drug conjugates and our findings support further investigation of trastuzumab deruxtecan in the pan-tumour setting. FUNDING AstraZeneca and Daiichi Sankyo.
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Affiliation(s)
- Bob T Li
- Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medicine, Cornell University, New York, NY, USA.
| | - Funda Meric-Bernstam
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aditya Bardia
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Yoichi Naito
- Department of General Internal Medicine, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Salvatore Siena
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Oncology and Hemato-Oncology, Università degli Studi di Milano (La Statale), Milan, Italy
| | - Philippe Aftimos
- Institut Jules Bordet-Université Libre de Bruxelles, Brussels, Belgium
| | | | - Giuseppe Curigliano
- Istituto Europeo di Oncologia, IRCCS Milan, Italy; Department of Oncology and Hemato-Oncology, Università degli Studi di Milano (La Statale), Milan, Italy
| | - Maria de Miguel
- START Madrid Centro Integral Oncológico Clara Campal (CIOCC)-HM Sanchinarro University Hospital, Madrid, Spain
| | - Maitri Kalra
- Ball Memorial Hospital (IU Health), Muncie, IN, USA
| | - Do-Youn Oh
- Seoul National University Hospital, Cancer Research Institute, Seoul National University College of Medicine, Integrated Major in Innovative Medical Science, Seoul National University Graduate School, Seoul, Korea
| | - Joon Oh Park
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sophie Postel-Vinay
- Inserm Unit U981 Gustave Roussy, Villejuif, France; Cancer Institute, University College London, London, UK
| | - Sun Young Rha
- Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | | | - Iben Spanggaard
- Department of Oncology, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
| | - Flavia Michelini
- Translational Medicine, Oncology Research and Development, AstraZeneca, Waltham, MA, USA
| | - Ann Smith
- Oncology Biometrics, Oncology Research and Development, AstraZeneca, Cambridge, UK
| | - Karime Kalil Machado
- Late Development Oncology, Oncology Research and Development, AstraZeneca, Gaithersburg, MD, USA
| | - Cristina Saura
- Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
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Cardoso F, Paluch-Shimon S, Schumacher-Wulf E, Matos L, Gelmon K, Aapro MS, Bajpai J, Barrios CH, Bergh J, Bergsten-Nordström E, Biganzoli L, Cardoso MJ, Carey LA, Mac Gregor MC, Chidebe R, Cortés J, Curigliano G, Dent RA, El Saghir NS, Eniu A, Fallowfield L, Francis PA, Franco Millan SX, Gilchrist J, Gligorov J, Gradishar WJ, Haidinger R, Harbeck N, Hu X, Kaur R, Kiely B, Kim SB, Koppikar S, Kuper-Hommel MJJ, Lecouvet FE, Mason G, Mertz SA, Mueller V, Myerson C, Neciosup S, Offersen BV, Ohno S, Pagani O, Partridge AH, Penault-Llorca F, Prat A, Rugo HS, Senkus E, Sledge GW, Swain SM, Thomssen C, Vorobiof DA, Vuylsteke P, Wiseman T, Xu B, Costa A, Norton L, Winer EP. 6th and 7th International consensus guidelines for the management of advanced breast cancer (ABC guidelines 6 and 7). Breast 2024; 76:103756. [PMID: 38896983 DOI: 10.1016/j.breast.2024.103756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
This manuscript describes the Advanced Breast Cancer (ABC) international consensus guidelines updated at the last two ABC international consensus conferences (ABC 6 in 2021, virtual, and ABC 7 in 2023, in Lisbon, Portugal), organized by the ABC Global Alliance. It provides the main recommendations on how to best manage patients with advanced breast cancer (inoperable locally advanced or metastatic), of all breast cancer subtypes, as well as palliative and supportive care. These guidelines are based on available evidence or on expert opinion when a higher level of evidence is lacking. Each guideline is accompanied by the level of evidence (LoE), grade of recommendation (GoR) and percentage of consensus reached at the consensus conferences. Updated diagnostic and treatment algorithms are also provided. The guidelines represent the best management options for patients living with ABC globally, assuming accessibility to all available therapies. Their adaptation (i.e. resource-stratified guidelines) is often needed in settings where access to care is limited.
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Affiliation(s)
- Fatima Cardoso
- Breast Unit, Champalimaud Clinical Centre/Champalimaud Foundation, and ABC Global Alliance, Lisbon, Portugal.
| | - Shani Paluch-Shimon
- Hadassah University Hospital - Sharett Institute of Oncology, Jerusalem, Israel
| | | | - Leonor Matos
- Breast Unit, Champalimaud Clinical Centre/Champalimaud Foundation, Lisbon, Portugal
| | - Karen Gelmon
- BC Cancer Agency, Department of Medical Oncology, Vancouver, Canada
| | - Matti S Aapro
- Cancer Center, Clinique de Genolier, Genolier, Switzerland
| | | | - Carlos H Barrios
- Latin American Cooperative Oncology Group (LACOG), Grupo Oncoclínicas, Porto Alegre, Brazil
| | - Jonas Bergh
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | | | - Laura Biganzoli
- Department of Oncology, Hospital of Prato - Azienda USL Toscana Centro Prato, Italy and European Society of Breast Cancer Specialists (EUSOMA), Italy
| | - Maria João Cardoso
- Breast Unit, Champalimaud Clinical Centre/Champalimaud Foundation and Lisbon University, Faculty of Medicine, Lisbon, Portugal
| | - Lisa A Carey
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, USA
| | - Mariana Chavez Mac Gregor
- Health Services Research, Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, USA and American Society of Clinical Oncology (ASCO), Houston, USA
| | | | - Javier Cortés
- International Breast Cancer Center (IBCC), Madrid and Barcelona, Spain
| | - Giuseppe Curigliano
- European Institute of Oncology, IRCCS, Milano, Italy; Department of Oncology and Hemato-Oncology, University of Milano, Milano, Italy
| | | | - Nagi S El Saghir
- NK Basile Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Alexandru Eniu
- Hôpital Riviera-Chablais, Vaud-Valais Rennaz, Switzerland and European School of Oncology (ESO), United Kingdom
| | - Lesley Fallowfield
- Brighton & Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Prudence A Francis
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia
| | | | | | - Joseph Gligorov
- Department of Medical Oncology, Cancer Est APHP Tenon, University Paris VI, Nice/St Paul Guidelines, Paris, France
| | - William J Gradishar
- Northwestern Medicine, Illinois, USA and National Comprehensive Cancer Network (NCCN), USA
| | | | - Nadia Harbeck
- Breast Centre, University of Munich, Munich and Arbeitsgemeinschaft Gynäkologische Onkologie, Kommission Mamma (AGO Guidelines), Germany
| | - Xichun Hu
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ranjit Kaur
- Breast Cancer Welfare Association, Petaling Jaya, Malaysia
| | - Belinda Kiely
- NHMRC Clinical Trials Centre, Sydney Medical School, Sydney, Australia
| | - Sung-Bae Kim
- Asan Medical Centre, Department of Oncology, Seoul, South Korea
| | - Smruti Koppikar
- Lilavati Hospital and Research Centre, Bombay Hospital Institute of Medical Sciences, Asian Cancer Institute, Mumbai, India
| | - Marion J J Kuper-Hommel
- Te Whatu Ora Waikato, Midland Regional Cancer Centre, NZ ABC Guidelines, Hamilton, New Zealand
| | - Frédéric E Lecouvet
- Department of Radiology, Institut Roi Albert II and Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Ginny Mason
- Inflammatory Breast Cancer Research Foundation, West Lafayette, USA
| | - Shirley A Mertz
- MBC US Alliance and Metastatic Breast Cancer Network US, Inverness, USA
| | - Volkmar Mueller
- University Medical Center Hamburg-Eppendorf, Hamburg and Arbeitsgemeinschaft Gynäkologische Onkologie, Kommission Mamma (AGO Guidelines), Germany
| | | | - Silvia Neciosup
- Department of Medical Oncology, National Institute of Neoplastic Diseases, Lima, ABC Latin America Guidelines, Peru
| | - Birgitte V Offersen
- Department of Oncology, Aarhus University Hospital, Aarhus, European Society for Radiotherapy and Oncology (ESTRO), Denmark
| | - Shinji Ohno
- Breast Oncology Centre, Cancer Institute Hospital, Tokyo, Japan
| | - Olivia Pagani
- Hôpital Riviera-Chablais, Vaud-Valais Rennaz, Switzerland
| | - Ann H Partridge
- Dana-Farber Cancer Institute, Department of Medical Oncology and Division of Breast Oncology, Boston, USA and American Society of Clinical Oncology (ASCO), USA
| | - Frédérique Penault-Llorca
- Centre Jean Perrin, Université Clermont Auvergne, INSERM, U1240 Imagerie Moléculaire et Stratégies Théranostiques, F-63000, Clermont Ferrand, Nice/St Paul Guidelines, France
| | - Aleix Prat
- Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Hope S Rugo
- Breast Oncology and Clinical Trials Education, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, USA
| | - Elzbieta Senkus
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland
| | - George W Sledge
- Division of Oncology, Stanford School of Medicine, Stanford, USA
| | - Sandra M Swain
- Georgetown University Lombardi Comprehensive Cancer Center and MedStar Health, Washington DC, USA
| | - Christoph Thomssen
- Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle (Saale) and Arbeitsgemeinschaft Gynäkologische Onkologie, Kommission Mamma (AGO Guidelines), Germany
| | | | - Peter Vuylsteke
- University of Botswana, Gaborone, Botswana and CHU UCL Namur Hospital, UCLouvain, Belgium
| | - Theresa Wiseman
- The Royal Marsden NHS Foundation Trust, University of Southampton, United Kingdom and European Oncology Nursing Society (EONS), United Kingdom
| | - Binghe Xu
- Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Alberto Costa
- European School of Oncology, Milan, Italy and Bellinzona, Switzerland
| | - Larry Norton
- Breast Cancer Programs, Memorial Sloan-Kettering Cancer Centre, New York, USA
| | - Eric P Winer
- Yale Cancer Center, Yale University School of Medicine, New Haven, CT, USA
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Collineau B, Gonçalves A, Bertucci F, de Nonneville A. [Treatment-related adverse events associated with antibody drug conjugate in breast cancer]. Bull Cancer 2024:S0007-4551(24)00155-3. [PMID: 38772845 DOI: 10.1016/j.bulcan.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 05/23/2024]
Abstract
Therapeutic options for breast cancer have recently been enriched by new antibody-drug conjugates (ADC), which are now being utilized across all known molecular subtypes. ADCs represent a groundbreaking class of therapies that combine a cytotoxic agent with a monoclonal antibody via a combination molecule (linker). The primary objective is to selectively deliver chemotherapy to cells expressing the target antigen, thereby enhancing the therapeutic index. Trastuzumab-emtansine marked the pioneering use of this approach for HER2-overexpressed breast cancer. More recently, trastuzumab-deruxtecan and sacituzumab-govitecan have demonstrated efficacy in progression-free survival and overall survival in HER2-overexpressed and HER2-low breast cancer for the former, and HER2-non-overexpressed (including HER-low) for the latter. Numerous other ADCs are currently under development in breast cancer. While ADCs were initially designed to widen the therapeutic index and mitigate toxicities, managing ADC-related adverse events in the clinical setting remains a challenge. This review article aims to provide an overview of the toxicity profiles of these drugs already in current clinical practice or under development, drawing from results observed in various studies.
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Affiliation(s)
- Bérénice Collineau
- Department of Medical Oncology, CRCM, Aix-Marseille université, CNRS, Inserm, Institut Paoli-Calmettes, Marseille, France
| | - Anthony Gonçalves
- Department of Medical Oncology, CRCM, Aix-Marseille université, CNRS, Inserm, Institut Paoli-Calmettes, Marseille, France
| | - François Bertucci
- Department of Medical Oncology, CRCM, Aix-Marseille université, CNRS, Inserm, Institut Paoli-Calmettes, Marseille, France; Laboratory of Predictive Oncology, Centre de recherche en cancérologie de Marseille, Institut Paoli-Calmettes, Inserm UMR1068, CNRS UMR725, équipe labellisée Ligue nationale contre le cancer, Marseille, France
| | - Alexandre de Nonneville
- Department of Medical Oncology, CRCM, Aix-Marseille université, CNRS, Inserm, Institut Paoli-Calmettes, Marseille, France; Laboratory of Predictive Oncology, Centre de recherche en cancérologie de Marseille, Institut Paoli-Calmettes, Inserm UMR1068, CNRS UMR725, équipe labellisée Ligue nationale contre le cancer, Marseille, France.
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Kundu M, Butti R, Panda VK, Malhotra D, Das S, Mitra T, Kapse P, Gosavi SW, Kundu GC. Modulation of the tumor microenvironment and mechanism of immunotherapy-based drug resistance in breast cancer. Mol Cancer 2024; 23:92. [PMID: 38715072 PMCID: PMC11075356 DOI: 10.1186/s12943-024-01990-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 04/02/2024] [Indexed: 05/12/2024] Open
Abstract
Breast cancer, the most frequent female malignancy, is often curable when detected at an early stage. The treatment of metastatic breast cancer is more challenging and may be unresponsive to conventional therapy. Immunotherapy is crucial for treating metastatic breast cancer, but its resistance is a major limitation. The tumor microenvironment (TME) is vital in modulating the immunotherapy response. Various tumor microenvironmental components, such as cancer-associated fibroblasts (CAFs), tumor-associated macrophages (TAMs), and myeloid-derived suppressor cells (MDSCs), are involved in TME modulation to cause immunotherapy resistance. This review highlights the role of stromal cells in modulating the breast tumor microenvironment, including the involvement of CAF-TAM interaction, alteration of tumor metabolism leading to immunotherapy failure, and other latest strategies, including high throughput genomic screening, single-cell and spatial omics techniques for identifying tumor immune genes regulating immunotherapy response. This review emphasizes the therapeutic approach to overcome breast cancer immune resistance through CAF reprogramming, modulation of TAM polarization, tumor metabolism, and genomic alterations.
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Affiliation(s)
- Moumita Kundu
- School of Biotechnology, KIIT Deemed to be University, Bhubaneswar, 751024, India
- Department of Pharmaceutical Technology, Brainware University, West Bengal, 700125, India
| | - Ramesh Butti
- Department of Internal Medicine, Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, TX, 75235, USA
| | - Venketesh K Panda
- School of Biotechnology, KIIT Deemed to be University, Bhubaneswar, 751024, India
| | - Diksha Malhotra
- School of Biotechnology, KIIT Deemed to be University, Bhubaneswar, 751024, India
| | - Sumit Das
- National Centre for Cell Sciences, Savitribai Phule Pune University Campus, Pune, 411007, India
| | - Tandrima Mitra
- School of Biotechnology, KIIT Deemed to be University, Bhubaneswar, 751024, India
| | - Prachi Kapse
- School of Basic Medical Sciences, Savitribai Phule Pune University, Pune, 411007, India
| | - Suresh W Gosavi
- School of Basic Medical Sciences, Savitribai Phule Pune University, Pune, 411007, India
| | - Gopal C Kundu
- School of Biotechnology, KIIT Deemed to be University, Bhubaneswar, 751024, India.
- Kalinga Institute of Medical Sciences (KIMS), KIIT Deemed to be University, Bhubaneswar, 751024, India.
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7
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Staropoli N, Scionti F, Farenza V, Falcone F, Luciano F, Renne M, Di Martino MT, Ciliberto D, Tedesco L, Crispino A, Labanca C, Cucè M, Esposito S, Agapito G, Cannataro M, Tassone P, Tagliaferri P, Arbitrio M. Identification of ADME genes polymorphic variants linked to trastuzumab-induced cardiotoxicity in breast cancer patients: Case series of mono-institutional experience. Biomed Pharmacother 2024; 174:116478. [PMID: 38547766 DOI: 10.1016/j.biopha.2024.116478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Long-term survival induced by anticancer treatments discloses emerging frailty among breast cancer (BC) survivors. Trastuzumab-induced cardiotoxicity (TIC) is reported in at least 5% of HER2+BC patients. However, TIC mechanism remains unclear and predictive genetic biomarkers are still lacking. Interaction between systemic inflammation, cytokine release and ADME genes in cancer patients might contribute to explain mechanisms underlying individual susceptibility to TIC and drug response variability. We present a single institution case series to investigate the potential role of genetic variants in ADME genes in HER2+BC patients TIC experienced. METHODS We selected data related to 40 HER2+ BC patients undergone to DMET genotyping of ADME constitutive variant profiling, with the aim to prospectively explore their potential role in developing TIC. Only 3 patients ("case series"), who experienced TIC, were compared to 37 "control group" matched patients cardiotoxicity-sparing. All patients underwent to left ventricular ejection fraction (LVEF) evaluation at diagnosis and during anti-HER2 therapy. Each single probe was clustered to detect SNPs related to cardiotoxicity. RESULTS In this retrospective analysis, our 3 cases were homogeneous in terms of clinical-pathological characteristics, trastuzumab-based treatment and LVEF decline. We identified 9 polymorphic variants in 8 ADME genes (UGT1A1, UGT1A6, UGT1A7, UGT2B15, SLC22A1, CYP3A5, ABCC4, CYP2D6) potentially associated with TIC. CONCLUSION Real-world TIC incidence is higher compared to randomized clinical trials and biomarkers with potential predictive value aren't available. Our preliminary data, as proof of concept, could suggest a predictive role of pharmacogenomic approach in the identification of cardiotoxicity risk biomarkers for anti-HER2 treatment.
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Affiliation(s)
- Nicoletta Staropoli
- Medical Oncology Unit, R. Dulbecco (Mater Domini facility), Teaching Hospital, Magna Græcia University and Cancer Center, Campus Salvatore Venuta, Catanzaro, Italy; Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy.
| | - Francesca Scionti
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Valentina Farenza
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Federica Falcone
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Francesco Luciano
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Maria Renne
- Surgery Unit, Magna Græcia University and Cancer Center, Campus Salvatore Venuta, Catanzaro, Italy
| | - Maria Teresa Di Martino
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Domenico Ciliberto
- Medical Oncology Unit, R. Dulbecco (Mater Domini facility), Teaching Hospital, Magna Græcia University and Cancer Center, Campus Salvatore Venuta, Catanzaro, Italy
| | - Ludovica Tedesco
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Antonella Crispino
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Caterina Labanca
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Maria Cucè
- Medical Oncology Unit, R. Dulbecco (Mater Domini facility), Teaching Hospital, Magna Græcia University and Cancer Center, Campus Salvatore Venuta, Catanzaro, Italy
| | - Stefania Esposito
- Pharmacy Unit, R. Dulbecco (Mater Domini facility), Teaching Hospital, Campus Salvatore Venuta, Catanzaro, Italy
| | - Giuseppe Agapito
- Department of Law, Economics and Sociology, Magna Graecia University of Catanzaro, Catanzaro 88100, Italy; Data Analytics Research Center, Magna Graecia University of Catanzaro, Catanzaro 88100, Italy
| | - Mario Cannataro
- Department of Medical and Surgical Science, Magna Graecia University of Catanzaro, Catanzaro 88100, Italy
| | - Pierfrancesco Tassone
- Medical Oncology Unit, R. Dulbecco (Mater Domini facility), Teaching Hospital, Magna Græcia University and Cancer Center, Campus Salvatore Venuta, Catanzaro, Italy; Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Pierosandro Tagliaferri
- Medical Oncology Unit, R. Dulbecco (Mater Domini facility), Teaching Hospital, Magna Græcia University and Cancer Center, Campus Salvatore Venuta, Catanzaro, Italy; Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy.
| | - Mariamena Arbitrio
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), Catanzaro 88100, Italy.
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8
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Guarneri V, Passos Coelho JL, Duhoux FP, Egle D, García-Sáenz JÁ, Penault-Llorca F, Selander K, Wildiers H, Zaman K, Laeis P, Lucerna M, Pierga JY. Study design for DESTINY-Breast Respond HER2-low Europe: T-DXd in patients with HER2-low advanced breast cancer. Future Oncol 2024:1-14. [PMID: 38592002 DOI: 10.2217/fon-2024-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/07/2024] [Indexed: 04/10/2024] Open
Abstract
Trastuzumab deruxtecan (T-DXd) is approved for the treatment of human epidermal growth factor receptor 2 (HER2)-low metastatic breast cancer (mBC). Results on T-DXd treatment in HER2-low mBC have so far been limited to clinical trials. DESTINY-Breast Respond HER2-low Europe (NCT05945732) is a multi-center, multi-country, observational, prospective, non-interventional study planning to enroll 1350 patients from 216 sites receiving T-DXd or conventional chemotherapy as their routine clinical care for advanced stage breast cancer in 12 European countries. This non-interventional study will provide real-world insight into T-DXd treatment for HER2-low mBC with data on effectiveness, safety and tolerability, patient-reported outcomes, treatment patterns, geriatric health status and HER2 testing. This will be beneficial for improving guidance to maximize patient treatment benefit.
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Affiliation(s)
- Valentina Guarneri
- Medical Oncology 2, Veneto Institute of Oncology (IOV), IRCCS, Via Gattamelata, 64, 35128 Padova PD, Italy
- Department of Surgery, Oncology & Gastroenterology, University of Padova, Via Nicolò Giustiniani, 2, 35128 Padova PD, Italy
| | | | - Francois P Duhoux
- Department of Medical Oncology, King Albert II Cancer Institute, Cliniques Universitaires Saint-Luc, Av. Hippocrate 10, 1200 Brussels, Belgium
| | - Daniel Egle
- Department of Gynaecology & Obstetrics, Medical University of Innsbruck, Christoph-Probst-Platz 1, Innrain 52 A, Fritz-Pregl-Straße 3, 6020 Innsbruck, Austria
| | - José Ángel García-Sáenz
- Department of Medical Oncology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria Hospital Clínico San Carlos (IdISSC), Calle del Prof Martin Lagos, s/n, Moncloa - Aravaca, 28040 Madrid, Spain
| | - Frédérique Penault-Llorca
- Centre Jean Perrin, Université Clermont Auvergne, INSERM, U1240 Imagerie Moléculaire Et Stratégies Théranostiques, Rue Montalebert, 63000 Clermont-Ferrand, France
| | - Katri Selander
- Department of Oncology & Radiation Therapy, Oulu University Hospital, Kajaanintie 50, 90220 Oulu, Finland
- Cancer Research & Translational Medicine Research Unit, University of Oulu, Pentti Kaiteran katu 1, 90570 Oulu, Finland
| | - Hans Wildiers
- Department of General Medical Oncology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Khalil Zaman
- Department of Oncology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Petra Laeis
- Daiichi Sankyo Europe GmbH, Zielstattstraße 48 81379 Munich, Germany
| | - Markus Lucerna
- Daiichi Sankyo Europe GmbH, Zielstattstraße 48 81379 Munich, Germany
| | - Jean-Yves Pierga
- Department of Medical Oncology, Institut Curie, Université Paris Cité, 75005 Paris, France
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9
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Curigliano G, Dent R, Earle H, Modi S, Tarantino P, Viale G, Tolaney SM. Open questions, current challenges, and future perspectives in targeting human epidermal growth factor receptor 2-low breast cancer. ESMO Open 2024; 9:102989. [PMID: 38613914 PMCID: PMC11024577 DOI: 10.1016/j.esmoop.2024.102989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 04/15/2024] Open
Abstract
Approximately 60% of traditionally defined human epidermal growth factor receptor 2 (HER2)-negative breast cancers express low levels of HER2 [HER2-low; defined as immunohistochemistry (IHC) 1+ or IHC 2+/in situ hybridization (ISH)-]. HER2-low breast cancers encompass a large percentage of both hormone receptor-positive (up to 85%) and triple-negative (up to 63%) breast cancers. The DESTINY-Breast04 trial established that HER2-low tumors are targetable, leading to the approval of trastuzumab deruxtecan (T-DXd) as the first HER2-directed therapy for the treatment of HER2-low breast cancer in the United States and Europe. This change in the clinical landscape results in a number of questions and challenges-including those related to HER2 assessment and patient identification-and highlights the need for careful assessment of HER2 expression to identify patients eligible for T-DXd. This review provides context for understanding how to identify patients with HER2-low breast cancer with respect to sample types, scoring and reporting HER2 status, and testing methods and assays. It also discusses management of important T-DXd-related adverse events. Available evidence supports the efficacy of T-DXd in patients with any history of IHC 1+ or IHC 2+/ISH- scores; however, future research may further refine the population who could benefit from T-DXd or other HER2-directed therapies and identify novel methods for patient identification. Because HER2 expression can change with disease progression or treatment, and variability exists in scoring and interpretation of HER2 status, careful re-evaluation in certain scenarios may help to identify more patients who may benefit from T-DXd.
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Affiliation(s)
- G Curigliano
- European Institute of Oncology, IRCCS, Milan; Department of Oncology and Hematology-Oncology, University of Milan, Milan, Italy.
| | - R Dent
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - H Earle
- Blogger at hannahincancerland.com, New Hampshire, USA; Patient at Dana-Farber Cancer Institute, Harvard Medical School, Boston
| | - S Modi
- Memorial Sloan Kettering Cancer Center, New York, USA
| | - P Tarantino
- Department of Oncology and Hematology-Oncology, University of Milan, Milan, Italy; Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - G Viale
- European Institute of Oncology, IRCCS, Milan
| | - S M Tolaney
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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10
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Stravodimou A, Voutsadakis IA. Neo-adjuvant therapies for ER positive/HER2 negative breast cancers: from chemotherapy to hormonal therapy, CDK inhibitors, and beyond. Expert Rev Anticancer Ther 2024; 24:117-135. [PMID: 38475990 DOI: 10.1080/14737140.2024.2330601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 02/02/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Chemotherapy has been traditionally used as neo-adjuvant therapy in breast cancer for down-staging of locally advanced disease in all sub-types. In the adjuvant setting, genomic assays have shown that a significant proportion of ER positive/HER2 negative patients do not derive benefit from the addition of chemotherapy to adjuvant endocrine therapy. An interest in hormonal treatments as neo-adjuvant therapies in ER positive/HER2 negative cancers has been borne by their documented success in the adjuvant setting. Moreover, cytotoxic chemotherapy is less effective in ER positive/HER2 negative disease compared with other breast cancer subtypes in obtaining pathologic complete responses. AREAS COVERED Neo-adjuvant therapies for ER positive/HER2 negative breast cancers and associated biomarkers are reviewed, using a Medline survey. A focus of discussion is the prediction of patients that are unlikely to derive extra benefit from chemotherapy and have the highest probabilities of benefiting from hormonal and other targeted therapies. EXPERT OPINION Predictive biomarkers of response to neo-adjuvant chemotherapy and hormonal therapies are instrumental for selecting ER positive/HER2 negative breast cancer patients for each treatment. Chemotherapy remains the standard of care for many of those patients requiring neo-adjuvant treatment, but other neo-adjuvant therapies are increasingly used.
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Affiliation(s)
- Athina Stravodimou
- Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Ioannis A Voutsadakis
- Algoma District Cancer Program, Sault Area Hospital, Sault Ste Marie, Ontario, Canada
- Division of Clinical Sciences, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
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11
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Saura C, Modi S, Krop I, Park YH, Kim SB, Tamura K, Iwata H, Tsurutani J, Sohn J, Mathias E, Liu Y, Cathcart J, Singh J, Yamashita T. Trastuzumab deruxtecan in previously treated patients with HER2-positive metastatic breast cancer: updated survival results from a phase II trial (DESTINY-Breast01). Ann Oncol 2024; 35:302-307. [PMID: 38092229 DOI: 10.1016/j.annonc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/02/2023] [Accepted: 12/04/2023] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Primary analysis of the multicenter, open-label, single-arm, phase II DESTINY-Breast01 trial (median follow-up 11.1 months) demonstrated durable antitumor activity with trastuzumab deruxtecan (T-DXd) in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (mBC) previously treated with trastuzumab emtansine (T-DM1). We report updated cumulative survival outcomes with a median follow-up of 26.5 months (data cut-off 26 March 2021). PATIENTS AND METHODS Patients with HER2-positive mBC resistant or refractory to T-DM1 received T-DXd 5.4 mg/kg intravenously every 3 weeks until disease progression, unacceptable adverse events, or withdrawal of consent. The primary endpoint was confirmed objective response rate (ORR) by independent central review (ICR). Secondary endpoints included overall survival (OS), duration of response (DoR), progression-free survival (PFS), and safety. RESULTS The ORR by ICR was 62.0% [95% confidence interval (CI) 54.5% to 69.0%] in patients who received T-DXd 5.4 mg/kg every 3 weeks (n = 184). Median OS was 29.1 months (95% CI 24.6-36.1 months). Median PFS and DoR were 19.4 months (95% CI 14.1-25.0 months) and 18.2 months (95% CI 15.0 months-not evaluable), respectively. Drug-related treatment-emergent adverse events (TEAEs) were observed in 183 patients (99.5%), and 99 patients (53.8%) had one or more grade ≥3 TEAEs. Adjudicated drug-related interstitial lung disease/pneumonitis occurred in 15.8% of patients (n = 29), of which 2.7% (n = 5) were grade 5. CONCLUSIONS These updated results provide further evidence of sustained antitumor activity of T-DXd with a consistent safety profile in heavily pretreated patients with HER2-positive mBC.
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Affiliation(s)
- C Saura
- Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain.
| | - S Modi
- Memorial Sloan Kettering Cancer Center, New York
| | - I Krop
- Yale Cancer Center, New Haven, USA
| | | | - S-B Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - K Tamura
- Shimane University Hospital, Izumo
| | - H Iwata
- Aichi Cancer Center Hospital, Nagoya
| | - J Tsurutani
- Advanced Cancer Translational Research Institute, Showa University, Tokyo, Japan
| | - J Sohn
- Yonsei Cancer Center, Yonsei University Health System, Seoul, South Korea
| | - E Mathias
- Daiichi Sankyo, Inc., Basking Ridge, USA
| | - Y Liu
- Daiichi Sankyo, Inc., Basking Ridge, USA
| | - J Cathcart
- Daiichi Sankyo, Inc., Basking Ridge, USA
| | - J Singh
- Daiichi Sankyo, Inc., Basking Ridge, USA
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12
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Marra A, Chandarlapaty S, Modi S. Management of patients with advanced-stage HER2-positive breast cancer: current evidence and future perspectives. Nat Rev Clin Oncol 2024; 21:185-202. [PMID: 38191924 DOI: 10.1038/s41571-023-00849-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/10/2024]
Abstract
Amplification and/or overexpression of ERBB2, the gene encoding HER2, can be found in 15-20% of invasive breast cancers and is associated with an aggressive phenotype and poor clinical outcomes. Relentless research efforts in molecular biology and drug development have led to the implementation of several HER2-targeted therapies, including monoclonal antibodies, tyrosine-kinase inhibitors and antibody-drug conjugates, constituting one of the best examples of bench-to-bedside translation in oncology. Each individual drug class has improved patient outcomes and, importantly, the combinatorial and sequential use of different HER2-targeted therapies has increased cure rates in the early stage disease setting and substantially prolonged survival for patients with advanced-stage disease. In this Review, we describe key steps in the development of the modern paradigm for the treatment of HER2-positive advanced-stage breast cancer, including selecting and sequencing new-generation HER2-targeted therapies, and summarize efficacy and safety outcomes from pivotal studies. We then outline the factors that are currently known to be related to resistance to HER2-targeted therapies, such as HER2 intratumoural heterogeneity, activation of alternative signalling pathways and immune escape mechanisms, as well as potential strategies that might be used in the future to overcome this resistance and further improve patient outcomes.
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Affiliation(s)
- Antonio Marra
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy
| | - Sarat Chandarlapaty
- Human Oncology and Pathogenesis Program (HOPP), Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Shanu Modi
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Weill Cornell Medical College, New York, NY, USA.
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13
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Chai M, Li L, Wu H, Liu Y, Yi Z, Yu H. Lung toxicity induced by anti-HER2 antibody - drug conjugates for breast cancer. Crit Rev Oncol Hematol 2024; 195:104274. [PMID: 38295890 DOI: 10.1016/j.critrevonc.2024.104274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/20/2024] [Accepted: 01/26/2024] [Indexed: 02/10/2024] Open
Abstract
Human epidermal growth factor receptor 2 (HER2) serves as both a prognostic indicator and a therapeutic target for breast cancer. Therefore, anti-HER2 therapy plays a crucial role in the treatment of HER2-positive cancer. Antibody-drug conjugates (ADCs) are composed of a monoclonal antibody, a chemical linker and a payload, wherein their aim is to reduce the toxicity associated with chemotherapy drugs by utilizing specific antibodies. Among the anti-HER2 ADCs currently approved for clinical use, trastuzumab emtansine(T-DM1) and trastuzumab deruxtecan (T-Dxd) have demonstrated remarkable efficacy in treating HER2-positive breast cancer. However, it is essential to emphasize the occurrence of lung toxicity during the treatment process, which can be life-threatening. In this review, we provide an overview of the new epidemiological features associated with interstitial lung disease (ILD) related to anti-HER2 ADCs in breast cancer. We also summarize the potential pathogenesis and explore the diagnosis and treatment strategies within this field.
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Affiliation(s)
- Mengting Chai
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Li Li
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Huachao Wu
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Yue Liu
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
| | - Zongbi Yi
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
| | - Haijun Yu
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan 430071, China.
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14
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Karlsen EA, Walpole E, Simpson F. Steroid Premedication and Monoclonal Antibody Therapy: Should We Reconsider? Curr Treat Options Oncol 2024; 25:275-283. [PMID: 38270799 PMCID: PMC10894762 DOI: 10.1007/s11864-023-01170-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 01/26/2024]
Abstract
OPINION STATEMENT Monoclonal antibody (mAb) therapy is now considered a main component of cancer therapy in Australia. Although traditionally thought of as pure signalling inhibitors, a large proponent of these medications function through antibody-dependent cell-mediated cytotoxicity (ADCC). Currently, most protocols and institutional guidelines for ADCC-mediated mAbs promote the use of corticosteroids as premedication: this is implemented to reduce infusion-related reactions (IRRs) and antiemesis prophylaxis and combat concurrently administered chemotherapy-related syndromes. Concerningly, the inhibitory effects of ADCC by corticosteroids are well documented; henceforth, it is possible the current standard of care is misaligned to the literature surrounding ADCC. Subsequently, clinicians' decisions to act in contrast to this literature may be reducing the efficacy of mAbs. The literature suggests that the redundant use of corticosteroids should be cautioned against when used in conjunction with ADCC-mediated mAbs-this is due to the consequent reduction in anti-tumour activity. Owing to the fact IRRs typically occur upon initial infusion, the authors advocate for individual clinicians and institutional protocols to considering augmenting their practice to corticosteroid premedication at the first dose only, unless clinically indicated. Additionally, product information (PI) and consumer medicine information (CMI) documents distributed by Australian and international regulatory agencies should consider disclosing the risk of concurrent steroids with these medications. Moreover, the authors suggest considering alternative medications for the management of side effects.
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Affiliation(s)
- Emma-Anne Karlsen
- Frazer Institute, The University of Queensland, Brisbane, Australia.
- Department of General Surgery, Mater Hospital Brisbane, Brisbane, Australia.
- School of Medicine, The University of Queensland, Brisbane, Australia.
- Simpson Laboratory - Frazer Institute, The University of Queensland, 37 Kent Street, Woolloongabba, QLD, 4102, Australia.
| | - Euan Walpole
- School of Medicine, The University of Queensland, Brisbane, Australia
- Division of Cancer Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Fiona Simpson
- Frazer Institute, The University of Queensland, Brisbane, Australia
- Simpson Laboratory - Frazer Institute, The University of Queensland, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
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15
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Monteiro MR, Nunes NCC, Junior AADS, Fêde ABDS, Bretas GDO, Souza CDP, Mano M, da Silva JL. Antibody-Drug Conjugates in Breast Cancer: A Comprehensive Review of How to Selectively Deliver Payloads. BREAST CANCER (DOVE MEDICAL PRESS) 2024; 16:51-70. [PMID: 38434801 PMCID: PMC10909371 DOI: 10.2147/bctt.s448191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/10/2024] [Indexed: 03/05/2024]
Abstract
Antibody-drug conjugates (ADCs) have surfaced as a promising group of anticancer agents employing the precise targeting capacity of monoclonal antibodies to transport highly effective cytotoxic payloads. Compared to conventional chemotherapy, they aim to selectively eradicate cancer cells while minimizing off-target toxicity on healthy tissues. An increasing body of evidence has provided support for the efficacy of ADCs in treating breast cancer across various contexts and tumor subtypes, resulting in significant changes in clinical practice. Nevertheless, unlocking the full potential of these therapeutic agents demands innovative molecular designs to address complex clinical challenges, including drug resistance, tumor heterogeneity, and treatment-related adverse events. This thorough review provides an in-depth analysis of the clinical data on ADCs, offering crucial insights from pivotal clinical trials that assess the efficacy of ADCs in diverse breast cancer settings. This aids in providing a comprehensive understanding of the current state of ADCs in breast cancer therapy, while also providing valuable perspectives for the future.
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Affiliation(s)
| | | | | | | | | | | | - Max Mano
- Grupo Oncoclínicas, São Paulo, Brazil
| | - Jesse Lopes da Silva
- Grupo Oncoclínicas, Rio de Janeiro, Brazil
- Divisão de Pesquisa Clínica e Desenvolvimento Tecnológico, Instituto Nacional do Câncer, Rio de Janeiro, Brazil
- Hospital da Força Aérea do Galeão, Rio de Janeiro, Brazil
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16
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You X, Zhu C, Yu P, Wang X, Wang Y, Wang J, Yu J, Wang K. Emerging strategy for the treatment of urothelial carcinoma: Advances in antibody-drug conjugates combination therapy. Biomed Pharmacother 2024; 171:116152. [PMID: 38228034 DOI: 10.1016/j.biopha.2024.116152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 01/18/2024] Open
Abstract
Urothelial carcinoma (UC) is a prevalent malignant tumor involving the urinary system. Although there are various treatment modalities, including surgery, chemotherapy, and immune checkpoint inhibitor (ICI) therapy, some patients experience disease recurrence and metastasis with poor prognosis and dismal long-term survival. Antibody-drug conjugates (ADCs), which combine the targeting ability of antibody drugs with the cytotoxicity of chemotherapeutic drugs, have recently emerged as a prominent research focus in the development of individualized precision cancer therapy. Although ADCs have improved the overall response rate in patients with UC, their effectiveness remains limited. Currently, ADC-based combination therapies, particularly ADC combined with ICIs, have demonstrated promising efficacy. This combination approach has advanced the treatment of UC, exhibiting the potential to become the standard first-line therapy for advanced UC in the future. This article reviewed clinical trials involving ADC-based combination therapy for UC and discussed the possible challenges and future perspectives to provide guidance for the clinical treatment of UC.
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Affiliation(s)
- Xiangyun You
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang 110004, China; Department of Urology, The First College of Clinical Medical Science, China Three Gorges University, Yichang 443000, China
| | - Chunming Zhu
- Department of Family Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Puguang Yu
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Xia Wang
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Yibing Wang
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang 110004, China.
| | - Jiahe Wang
- Department of Urology, The First College of Clinical Medical Science, China Three Gorges University, Yichang 443000, China.
| | - Junfeng Yu
- Department of Urology, The First College of Clinical Medical Science, China Three Gorges University, Yichang 443000, China.
| | - Kefeng Wang
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang 110004, China.
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17
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Liang Y, Zhang P, Li F, Lai H, Qi T, Wang Y. Advances in the study of marketed antibody-drug Conjugates (ADCs) for the treatment of breast cancer. Front Pharmacol 2024; 14:1332539. [PMID: 38352694 PMCID: PMC10862125 DOI: 10.3389/fphar.2023.1332539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/21/2023] [Indexed: 02/16/2024] Open
Abstract
Breast cancer continues to have a high incidence rate among female malignancies. Despite significant advancements in treatment modalities, the heterogeneous nature of breast cancer and its resistance to various therapeutic approaches pose considerable challenges. Antibody-drug conjugates (ADCs) effectively merge the specificity of antibodies with the cytotoxicity of chemotherapeutic agents, offering a novel strategy for precision treatment of breast cancer. Notably, trastuzumab emtansine (T-DM1) has provided a new therapeutic option for HER2-positive breast cancer patients globally, especially those resistant to conventional treatments. The development of trastuzumab deruxtecan (T-DXd) and sacituzumab govitecan (SG) has further broadened the applicability of ADCs in breast cancer therapy, presenting new hopes for patients with low HER2 expression and triple-negative breast cancer. However, the application of ADCs presents certain challenges. For instance, their treatment may lead to adverse reactions such as interstitial lung disease, thrombocytopenia, and diarrhea. Moreover, prolonged treatment could result in ADCs resistance, complicating the therapeutic process. Economically, the high costs of ADCs might hinder their accessibility in low-income regions. This article reviews the structure, mechanism of action, and clinical trials of commercially available ADCs for breast cancer treatment, with a focus on the clinical trials of the three drugs, aiming to provide insights for clinical applications and future research.
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Affiliation(s)
- Yan Liang
- Sichuan Cancer Hospital, Cancer Hospital Affiliate University of Electronic Science and Technology, Chengdu, China
- School of Medicine, University of Electronic Science and Technology, Chengdu, China
| | - Purong Zhang
- Sichuan Cancer Hospital, Cancer Hospital Affiliate University of Electronic Science and Technology, Chengdu, China
| | - Feng Li
- Sichuan Cancer Hospital, Cancer Hospital Affiliate University of Electronic Science and Technology, Chengdu, China
- School of Medicine, University of Electronic Science and Technology, Chengdu, China
| | - Houyun Lai
- Sichuan Cancer Hospital, Cancer Hospital Affiliate University of Electronic Science and Technology, Chengdu, China
- School of Medicine, University of Electronic Science and Technology, Chengdu, China
| | - Tingting Qi
- Sichuan Cancer Hospital, Cancer Hospital Affiliate University of Electronic Science and Technology, Chengdu, China
| | - Yixin Wang
- Sichuan Cancer Hospital, Cancer Hospital Affiliate University of Electronic Science and Technology, Chengdu, China
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18
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Meric-Bernstam F, Makker V, Oaknin A, Oh DY, Banerjee S, González-Martín A, Jung KH, Ługowska I, Manso L, Manzano A, Melichar B, Siena S, Stroyakovskiy D, Fielding A, Ma Y, Puvvada S, Shire N, Lee JY. Efficacy and Safety of Trastuzumab Deruxtecan in Patients With HER2-Expressing Solid Tumors: Primary Results From the DESTINY-PanTumor02 Phase II Trial. J Clin Oncol 2024; 42:47-58. [PMID: 37870536 PMCID: PMC10730032 DOI: 10.1200/jco.23.02005] [Citation(s) in RCA: 48] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/03/2023] [Accepted: 10/12/2023] [Indexed: 10/24/2023] Open
Abstract
PURPOSE Trastuzumab deruxtecan (T-DXd) is a human epidermal growth factor 2 (HER2)-directed antibody-drug conjugate approved in HER2-expressing breast and gastric cancers and HER2-mutant non-small-cell lung cancer. Treatments are limited for other HER2-expressing solid tumors. METHODS This open-label phase II study evaluated T-DXd (5.4 mg/kg once every 3 weeks) for HER2-expressing (immunohistochemistry [IHC] 3+/2+ by local or central testing) locally advanced or metastatic disease after ≥1 systemic treatment or without alternative treatments. The primary end point was investigator-assessed confirmed objective response rate (ORR). Secondary end points included safety, duration of response, progression-free survival (PFS), and overall survival (OS). RESULTS At primary analysis, 267 patients received treatment across seven tumor cohorts: endometrial, cervical, ovarian, bladder, biliary tract, pancreatic, and other. The median follow-up was 12.75 months. In all patients, the ORR was 37.1% (n = 99; [95% CI, 31.3 to 43.2]), with responses in all cohorts; the median DOR was 11.3 months (95% CI, 9.6 to 17.8); the median PFS was 6.9 months (95% CI, 5.6 to 8.0); and the median OS was 13.4 months (95% CI, 11.9 to 15.5). In patients with central HER2 IHC 3+ expression (n = 75), the ORR was 61.3% (95% CI, 49.4 to 72.4), the median DOR was 22.1 months (95% CI, 9.6 to not reached), the median PFS was 11.9 months (95% CI, 8.2 to 13.0), and the median OS was 21.1 months (95% CI, 15.3 to 29.6). Grade ≥3 drug-related adverse events were observed in 40.8% of patients; 10.5% experienced adjudicated drug-related interstitial lung disease (ILD), with three deaths. CONCLUSION Our study demonstrates durable clinical benefit, meaningful survival outcomes, and safety consistent with the known profile (including ILD) in pretreated patients with HER2-expressing tumors receiving T-DXd. Greatest benefit was observed for the IHC 3+ population. These data support the potential role of T-DXd as a tumor-agnostic therapy for patients with HER2-expressing solid tumors.
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Affiliation(s)
- Funda Meric-Bernstam
- Department of Investigational Cancer Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vicky Makker
- Gynecologic Medical Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Ana Oaknin
- Gynaecologic Cancer Programme, Vall d’Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Do-Youn Oh
- Seoul National University Hospital; Cancer Research Institute, Seoul National University College of Medicine; Integrated Major in Innovative Medical Science, Seoul National University Graduate School, Seoul, South Korea
| | - Susana Banerjee
- Gynaecology Unit, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, United Kingdom
| | - Antonio González-Martín
- Medical Oncology Department and Programme in Solid Tumours-CIMA, Cancer Center Clínica Universidad de Navarra, Madrid, Spain
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Iwona Ługowska
- Early Phase Clinical Trials Unit and Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Luis Manso
- Department of Medical Oncology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Aránzazu Manzano
- Experimental Therapeutics in Cancer (UTEC), Department of Medical Oncology, Hospital Clínico San Carlos, Madrid, Spain
| | - Bohuslav Melichar
- Department of Oncology, Palacký University Medical School and University Hospital, Olomouc, Czech Republic
| | - Salvatore Siena
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda and the Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Piazza dell’Ospedale Maggiore, Milan, Italy
| | | | | | - Yan Ma
- Oncology R&D, AstraZeneca, Cambridge, United Kingdom
| | | | | | - Jung-Yun Lee
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, South Korea
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Ali A, Graff SL. Exploring DESTINY: the Past, Present, and Future of Trastuzumab Deruxtecan. Curr Oncol Rep 2024; 26:1-9. [PMID: 38091201 DOI: 10.1007/s11912-023-01478-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2023] [Indexed: 02/12/2024]
Abstract
PURPOSE OF REVIEW HER2-positive breast cancer accounts for 10-15% of all breast cancers and fam-trastuzumab deruxtecan (T-DXd) has played a major role in moving the treatment of HER2-expressing disease forward. RECENT FINDINGS T-DXd is a novel antibody-drug conjugate (ADC) composed of a humanized IgG1 monoclonal antibody against HER2 receptor bound to a potent topoisomerase I cytotoxin payload by a cleavable peptide linker. It has been shown to have robust preclinical activity in pretreated cancer cell lines, as well as meaningful clinical activity in advanced HER2-expressing breast cancer. Recent studies have demonstrated T-DXd as an active agent for metastatic HER2-positive patients, and as a viable additional line for heavily pretreated patients with HER2-low disease. The toxicity of T-DXd remains manageable and burden of side effects seems to be lower when offered as an earlier line of therapy over the course of treatment. In this review, we discuss the pharmacology of T-DXd, review pertinent preclinical and clinical data, and address potential challenges and future directions related to the use of T-DXd in clinical practice.
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Affiliation(s)
- Azka Ali
- Department of Breast Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, 9500 Euclid Ave / CA-060, Cleveland, OH, 44195, USA.
| | - Stephanie L Graff
- Division of Hematology & Medical Oncology, Lifespan Cancer Institute, Legorreta Cancer Center at Brown University, 593 Eddy St., Providence, RI, 02903, USA
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20
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Wekking D, Porcu M, Pellegrino B, Lai E, Mura G, Denaro N, Saba L, Musolino A, Scartozzi M, Solinas C. Multidisciplinary clinical guidelines in proactive monitoring, early diagnosis, and effective management of trastuzumab deruxtecan (T-DXd)-induced interstitial lung disease (ILD) in breast cancer patients. ESMO Open 2023; 8:102043. [PMID: 37951130 PMCID: PMC10679891 DOI: 10.1016/j.esmoop.2023.102043] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 11/13/2023] Open
Abstract
Trastuzumab deruxtecan (T-DXd), a human epidermal growth factor receptor 2 (HER2)-directed antibody-drug conjugate (ADC), has altered the treatment landscape in breast cancer (BC), irrespective of the HR-receptor status. The use of the agent is increasing, despite the finding that exposure to T-DXd increases the risk of interstitial lung disease (ILD), particularly in BC patients. Although T-DXd-related ILD can be potentially severe and life-threatening, most low-grade cases can be treated safely using a multidisciplinary approach comprising early and accurate diagnosis, effective management, close monitoring, and the prompt administration of steroids. Additionally, increasing patients' education on ILD symptoms ensures close attention and enables prompt reporting, enhancing patient outcomes. It is recommended that predictive biomarkers are assessed in patients with risk factors for developing ILD. Currently, diagnostic criteria comprise newly identified pulmonary opacities, the relation of symptom onset to medication initiation, and the exclusion of other causes of ILD. The general condition of patients is weakened during the management of ILD (BC progression and corticosteroid treatment). Consequently, BC chemotherapy might be attenuated. This highlights the importance of preventing (high-grade) ILD, especially since its use is expanded. Identifying high-risk patients, diagnosing, and customizing treatment is, however, challenging and additional information on patient selection is often not fully clarified. In this paper, we provide updated multidisciplinary clinical guidance for patient selection, proactive monitoring, early diagnosis, and effectively management of T-DXd-induced ILD in HER2-positive BC patients. We describe the risk factors for developing ILD, patients' characteristics of ILD, and the histopathological and radiographic characteristics of ILD, including real-world clinical practice reports. These recommendations provide a structured step-by-step approach for managing each suspected BC-related ILD grade.
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Affiliation(s)
- D Wekking
- Amsterdam UMC, Location Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - M Porcu
- Radiology Department, AOU Cagliari, Cagliari University, Policlinico di Monserrato, Monserrato (CA)
| | - B Pellegrino
- Department of Medicine and Surgery, University of Parma, Parma; Medical Oncology and Breast Unit, University Hospital of Parma, Parma; Gruppo Oncologico Italiano di Ricerca Clinica(GOIRC), Parma
| | - E Lai
- Medical Oncology, AOU Cagliari, Policlinico di Monserrato, Monserrato
| | - G Mura
- Anatomical Pathology, Valdes Laboratory, Cagliari
| | - N Denaro
- IRCCS Fondazone Ca' Granda Policlinico Milano, SC Oncologia, Milan, Italy
| | - L Saba
- Radiology Department, AOU Cagliari, Cagliari University, Policlinico di Monserrato, Monserrato (CA)
| | - A Musolino
- Department of Medicine and Surgery, University of Parma, Parma; Medical Oncology and Breast Unit, University Hospital of Parma, Parma; Gruppo Oncologico Italiano di Ricerca Clinica(GOIRC), Parma
| | - M Scartozzi
- Medical Oncology, AOU Cagliari, Policlinico di Monserrato, Monserrato
| | - C Solinas
- Medical Oncology, AOU Cagliari, Policlinico di Monserrato, Monserrato
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21
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Filis P, Zerdes I, Soumala T, Matikas A, Foukakis T. The ever-expanding landscape of antibody-drug conjugates (ADCs) in solid tumors: A systematic review. Crit Rev Oncol Hematol 2023; 192:104189. [PMID: 37866413 DOI: 10.1016/j.critrevonc.2023.104189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 09/29/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND The advent of targeted therapies signaled novel avenues for more optimal oncological outcomes. Antibody-drug conjugates (ADCs) have risen as a cornerstone of the ever-expanding targeted therapy era. The purpose of this systematic review is to delineate the rapidly evolving clinical landscape of ADCs for solid tumors. METHODS A literature search was performed in Medline, Embase and Cochrane databases for phase II and III clinical trials. Outcomes of interest were the objective response rate, overall survival, progression-free survival and adverse events. RESULTS A total of 92 clinical trials (76 phase II and 16 phase III) evaluated the efficacy and safety of ADCs for a plethora of solid tumors. Out of the 30 investigated ADCs, 8 have received approval by regulatory organizations for solid tumors. Currently, 52 phase III clinical trials for ADCs are ongoing. CONCLUSION ADCs have shown promising results for several solid tumors and various cancer settings.
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Affiliation(s)
- Panagiotis Filis
- Department of Oncology/Pathology, Karolinska Institutet, Stockholm, Sweden; Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece.
| | - Ioannis Zerdes
- Department of Oncology/Pathology, Karolinska Institutet, Stockholm, Sweden; Breast Center, Karolinska Comprehensive Cancer Center and Karolinska University Hospital, Stockholm, Sweden
| | - Theodora Soumala
- Department of Oncology/Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Alexios Matikas
- Department of Oncology/Pathology, Karolinska Institutet, Stockholm, Sweden; Breast Center, Karolinska Comprehensive Cancer Center and Karolinska University Hospital, Stockholm, Sweden
| | - Theodoros Foukakis
- Department of Oncology/Pathology, Karolinska Institutet, Stockholm, Sweden; Breast Center, Karolinska Comprehensive Cancer Center and Karolinska University Hospital, Stockholm, Sweden.
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22
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Neupane N, Thapa S, Bhattarai A, Ahuja K, Schlam I, Mittal A, Tolaney SM, Tarantino P. Opportunities and Challenges for a Histology-Agnostic Utilization of Trastuzumab Deruxtecan. Curr Oncol Rep 2023; 25:1467-1482. [PMID: 37938529 DOI: 10.1007/s11912-023-01469-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE OF REVIEW This review delves into the prospects and challenges offered by a potential pan-histological utilization of trastuzumab deruxtecan (T-DXd) in patients with advanced solid tumors. RECENT FINDINGS The HER2-targeted antibody-drug conjugate (ADC) T-DXd has shown broad activity across cancer types, with current indications for patients with biomarker-selected breast, gastric, and non-small-cell lung cancer and relevant activity observed in multiple histology-specific trials. Moreover, two recently reported phase 2 trials (DESTINY-Pantumor02 and HERALD) have supported the potential for a pan-cancer utilization of this ADC in patients with advanced cancers expressing HER2 or with HER2 amplifications. By improving the delivery of cytotoxic chemotherapy, ADCs have allowed for meaningful clinical advantages in broad populations of cancer patients, often leading to survival advantages over conventional chemotherapy. Notably, the broad spectrum of activity of certain ADCs has led to the hypothesis of a histology-agnostic utilization based on detecting specific biomarkers, similar to what is already established for certain targeted treatments and immunotherapy. To date, T-DXd has shown the broadest activity across cancer types, with current approvals in breast, gastric, and lung cancer, and relevant antitumor activity observed in a multiplicity of additional cancer types. The optimization of the drug dose, identification of predictive biomarkers, and clarification of mechanisms of resistance will be critical steps in view of a pan-histological expansion in the use of T-DXd.
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Affiliation(s)
| | - Sangharsha Thapa
- Westchester Medical Center, New York Medical College, New York, NY, USA
| | - Abhinav Bhattarai
- Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
- Medical Database, Irvine, CA, USA
| | - Kriti Ahuja
- Internal Medicine, John H Stroger Hospital of Cook County, Chicago, IL, USA
| | - Ilana Schlam
- Division of Hematology and Oncology, Tufts Medical Center, Boston, MA, USA
- Tufts University, Boston, MA, USA
| | - Abhenil Mittal
- Health Sciences North, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Sara M Tolaney
- Breast Oncology Program, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Paolo Tarantino
- Breast Oncology Program, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
- Harvard Medical School, Boston, MA, USA.
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
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23
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Baba T, Kusumoto M, Kato T, Kurihara Y, Sasaki S, Oikado K, Saito Y, Endo M, Fujiwara Y, Kenmotsu H, Sata M, Takano T, Kato K, Hirata K, Katagiri T, Saito H, Kuwano K. Clinical and imaging features of interstitial lung disease in cancer patients treated with trastuzumab deruxtecan. Int J Clin Oncol 2023; 28:1585-1596. [PMID: 37787866 PMCID: PMC10687185 DOI: 10.1007/s10147-023-02414-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/06/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Interstitial lung disease/pneumonitis (ILD/pneumonitis) has been identified as a drug-related adverse event of special interest of trastuzumab deruxtecan (T-DXd), but there were a few reports of T-DXd-related ILD/pneumonitis in clinical practice. METHODS Between May 25, 2020 (the launch of T-DXd in Japan) and February 24, 2022, there were 287 physician-reported potential ILD/pneumonitis cases from the Japanese post-marketing all-case surveillance. By February 27, 2022, an independent adjudication committee assessed 138 cases and adjudicated 130 cases as T-DXd-related ILD/pneumonitis. The clinical features and imaging characteristics of these cases were evaluated. RESULTS The majority of adjudicated T-DXd-related ILD/pneumonitis cases were grade 1 or 2 (100/130, 76.9%). The most common radiological pattern types observed were organizing pneumonia patterns (63.1%), hypersensitivity pneumonitis patterns (16.9%), and diffuse alveolar damage (DAD) patterns (14.6%). Eleven cases (8.5%) from 130 resulted in death; the majority of these (8/11, 72.7%) had DAD patterns. The overall proportion of recovery (including the outcomes of recovered, recovered with sequelae, and recovering) was 76.9%, and the median time to recovery was 83.5 days (interquartile range: 42.25-143.75 days). Most cases (59/71, 83.1%) that were treated with corticosteroids were considered responsive to treatment. CONCLUSIONS This is the first report to evaluate T-DXd-related ILD/pneumonitis cases in clinical practice. Our findings are consistent with previous reports and suggest that patients with DAD patterns have poor outcomes. Evaluation of a larger real-world dataset may further identify predictors of clinical outcome.
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Affiliation(s)
- Tomohisa Baba
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomiokahigashi, Kanazawa-ku, Yokohama-shi, Kanagawa, 236-0051, Japan.
| | - Masahiko Kusumoto
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Terufumi Kato
- Department of Thoracic Oncology, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama-shi, Kanagawa, 241-8515, Japan
| | - Yasuyuki Kurihara
- Department of Radiology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Shinichi Sasaki
- Department of Respiratory Medicine, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu-shi, Chiba, 279-0021, Japan
| | - Katsunori Oikado
- Department of Diagnostic Imaging, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan
| | - Yoshinobu Saito
- Department of Pulmonary Medicine and Oncology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
| | - Masahiro Endo
- Division of Diagnostic Radiology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Yutaka Fujiwara
- Department of Thoracic Oncology, Aichi Cancer Center Hospital, 1-1 Shikoden, Chikusa-ku, Nagoya-shi, Aichi, 464-8681, Japan
| | - Hirotsugu Kenmotsu
- Division of Thoracic Oncology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Masafumi Sata
- Division of Respiratory Medicine, Department of Internal Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Toshimi Takano
- Breast Medical Oncology Department, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto, Tokyo, 135-8550, Japan
| | - Ken Kato
- Department of Head and Neck, Esophageal Medical Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Koji Hirata
- Clinical Safety and Pharmacovigilance Division, Medical Safety Department, Daiichi Sankyo Co., Ltd., 3-5-1, Nihonbashi Honcho, Chuo-ku, Tokyo, 103-8426, Japan
| | - Tomomi Katagiri
- Clinical Safety and Pharmacovigilance Division, Medical Safety Department, Daiichi Sankyo Co., Ltd., 3-5-1, Nihonbashi Honcho, Chuo-ku, Tokyo, 103-8426, Japan
| | - Hanako Saito
- Clinical Safety and Pharmacovigilance Division, Medical Safety Department, Daiichi Sankyo Co., Ltd., 3-5-1, Nihonbashi Honcho, Chuo-ku, Tokyo, 103-8426, Japan
| | - Kazuyoshi Kuwano
- Division of Respiratory Diseases, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan
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Gui X, Zhao J, Ding L, Chai J, Lai H, Cai Y, Luo S, Zeng Y, Wu W, Chen H, Yao H, Wang Y. Assessing real-world safety concerns of Sacituzumab govitecan: a disproportionality analysis using spontaneous reports in the FDA adverse event reporting system. Front Oncol 2023; 13:1276976. [PMID: 37869095 PMCID: PMC10587566 DOI: 10.3389/fonc.2023.1276976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
Aim The aim of this study was to identify potential safety concerns associated with Sacituzumab Govitecan (SG), an antibody-drug conjugate targeting trophoblastic cell-surface antigen-2, by analyzing real-world safety data from the largest publicly available worldwide pharmacovigilance database. Methods All data obtained from the FDA Adverse Event Reporting System (FAERS) database from the second quarter of 2020 to the fourth quarter of 2022 underwent disproportionality analysis and Bayesian analysis to detect and assess the adverse event signals of SG, considering statistical significance when the lower limit of the 95% CI >1, based on at least 3 reports. Results Total of 1072 cases were included. The main safety signals were blood and lymphatic system disorders [ROR(95CI)=7.23 (6.43-8.14)], gastrointestinal disorders [ROR(95CI)=2.01 (1.81-2.22)], and relative infection adverse events, such as neutropenic sepsis [ROR(95CI)=46.02 (27.15-77.99)] and neutropenic colitis [ROR(95CI)=188.02 (120.09-294.37)]. We also noted unexpected serious safety signals, including large intestine perforation [ROR(95CI)=10.77 (3.47-33.45)] and hepatic failure [ROR(95CI)=3.87 (1.45-10.31)], as well as a high signal for pneumonitis [ROR(95CI)=9.93 (5.75-17.12)]. Additionally, age sub-group analysis revealed that geriatric patients (>65 years old) were at an increased risk of neutropenic colitis [ROR(95CI)=282.05 (116.36-683.66)], neutropenic sepsis [ROR(95CI)=101.11 (41.83-244.43)], acute kidney injury [ROR(95CI)=3.29 (1.36-7.94)], and atrial fibrillation [ROR(95CI)=6.91 (2.86-16.69)]. Conclusion This study provides crucial real-world safety data on SG, complementing existing clinical trial information. Practitioners should identify contributing factors, employ monitoring and intervention strategies, and focus on adverse events like neutropenic sepsis, large intestine perforation, and hepatic failure. Further prospective studies are needed to address these safety concerns for a comprehensive understanding and effective management of associated risks.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Herui Yao
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ying Wang
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
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Chiu JWY, Lee SC, Ho JCM, Park YH, Chao TC, Kim SB, Lim E, Lin CH, Loi S, Low SY, Teo LLS, Yeo W, Dent R. Clinical Guidance on the Monitoring and Management of Trastuzumab Deruxtecan (T-DXd)-Related Adverse Events: Insights from an Asia-Pacific Multidisciplinary Panel. Drug Saf 2023; 46:927-949. [PMID: 37552439 PMCID: PMC10584766 DOI: 10.1007/s40264-023-01328-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 08/09/2023]
Abstract
Trastuzumab deruxtecan (T-DXd)-an antibody-drug conjugate targeting the human epidermal growth factor receptor 2 (HER2)-improved outcomes of patients with HER2-positive and HER2-low metastatic breast cancer. Guidance on monitoring and managing T-DXd-related adverse events (AEs) is an emerging unmet need as translating clinical trial experience into real-world practice may be difficult due to practical and cultural considerations and differences in health care infrastructure. Thus, 13 experts including oncologists, pulmonologists and a radiologist from the Asia-Pacific region gathered to provide recommendations for T-DXd-related AE monitoring and management by using the latest evidence from the DESTINY-Breast trials, our own clinical trial experience and loco-regional health care considerations. While subgroup analysis of Asian (excluding Japanese) versus overall population in the DESTINY-Breast03 uncovered no major differences in the AE profile, we concluded that proactive monitoring and management are essential in maximising the benefits with T-DXd. As interstitial lung disease (ILD)/pneumonitis is a serious AE, patients should undergo regular computed tomography scans, but the frequency may have to account for the median time of ILD/pneumonitis onset and access. Trastuzumab deruxtecan appears to be a highly emetic regimen, and prophylaxis with serotonin receptor antagonists and dexamethasone (with or without neurokinin-1 receptor antagonist) should be considered. Health care professionals should be vigilant for treatable causes of fatigue, and patients should be encouraged to use support groups and practice low-intensity exercises. To increase treatment acceptance, patients should be made aware of alopecia risk prior to starting T-DXd. Detailed monitoring and management recommendations for T-DXd-related AEs are discussed further.
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Affiliation(s)
- Joanne Wing Yan Chiu
- The University of Hong Kong, Hong Kong, Hong Kong Special Administrative Region Hong Kong
| | - Soo Chin Lee
- National University Cancer Institute Singapore, National University Health System, Singapore, Singapore
| | - James Chung-man Ho
- The University of Hong Kong, Hong Kong, Hong Kong Special Administrative Region Hong Kong
| | - Yeon Hee Park
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ta-Chung Chao
- Division of Medical Oncology, Department of Oncology, Faculty of Medicine, Taipei Veterans General Hospital, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Sung-Bae Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Elgene Lim
- Faculty of Medicine and Health, Garvan Institute of Medical Research and St Vincent’s Clinical School, University of New South Wales, Sydney, NSW Australia
| | - Ching-Hung Lin
- Cancer Center Branch, National Taiwan University Hospital, Taipei, Taiwan
| | - Sherene Loi
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Medical Oncology, University of Melbourne, Melbourne, Australia
| | - Su Ying Low
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Winnie Yeo
- The Chinese University of Hong Kong, Sha Tin, Hong Kong Special Administrative Region Hong Kong
| | - Rebecca Dent
- National Cancer Centre Singapore, Singapore, Singapore
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de Weger VA, Schutte T, Konings IRHM, Menke-van der Houven van Oordt CW. Successful Trastuzumab-Deruxtecan Rechallenge After Interstitial Lung Disease: A Case Report. J Breast Cancer 2023; 26:519-523. [PMID: 37926069 PMCID: PMC10625870 DOI: 10.4048/jbc.2023.26.e38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/20/2023] [Accepted: 08/08/2023] [Indexed: 11/07/2023] Open
Abstract
Trastuzumab deruxtecan (T-DXd) is used to treat human epidermal growth factor receptor 2-positive advanced breast cancer. Interstitial lung disease (ILD) is a severe adverse event associated with T-DXd. Current guidelines recommend permanent discontinuation of T-DXd after Common Terminology Criteria for Adverse Events (CTCAE) grade ≥ 2 ILD. Here, we describe a case of successful rechallenge with T-DXd after CTCAE grade 2 treatment-induced ILD. After discontinuation of T-DXd, ILD was treated with steroids until complete resolution. Given the initial beneficial antitumor response, retreatment was discussed during disease progression. In a shared decision with the patient, T-DXd was restarted at the lowest registered dose, along with low-dose steroids. ILD did not reoccur. Importantly, both clinical and radiological responses to the treatment were observed, with an improvement in the patient's quality of life. This case demonstrates that retreatment with T-DXd after a grade 2 ILD event is feasible and yields clinical benefit.
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Affiliation(s)
- Vincent A de Weger
- Department of Medical Oncology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Tim Schutte
- Department of Medical Oncology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Inge R H M Konings
- Department of Medical Oncology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
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27
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Tapia M, Hernando C, Martínez MT, Burgués O, Tebar-Sánchez C, Lameirinhas A, Ágreda-Roca A, Torres-Ruiz S, Garrido-Cano I, Lluch A, Bermejo B, Eroles P. Clinical Impact of New Treatment Strategies for HER2-Positive Metastatic Breast Cancer Patients with Resistance to Classical Anti-HER Therapies. Cancers (Basel) 2023; 15:4522. [PMID: 37760491 PMCID: PMC10527351 DOI: 10.3390/cancers15184522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/24/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
HER2-positive breast cancer accounts for 15-20% of all breast cancer cases. This subtype is characterized by an aggressive behavior and poor prognosis. Anti-HER2 therapies have considerably improved the natural course of the disease. Despite this, relapse still occurs in around 20% of patients due to primary or acquired treatment resistance, and metastasis remains an incurable disease. This article reviews the main mechanisms underlying resistance to anti-HER2 treatments, focusing on newer HER2-targeted therapies. The progress in anti-HER2 drugs includes the development of novel antibody-drug conjugates with improvements in the conjugation process and novel linkers and payloads. Moreover, trastuzumab deruxtecan has enhanced the efficacy of trastuzumab emtansine, and the new drug trastuzumab duocarmazine is currently undergoing clinical trials to assess its effect. The combination of anti-HER2 agents with other drugs is also being evaluated. The addition of immunotherapy checkpoint inhibitors shows some benefit in a subset of patients, indicating the need for useful biomarkers to properly stratify patients. Besides, CDK4/6 and tyrosine kinase inhibitors are also included in the design of new treatment strategies. Lapitinib, neratinib and tucatinib have been approved for HER2-positive metastasis patients, however clinical trials are currently ongoing to optimize combined strategies, to reduce toxicity, and to better define the useful setting. Clinical research should be strengthened along with the discovery and validation of new biomarkers, as well as a deeper understanding of drug resistance and action mechanisms.
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Affiliation(s)
- Marta Tapia
- Department of Clinical Oncology, University Clinical Hospital of Valencia, 46010 Valencia, Spain; (M.T.); (C.H.); (M.T.M.); (C.T.-S.); (A.L.); (B.B.)
- Biomedical Research Institute INCLIVA, 46010 Valencia, Spain; (A.L.); (A.Á.-R.); (S.T.-R.); (I.G.-C.)
| | - Cristina Hernando
- Department of Clinical Oncology, University Clinical Hospital of Valencia, 46010 Valencia, Spain; (M.T.); (C.H.); (M.T.M.); (C.T.-S.); (A.L.); (B.B.)
- Biomedical Research Institute INCLIVA, 46010 Valencia, Spain; (A.L.); (A.Á.-R.); (S.T.-R.); (I.G.-C.)
| | - María Teresa Martínez
- Department of Clinical Oncology, University Clinical Hospital of Valencia, 46010 Valencia, Spain; (M.T.); (C.H.); (M.T.M.); (C.T.-S.); (A.L.); (B.B.)
- Biomedical Research Institute INCLIVA, 46010 Valencia, Spain; (A.L.); (A.Á.-R.); (S.T.-R.); (I.G.-C.)
| | - Octavio Burgués
- Department of Pathology, Hospital Clinic of Valencia, 46010 Valencia, Spain;
- Biomedical Research Networking Center in Oncology (CIBERONC), 28029 Madrid, Spain
| | - Cristina Tebar-Sánchez
- Department of Clinical Oncology, University Clinical Hospital of Valencia, 46010 Valencia, Spain; (M.T.); (C.H.); (M.T.M.); (C.T.-S.); (A.L.); (B.B.)
- Biomedical Research Institute INCLIVA, 46010 Valencia, Spain; (A.L.); (A.Á.-R.); (S.T.-R.); (I.G.-C.)
| | - Ana Lameirinhas
- Biomedical Research Institute INCLIVA, 46010 Valencia, Spain; (A.L.); (A.Á.-R.); (S.T.-R.); (I.G.-C.)
| | - Anna Ágreda-Roca
- Biomedical Research Institute INCLIVA, 46010 Valencia, Spain; (A.L.); (A.Á.-R.); (S.T.-R.); (I.G.-C.)
| | - Sandra Torres-Ruiz
- Biomedical Research Institute INCLIVA, 46010 Valencia, Spain; (A.L.); (A.Á.-R.); (S.T.-R.); (I.G.-C.)
| | - Iris Garrido-Cano
- Biomedical Research Institute INCLIVA, 46010 Valencia, Spain; (A.L.); (A.Á.-R.); (S.T.-R.); (I.G.-C.)
- Interuniversity Research Institute for Molecular Recognition and Technological Development (IDM), Polytechnic University of Valencia, University of Valencia, 46022 Valencia, Spain
| | - Ana Lluch
- Department of Clinical Oncology, University Clinical Hospital of Valencia, 46010 Valencia, Spain; (M.T.); (C.H.); (M.T.M.); (C.T.-S.); (A.L.); (B.B.)
- Biomedical Research Institute INCLIVA, 46010 Valencia, Spain; (A.L.); (A.Á.-R.); (S.T.-R.); (I.G.-C.)
- Biomedical Research Networking Center in Oncology (CIBERONC), 28029 Madrid, Spain
- Department of Medicine, University of Valencia, 46010 Valencia, Spain
| | - Begoña Bermejo
- Department of Clinical Oncology, University Clinical Hospital of Valencia, 46010 Valencia, Spain; (M.T.); (C.H.); (M.T.M.); (C.T.-S.); (A.L.); (B.B.)
- Biomedical Research Institute INCLIVA, 46010 Valencia, Spain; (A.L.); (A.Á.-R.); (S.T.-R.); (I.G.-C.)
- Biomedical Research Networking Center in Oncology (CIBERONC), 28029 Madrid, Spain
- Department of Medicine, University of Valencia, 46010 Valencia, Spain
| | - Pilar Eroles
- Biomedical Research Institute INCLIVA, 46010 Valencia, Spain; (A.L.); (A.Á.-R.); (S.T.-R.); (I.G.-C.)
- Biomedical Research Networking Center in Oncology (CIBERONC), 28029 Madrid, Spain
- Department of Physiology, University of Valencia, 46010 Valencia, Spain
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Teixeira L, Diéras V, Crestani B, Lederlin M, Villanueva C, Duchemann B, Pierga JY, Cadranel J. [Diagnosis and management of interstitial lung disease induced by antibody-drug conjugates in breast cancer: A French expert opinion paper]. Bull Cancer 2023; 110:937-949. [PMID: 37331827 DOI: 10.1016/j.bulcan.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 06/20/2023]
Abstract
Interstitial lung disease (ILD) has been reported with many cancer drugs including some recent antibody-drug conjugates (ADCs). The mechanisms of ILD induced by many chemotherapy drugs, other drug classes and ADCs used in cancer, including breast cancer, are not clearly elucidated. In the absence of specific clinical or radiological signs, the diagnosis of drug-induced ILD is often a diagnosis of exclusion. When present, the most frequent symptoms are respiratory signs (cough, dyspnea, chest pain) and general signs (fatigue, fever). Any suspicion of ILD should be evaluated by imaging and, if in doubt, the CT scan should be evaluated by a pulmonologist and a radiologist. A network of multidisciplinary experts for proactive early management of ILD is important, including oncologist, radiologist, pulmonologist, infectious disease specialist and nurses. Patient education is essential to report new or exacerbated lung symptoms and prevent high-grade ILD. Study drug is discontinued temporarily or permanently according to ILD severity and type of ADC. For asymptomatic cases (Grade 1), the efficacy of corticosteroids is not clearly established; for higher grades, the benefit/risk balance of long-term corticosteroid therapy should be considered for the dose and treatment duration. Hospitalization and oxygen supplementation are required for severe cases (Grades 3-4). For patient follow-up, the expertise of a pulmonologist is necessary with repeated chest scans, spirometry and DLCO. Preventing ADC-induced ILDs and evolution to high grade rests on a network of multidisciplinary experts for assessment of individual risk factors, early management, close follow-up and patient education.
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Affiliation(s)
- Luis Teixeira
- AP-HP, hôpital Saint-Louis, service de sénologie, Inserm U976, HIPI, Paris, France; Université Paris Cité, Paris, France.
| | - Véronique Diéras
- Centre Eugène-Marquis, département d'oncologie médicale, Rennes, France
| | - Bruno Crestani
- Université Paris Cité, Inserm U1152, Paris, France; Assistance publique-Hôpitaux de Paris, hôpital Bichat, département de pneumologie, Paris, France
| | - Mathieu Lederlin
- CHU de Rennes, université de Rennes, département de radiologie, Rennes, France
| | - Cristian Villanueva
- Centre de cancérologie de Montpellier, département d'oncologie médicale, Montpellier, France
| | - Boris Duchemann
- Hôpital Avicenne, département d'oncologie médicale, Bobigny, France
| | - Jean-Yves Pierga
- Institut Curie, département d'oncologie médicale, Paris et Saint-Cloud, France; Université Paris Cité, Paris, France
| | - Jacques Cadranel
- AP-HP Tenon, Sorbonne université, centre de référence constitutif des maladies pulmonaires rares, service de pneumologie et oncologie thoracique, Paris, France
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29
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Henning JW, Brezden-Masley C, Gelmon K, Chia S, Shapera S, McInnis M, Rayson D, Asselah J. Managing the Risk of Lung Toxicity with Trastuzumab Deruxtecan (T-DXd): A Canadian Perspective. Curr Oncol 2023; 30:8019-8038. [PMID: 37754497 PMCID: PMC10529919 DOI: 10.3390/curroncol30090582] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 09/28/2023] Open
Abstract
Ongoing advances in precision cancer therapy have increased the number of molecularly targeted and immuno-oncology agents for a variety of cancers, many of which have been associated with a risk of pulmonary complications, among the most concerning being drug-induced interstitial lung disease/pneumonitis (DI-ILD). As the number of patients undergoing treatment with novel anticancer agents continues to grow, DI-ILD is expected to become an increasingly significant clinical challenge. Trastuzumab deruxtecan (T-DXd) is an antibody-drug conjugate targeting human epidermal growth factor receptor 2 that is gaining widespread use in the metastatic breast cancer setting and is undergoing exploration for other oncologic indications. ILD/pneumonitis is an adverse event of special interest associated with T-DXd, which has potentially fatal consequences if left untreated and allowed to progress. When identified in the asymptomatic stage (grade 1), T-DXd-related ILD can be monitored and treated effectively with the possibility of treatment continuation. Delayed diagnosis and/or treatment, however, results in progression to grade 2 or higher toxicity and necessitates immediate and permanent discontinuation of this active agent. Strategies are, therefore, needed to optimize careful monitoring during treatment to ensure patient safety and optimize outcomes. Several guidance documents have been developed regarding strategies for the early identification and management of T-DXd-related ILD, although none have been within the context of the Canadian health care environment. A Canadian multidisciplinary steering committee was, therefore, convened to evaluate existing recommendations and adapt them for application in Canada. A multidisciplinary approach involving collaboration among medical oncologists, radiologists, respirologists, and allied health care professionals is needed to ensure the proactive identification and management of T-DXd-related ILD and DI-ILD associated with other agents with a similar toxicity profile.
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Affiliation(s)
| | | | - Karen Gelmon
- BC Cancer Agency, 600 10th Avenue West, Vancouver, BC V5Z 4E6, Canada; (K.G.); (S.C.)
| | - Stephen Chia
- BC Cancer Agency, 600 10th Avenue West, Vancouver, BC V5Z 4E6, Canada; (K.G.); (S.C.)
| | - Shane Shapera
- University Health Network, University of Toronto, Toronto General Hospital, 9N-971, 585 University Avenue, Toronto, ON M5G 2N2, Canada;
| | - Micheal McInnis
- Department of Medical Imaging, University of Toronto, 585 University Ave, Toronto, ON M5G 2N2, Canada;
| | - Daniel Rayson
- Department of Medical Oncology, Dalhousie University, QEII-Bethune Building, 1276 South Park Street, Halifax, NS B3H 2Y9, Canada;
| | - Jamil Asselah
- Cedars Cancer Centre, McGill University Health Centre, 1001 Decarie Boulevard, Montreal, QC H4A 3J1, Canada;
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30
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Soares LR, Vilbert M, Rosa VDL, Oliveira JL, Deus MM, Freitas-Junior R. Incidence of interstitial lung disease and cardiotoxicity with trastuzumab deruxtecan in breast cancer patients: a systematic review and single-arm meta-analysis. ESMO Open 2023; 8:101613. [PMID: 37481956 PMCID: PMC10485391 DOI: 10.1016/j.esmoop.2023.101613] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/30/2023] [Accepted: 06/24/2023] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND Trastuzumab deruxtecan (T-DXd) has been shown to benefit progression-free survival and overall survival in patients with metastatic breast cancer (mBC) after progression on ≥1 human epidermal growth factor receptor 2 (HER2)-targeted therapies. However, interstitial lung disease (ILD) and cardiotoxicity are the most significant toxicities associated with T-DXd. Therefore, we conducted a systematic review and meta-analysis to assess the incidence and severity of these toxicities in mBC patients treated with T-DXd. MATERIALS AND METHODS We searched PubMed, Cochrane, and Scopus databases, and conferences websites for randomized clinical trials and nonrandomized studies of intervention including HER2-low or HER2-positive mBC patients who received at least one dose of T-DXd. Statistical analysis was carried out using R software. RESULTS We included 15 studies comprising 1970 patients with a mean follow-up of 13.3 months. Median age ranged from 53 to 59 years, 61.9% were non-Asian, and 67.4% had hormone receptor-positive mBC. In a pooled analysis, the incidence of ILD was 11.7% [222 patients; 95% confidence interval (CI) 9.1% to 15.0%]. Patients receiving T-DXd dose of 6.4 mg/kg developed a significantly higher rate of ILD (22.7%) compared to those receiving a dose of 5.4 mg/kg (9.3%) (P < 0.01). Most cases of ILD (80.2%; 174/217 patients) were mild (grade 1 or 2). Grade 3 or 4 ILD was reported in 29 patients (13.4%), and grade 5 in 14 patients (6.4%). The incidence of decreased left ventricular ejection fraction (LVEF) was 1.95% (95% CI 0.65% to 3.73%), and the QT interval (QTi) prolongation was 7.77% (95% CI 2.74% to 20.11%). Most patients were asymptomatic, but four had LV dysfunction and heart failure (0.26%). CONCLUSIONS In this meta-analysis of 1970 patients with mBC, treatment with T-DXd was associated with a 11.7% incidence of ILD, 7.7% incidence of prolonged QTi, and 1.9% incidence of reduced LVEF. Early detection and management of T-DXd-related toxicity by a multidisciplinary team may ultimately improve patient outcomes.
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Affiliation(s)
- L R Soares
- Centro Avançado de Diagnóstico da Mama (CORA), Teaching Hospital, Federal University of Goiás (UFG), Goiânia; Department of Medicine, Post-Graduation Program in Health Sciences, Federal University of Goiás (UFG), Goiânia; Dona Íris Hospital and Maternity, Municipal Health Department, Goiânia, Brazil.
| | - M Vilbert
- Princess Margaret Cancer Centre, University Health Network, Toronto; Department of Medicine, Division of Medical Oncology, University of Toronto, Toronto, Canada
| | - V D L Rosa
- Centro Avançado de Diagnóstico da Mama (CORA), Teaching Hospital, Federal University of Goiás (UFG), Goiânia; Department of Medicine, Post-Graduation Program in Health Sciences, Federal University of Goiás (UFG), Goiânia
| | - J L Oliveira
- Dona Íris Hospital and Maternity, Municipal Health Department, Goiânia, Brazil
| | - M M Deus
- Department of Medicine, Post-Graduation Program in Health Sciences, Federal University of Goiás (UFG), Goiânia
| | - R Freitas-Junior
- Centro Avançado de Diagnóstico da Mama (CORA), Teaching Hospital, Federal University of Goiás (UFG), Goiânia; Department of Medicine, Post-Graduation Program in Health Sciences, Federal University of Goiás (UFG), Goiânia
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31
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D’Arienzo A, Verrazzo A, Pagliuca M, Napolitano F, Parola S, Viggiani M, Caputo R, Puglisi F, Giuliano M, Del Mastro L, Arpino G, De Laurentiis M, Montemurro F. Toxicity profile of antibody-drug conjugates in breast cancer: practical considerations. EClinicalMedicine 2023; 62:102113. [PMID: 37554126 PMCID: PMC10404866 DOI: 10.1016/j.eclinm.2023.102113] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 08/10/2023] Open
Abstract
Antibody-drug conjugates (ADCs) represent a novel and evolving class of antineoplastic agents, constituted by monoclonal antibody linked to biologically active drugs, delivering cytotoxic compounds at the tumor site, reducing the likelihood of systemic exposure and toxicity. They are generally well tolerated, nevertheless some predictable adverse reactions need careful monitoring and timely approach. These include neutropenia, nausea and vomiting, alopecia, diarrhea, left ventricular dysfunction, ILD/pneumonitis. The mechanisms leading to drug-associated toxicities are summarized, and prophylaxis protocols and appropriate management strategies are proposed, based on current literature. This review aims to collect the most updated evidence on toxicities potentially occurring during breast cancer treatment with approved or under clinical investigation (advanced stage) ADCs. A focus is dedicated to monitoring protocols and clinical management, aimed at preventing and/or promptly address relevant problems, in order to avoid premature discontinuation or improper dose reduction.
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Affiliation(s)
- Andrea D’Arienzo
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Annarita Verrazzo
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
- Scuola Superiore Meridionale (SSM), Clinical and Translational Oncology, Via Mezzocannone 4, Naples 80138, Italy
| | - Martina Pagliuca
- Scuola Superiore Meridionale (SSM), Clinical and Translational Oncology, Via Mezzocannone 4, Naples 80138, Italy
- Molecular Predictors and New Targets in Oncology Unit 981, Gustave Roussy, 114 Rue Édouard-Vaillant, Villejuif 94805, France
| | - Fabiana Napolitano
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Sara Parola
- Oncology Unit, PO di San Felice a Cancello, Via Roma 349, San Felice a Cancello, Caserta 81021, Italy
| | - Martina Viggiani
- Department of Oncology, HFR Fribourg-Cantonal Hospital, Chemin des Pensionnats 2-6, Fribourg 1708, Switzerland
| | - Roberta Caputo
- Division of Breast Medical Oncology, Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, Via Mariano Semmola 52, Naples 80131, Italy
| | - Fabio Puglisi
- Department of Medicine, University of Udine, Via Palladio 8, Udine 33100, Italy
- Department of Medical Oncology, CRO Aviano, National Cancer Institute, IRCCS, Via Franco Gallini 2, Aviano, Pordenone 33081, Italy
| | - Mario Giuliano
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Lucia Del Mastro
- Department of Medical Oncology, UO Oncologia Medica 2, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, Genova 16132, Italy
| | - Grazia Arpino
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Michelino De Laurentiis
- Division of Breast Medical Oncology, Istituto Nazionale Tumori IRCCS “Fondazione G. Pascale”, Via Mariano Semmola 52, Naples 80131, Italy
| | - Filippo Montemurro
- Candiolo Cancer Institute, FPO-IRCCS, Strada Provinciale 142 -KM 3.95, Candiolo, Torino 10060, Italy
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32
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Moy B, Wolff AC, Rumble RB, Allison KH, Carey LA. Chemotherapy and Targeted Therapy for Endocrine-Pretreated or Hormone Receptor-Negative Metastatic Breast Cancer and Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer: ASCO Guideline Rapid Recommendation Update Q and A. JCO Oncol Pract 2023; 19:547-550. [PMID: 37284796 DOI: 10.1200/op.23.00047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/06/2023] [Accepted: 02/23/2023] [Indexed: 06/08/2023] Open
Abstract
5 med onc and path leaders help clinicians with HER2-low ADC decisions re patients, sequence, and AE
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Affiliation(s)
| | - Antonio C Wolff
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | | | - Lisa A Carey
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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Nader-Marta G, Molinelli C, Debien V, Martins-Branco D, Aftimos P, de Azambuja E, Awada A. Antibody-drug conjugates: the evolving field of targeted chemotherapy for breast cancer treatment. Ther Adv Med Oncol 2023; 15:17588359231183679. [PMID: 37435563 PMCID: PMC10331351 DOI: 10.1177/17588359231183679] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 05/31/2023] [Indexed: 07/13/2023] Open
Abstract
Antibody-drug conjugates (ADCs) are a class of antineoplastic agents whose structure is composed of three main components: a monoclonal antibody (mAB) targeting a specific target antigen, a cytotoxic payload, and a linker binding the antibody to the payload. By combining the specificity of mABs with the high potency of the payloads, ADCs constitute a smart drug delivery system with improved therapeutic index. After recognition and binding of the mAB to its target surface antigen, ADCs are internalized by endocytosis by the tumor cell, releasing the payloads into the cytoplasm, where they exert their cytotoxic activity, eventually leading to cell death. The composition of some of the new ADCs confers additional functional properties that allow expanding their activity to neighboring cells not expressing the target antigen, constituting a valuable strategy to overcome tumor heterogeneity. Some of these 'off-target effects', such as the bystander effect, are possibly the mechanism underlying the antitumor activity demonstrated in patients with low expression of the target antigens, which represents an important paradigm shift in anticancer targeted therapy. Three ADCs are currently approved for the treatment of breast cancer (BC); two anti-HER2 (human epidermal growth factor receptor 2) ADCs (trastuzumab emtansine and trastuzumab deruxtecan); and one Trop-2-targeted ADC (sacituzumab govitecan). Based on the unprecedented efficacy data demonstrated by these agents, ADCs have been incorporated as part of standard regimens for all subtypes of advanced BC, as well as for high-risk early HER2-positive BC. Despite the remarkable advances, several hurdles still remain to overcome, including the development of reliable biomarkers for patient selection, prevention, and management of potentially severe toxicities, ADC resistance mechanisms, post-ADC resistance patterns, and optimal treatment sequencing and combinations. In this review, we will summarize the currently available evidence related to the use of these agents, as well as explore the current landscape of ADC development for BC treatment.
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Affiliation(s)
| | - Chiara Molinelli
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Véronique Debien
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Diogo Martins-Branco
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Philippe Aftimos
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Evandro de Azambuja
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
| | - Ahmad Awada
- Université Libre de Bruxelles (ULB), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Brussels, Belgium
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34
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Yang C, Brezden-Masley C, Joy AA, Sehdev S, Modi S, Simmons C, Henning JW. Targeting HER2-low in metastatic breast cancer: an evolving treatment paradigm. Ther Adv Med Oncol 2023; 15:17588359231175440. [PMID: 37323186 PMCID: PMC10262633 DOI: 10.1177/17588359231175440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/25/2023] [Indexed: 06/17/2023] Open
Abstract
The results of the Phase III DESTINY-Breast04 trial of trastuzumab deruxtecan (T-DXd) are leading to a shift in both the classification and treatment of human epidermal growth factor receptor 2 (HER2)-negative metastatic breast cancer. In this trial, T-DXd was associated with a substantial survival benefit among patients with hormone receptor-positive and hormone receptor-negative disease and low expression of HER2, a biomarker previously considered unactionable in this treatment setting. Herein, we discuss the evolving therapeutic pathway for HER2-low disease, ongoing clinical trials, and the potential challenges and evidence gaps arising with treatment of this patient population.
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Affiliation(s)
- Charlie Yang
- Tom Baker Cancer Centre, University of Calgary, 1331 29 Street NW, Calgary, AB T2N 4N2, Canada
| | | | - Anil Abraham Joy
- Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada
| | | | - Shanu Modi
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christine Simmons
- BC Cancer Agency – Vancouver Centre, University of British Columbia, Vancouver, BC, Canada
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Hurvitz SA, Curigliano G, Egorov A, Ashfaque S, Cortés J. DESTINY-Breast03 trial: some questions remain - Authors' reply. Lancet 2023; 401:1653-1654. [PMID: 37210117 DOI: 10.1016/s0140-6736(23)00681-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/28/2023] [Indexed: 05/22/2023]
Affiliation(s)
- Sara A Hurvitz
- Department of Medicine, Division of Hematology-Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA.
| | - Giuseppe Curigliano
- European Institute of Oncology, IRCCS, Milano, Italy; Department of Oncology and Hemato-Oncology, University of Milano, Milano, Italy
| | | | | | - Javier Cortés
- International Breast Cancer Center, Pangaea Oncology, Quironsalud Group, Barcelona, Spain; Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain
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Shastry M, Gupta A, Chandarlapaty S, Young M, Powles T, Hamilton E. Rise of Antibody-Drug Conjugates: The Present and Future. Am Soc Clin Oncol Educ Book 2023; 43:e390094. [PMID: 37229614 DOI: 10.1200/edbk_390094] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Antibody-drug conjugates (ADCs) embody a simple, but elegant, vision for cancer therapy-the delivery of a potent cytotoxic agent to tumor cells with minimal damage to normal cells-so-called smart chemo. Although there were significant challenges in achieving this milestone culminating in the first Food and Drug Administration approval in 2000, subsequent advancements in technology have led to rapid drug development with regulatory approvals for ADCs targeting a variety of tumor types. The most successful application for solid tumors has been in breast cancer, with ADCs becoming the standard of care across traditional human epidermal growth factor receptor 2 (HER2)+, hormone receptor+ (HR+) and triple-negative disease subtypes. Moreover, the improved features and gains in potency with the development of ADCs have expanded the treatment-eligible population to those with low/heterogeneous expression of the target antigen on the tumor with trastuzumab deruxtecan or in the case of sacituzumab govitecan, agnostic to target expression. Despite their antibody-directed homing, these novel agents come with their share of toxicities obligating appropriate patient selection and vigilant monitoring while on treatment. As more ADCs are included in the treatment armamentarium, mechanisms of resistance need to be studied and understood for optimal sequencing. Modifying the payload to use immune-stimulating agents or combination therapies with immunotherapy and other effective targeted therapies may further extend the utility of these agents in the treatment of solid tumors.
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Affiliation(s)
| | - Avantika Gupta
- Department of Medicine, Human Oncology and Pathogenesis Program, MSKCC, New York, NY
| | - Sarat Chandarlapaty
- Department of Medicine, Human Oncology and Pathogenesis Program, MSKCC, New York, NY
| | - Matthew Young
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Thomas Powles
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Erika Hamilton
- Sarah Cannon Research Institute, Nashville, TN
- Tennessee Oncology, Nashville, TN
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