1
|
Villacampa G, Dennett S, Mello E, Holton J, Lai X, Kilburn L, Bliss J, Rekowski J, Yap C. Accrual and statistical power failure in published adjuvant phase III oncology trials: a comprehensive analysis from 2013 to 2023. ESMO Open 2024; 9:103603. [PMID: 38925083 PMCID: PMC11255358 DOI: 10.1016/j.esmoop.2024.103603] [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: 02/25/2024] [Revised: 05/19/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND In a competitive landscape with many ongoing adjuvant randomised controlled trials (RCTs), the prevalence of trials that failed to recruit their targeted sample size and were inadequately powered is unclear. The aims of the study are (i) to determine the percentage of trials with accrual and statistical power failure and (ii) to evaluate their potential impact on the drug development process. MATERIALS AND METHODS A systematic review was carried out to identify adjuvant phase III oncology RCTs reported between 2013 and 2023 across all solid tumours. No restrictions were applied regarding the type of intervention or journal of publication. The percentage of trials with accrual failure and power failure was estimated as well as their association with the efficacy endpoints. Logistic regression models were used to estimate the odds ratio (OR) and its 95% confidence interval (CI). RESULTS A total of 282 RCTs met the inclusion criteria with a median sample size of 661 patients and a median accrual period of 4.3 years. Most of these studies were superiority trials (83.0%). Accrual failure was observed in 22.0% of the studies, finishing recruitment without achieving the targeted sample size. Overall, 39.7% of the studies experienced power failure, having less power than specified in the protocol at the date of the read-out. Among superiority RCTs evaluating intermediate survival endpoints, only 31.1% presented statistically significant results. Trials with power failure were less likely to present statistically significant results (37.9% versus 21.9%, P = 0.04). The association was consistent across all cancer types. In the subset of non-inferiority trials, 35.0% formally demonstrated non-inferiority of the experimental arm. CONCLUSIONS Nearly 40% of adjuvant phase III RCTs experienced power failure, and the reduction in power significantly impacted the final study results. There is a need for procedural refinements in the design and implementation of future adjuvant RCTs to mitigate these fallacies.
Collapse
Affiliation(s)
- G Villacampa
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), London, UK; Statistics Unit, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain. https://twitter.com/G_Villacampa
| | - S Dennett
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), London, UK
| | - E Mello
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), London, UK
| | - J Holton
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), London, UK
| | - X Lai
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), London, UK
| | - L Kilburn
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), London, UK
| | - J Bliss
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), London, UK
| | - J Rekowski
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), London, UK
| | - C Yap
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), London, UK.
| |
Collapse
|
2
|
Bania A, Adamou A, Saloustros E. Racial and Ethnic Disparities in European Breast Cancer Clinical Trials. Cancers (Basel) 2024; 16:1726. [PMID: 38730678 PMCID: PMC11082959 DOI: 10.3390/cancers16091726] [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: 03/26/2024] [Revised: 04/26/2024] [Accepted: 04/27/2024] [Indexed: 05/13/2024] Open
Abstract
Breast cancer is the most prevalent female cancer worldwide with known correlations between the race and tumor characteristics of the patients and prognosis. International and US-based studies, however, have reported a disproportionate representation of Black and Hispanic patients in clinical trials. This is the first study assessing race and ethnicity reporting trends and inclusion in European breast cancer trials. The PubMed and ClinicalTrials.gov databases were systematically searched for trials on breast cancer treatment conducted exclusively in Europe between 2010 and 2022. Of the 97 identified trials, race was reported in 10.31%. Multinational participation, but not the study size or trial phase, was significantly associated with higher race reporting trends. These 10 trials featured a White-predominant population, with 1.08% Asian and 0.88% Black patients included. The acquisition of the race and ethnicity data of patients in European trials is lower compared to the U.S. or worldwide studies and does not permit extensive analysis of minority participation. In a limited analysis, the low rates of minority participation are concerning, based on population-based data on minorities in select European countries. These observations should encourage race reporting practices in European breast cancer trials and adequate minority participation to support the generalizability of the results of the studies and promote healthcare equity.
Collapse
Affiliation(s)
- Angelina Bania
- Faculty of Medicine, School of Health Sciences, University of Patras, 26504 Patras, Greece;
| | - Antonis Adamou
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, 30625 Hannover, Germany;
| | - Emmanouil Saloustros
- Division of Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece
| |
Collapse
|
3
|
Pérez-García JM, Cortés J, Ruiz-Borrego M, Colleoni M, Stradella A, Bermejo B, Dalenc F, Escrivá-de-Romaní S, Calvo Martínez L, Ribelles N, Marmé F, Cortés A, Albacar C, Gebhart G, Prat A, Kerrou K, Schmid P, Braga S, Di Cosimo S, Gion M, Antonarelli G, Popa C, Szostak E, Alcalá-López D, Gener P, Rodríguez-Morató J, Mina L, Sampayo-Cordero M, Llombart-Cussac A. 3-year invasive disease-free survival with chemotherapy de-escalation using an 18F-FDG-PET-based, pathological complete response-adapted strategy in HER2-positive early breast cancer (PHERGain): a randomised, open-label, phase 2 trial. Lancet 2024; 403:1649-1659. [PMID: 38582092 DOI: 10.1016/s0140-6736(24)00054-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/15/2023] [Accepted: 01/09/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND PHERGain was designed to assess the feasibility, safety, and efficacy of a chemotherapy-free treatment based on a dual human epidermal growth factor receptor 2 (HER2) blockade with trastuzumab and pertuzumab in patients with HER2-positive early breast cancer (EBC). It used an 18fluorine-fluorodeoxyglucose-PET-based, pathological complete response (pCR)-adapted strategy. METHODS PHERGain was a randomised, open-label, phase 2 trial that took place in 45 hospitals in seven European countries. It randomly allocated patients in a 1:4 ratio with centrally confirmed, HER2-positive, stage I-IIIA invasive, operable breast cancer with at least one PET-evaluable lesion to either group A, where patients received docetaxel (75 mg/m2, intravenous), carboplatin (area under the curve 6 mg/mL per min, intravenous), trastuzumab (600 mg fixed dose, subcutaneous), and pertuzumab (840 mg loading dose followed by 420 mg maintenance doses, intravenous; TCHP), or group B, where patients received trastuzumab and pertuzumab with or without endocrine therapy, every 3 weeks. Random allocation was stratified by hormone receptor status. Centrally reviewed PET was conducted at baseline and after two treatment cycles. Patients in group B were treated according to on-treatment PET results. Patients in group B who were PET-responders continued with trastuzumab and pertuzumab with or without endocrine therapy for six cycles, while PET-non-responders were switched to receive six cycles of TCHP. After surgery, patients in group B who were PET-responders who did not achieve a pCR received six cycles of TCHP, and all patients completed up to 18 cycles of trastuzumab and pertuzumab. The primary endpoints were pCR in patients who were group B PET-responders after two treatment cycles (the results for which have been reported previously) and 3-year invasive disease-free survival (iDFS) in patients in group B. The study is registered with ClinicalTrials.gov (NCT03161353) and is ongoing. FINDINGS Between June 26, 2017, and April 24, 2019, a total of 356 patients were randomly allocated (71 patients in group A and 285 patients in group B), and 63 (89%) and 267 (94%) patients proceeded to surgery in groups A and B, respectively. At this second analysis (data cutoff: Nov 4, 2022), the median duration of follow-up was 43·3 months (range 0·0-63·0). In group B, the 3-year iDFS rate was 94·8% (95% CI 91·4-97·1; p=0·001), meeting the primary endpoint. No new safety signals were identified. Treatment-related adverse events and serious adverse events (SAEs) were numerically higher in patients allocated to group A than to group B (grade ≥3 62% vs 33%; SAEs 28% vs 14%). Group B PET-responders with pCR presented the lowest incidence of treatment-related grade 3 or higher adverse events (1%) without any SAEs. INTERPRETATION Among HER2-positive EBC patients, a PET-based, pCR-adapted strategy was associated with an excellent 3-year iDFS. This strategy identified about a third of patients who had HER2-positive EBC who could safely omit chemotherapy. FUNDING F Hoffmann-La Roche.
Collapse
Affiliation(s)
- José Manuel Pérez-García
- International Breast Cancer Center (IBCC), Pangaea Oncology, Quiron Group, Barcelona 08022, Spain; Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
| | - Javier Cortés
- International Breast Cancer Center (IBCC), Pangaea Oncology, Quiron Group, Barcelona 08022, Spain; Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain; Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain
| | | | | | - Agostina Stradella
- Medical Oncology Department, Institut Català D'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Begoña Bermejo
- Medical Oncology, Hospital Clínico Universitario de Valencia, Biomedical Research Institute INCLIVA, Valencia, Spain; Medicine Department, Universidad de Valencia, Spain; Oncology Biomedical Research National Network (CIBERONC-ISCIII), Madrid, Spain
| | - Florence Dalenc
- Oncopole Claudius Regaud- IUCT, Inserm, Department of Medical Oncology, Toulouse, France
| | - Santiago Escrivá-de-Romaní
- Medical Oncology Department, Breast Cancer Group, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | | | - Nuria Ribelles
- UGC Oncología Intercentros, Hospitales Universitarios Regional y Virgen de la Victoria de Málaga, Instituto de Investigaciones Biomédicas de Málaga (IBIMA), Málaga, Spain
| | - Frederik Marmé
- University Hospital Mannheim; Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - Cinta Albacar
- Hospital Universitari Sant Joan de Reus, Reus, Spain
| | - Geraldine Gebhart
- Department of Nuclear Medicine, Institut Jules Bordet, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Aleix Prat
- Department of Medical Oncology, Hospital Clinic of Barcelona, Barcelona, Spain; Translational Genomics and Targeted Therapies Group, IDIBAPS, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Khaldoun Kerrou
- APHP, Tenon Hospital IUC-UPMC, Nuclear Medicine and PET Center Department, Sorbonne University, Paris, France; INSERM U938 (Cancer Biology and Therapeutics), Paris, France
| | - Peter Schmid
- Barts Experimental Cancer Medicine Centre, Barts Cancer Institute, Queen Mary University of London, UK; Barts Hospital NHS Trust, London, UK
| | - Sofia Braga
- Unidade de Mama, Instituto CUF de Oncologia, Lisbon, Portugal; NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Serena Di Cosimo
- Department of Advanced Diagnostics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maria Gion
- University Hospital Ramón y Cajal, Madrid, Spain
| | - Gabriele Antonarelli
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology (DIPO), University of Milan, Milan, Italy
| | - Crina Popa
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
| | - Emilia Szostak
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
| | | | - Petra Gener
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
| | | | - Leonardo Mina
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
| | | | - Antonio Llombart-Cussac
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain; Hospital Arnau de Vilanova, Universidad Católica de Valencia, Valencia, Spain.
| |
Collapse
|
4
|
Nguyen AQ, Tran OTM, Nguyen PK, Nguyen HT. Cost-effectiveness of one-year adjuvant trastuzumab therapy in treatment for early-stage breast cancer patients with HER2+ in Vietnam. PLoS One 2024; 19:e0300474. [PMID: 38489305 PMCID: PMC10942069 DOI: 10.1371/journal.pone.0300474] [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] [Received: 04/07/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND In Vietnam, trastuzumab is included in social health insurance's benefits package with a reimbursement rate of 60%, but policymakers have been concerned about its cost-effectiveness. The research aims to evaluate the cost-effectiveness of one-year adjuvant trastuzumab therapy for early-stage breast cancer patients with human epidermal growth receptor 2 (HER2+) from a societal perspective. METHOD A Markov model was developed and validated to estimate the lifetime cost and effectiveness (using life year and quality-adjusted life year) of one-year adjuvant trastuzumab therapy compared to chemotherapy (using paclitaxel) alone. Treatment efficacy and transition probabilities were estimated based on published trials (i.e., N9831, NSABP B-31, HERA, and BCIRG 006). Local cost and utility data were employed to capture the Vietnam context. One-way sensitivity analysis, probabilistic sensitivity analysis, threshold, and scenario analysis were also performed. RESULTS One-year adjuvant trastuzumab therapy combined with chemotherapy compared to chemotherapy alone yielded an additional cost of 888,453,971VND (39,062 US$) with an additional 3.09 LYs and 1.61 QALYs, resulting in an ICER of 287,390,682 VND (12,635 US$) per LY gained, or 519,616,972 VND (22,845 US$) per QALY gained. The ICER exceeds the cost-effective threshold of 1- and 3-time GDP per capita by 6.3 and 2.1 times. The probabilistic sensitivity analysis shows similar results. According to one-way sensitivity analysis, ICERs were driven mainly by transition probabilities and trastuzumab price. One-year adjuvant trastuzumab therapy would be cost-effective at the 3-time GDP per capita threshold if the cost of Herceptin 150mg and 450mg vials were reduced by 56% and 54%, correspondingly. CONCLUSION In Vietnam, one-year adjuvant trastuzumab therapy for early-stage breast cancer with HER2+ is not cost-effective. The research provided reliable and updated evidence to support policymakers in revising the health insurance benefit package. The policymakers should consider the options to reduce the cost of trastuzumab (e.g., regarding the use of trastuzumab biosimilars, price negotiation options, and options of optimizing the use of Herceptin vials among concurrent hospitalized breast cancer patients).
Collapse
Affiliation(s)
- Anh Quynh Nguyen
- Department of Health Policy and Economics, Hanoi University of Public Health, Hanoi, Vietnam
| | | | | | - Ha Thu Nguyen
- Department of Health Policy and Economics, Hanoi University of Public Health, Hanoi, Vietnam
| |
Collapse
|
5
|
Saleh NH, Al-Khafaji ASK, Babaei E. Study of hesperetin effect on modulating transcription levels of MLH1 and MSH2 genes in SKBR3 breast cancer cell line. J Adv Pharm Technol Res 2023; 14:338-344. [PMID: 38107455 PMCID: PMC10723173 DOI: 10.4103/japtr.japtr_278_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 12/19/2023] Open
Abstract
Hesperetin (HSP), a flavonoid, has been validated to modify gene expression and function as an epigenetic agent to stop the development of breast carcinoma cells. HSP was investigated in this research to evaluate the expression of the MLH1 and MSH2 genes in cancerous breast cell lines (SKBR3) and healthy cell lines (MCF-11A) after exposure to different dosages (200, 400, and 600 µM/mL) of HSP. After 48 h of exposure, SKBR3's half-maximal inhibitory concentration was 289.6 µM/mL and MCF-10A's was 855.4 µM/mL. The research found that increasing HSP concentrations were closely correlated with an increase in MLH1 gene levels in the SKBR3 cell line, as shown by median and percentile values. HSP therapy caused the MLH1 gene expression to substantially vary in different groups, and in the SKBR3 cell line, MSH2 gene expressions were elevated in a dose-escalating manner. Moreover, HSP also raised the number of apoptotic cells, with the fraction of apoptotic cells escalating substantially at doses of 400 and 600 µM/mL. The outcomes suggested that HSP has the potential to be utilized as a therapeutic intervention for breast cancer, as it can induce apoptosis and reduce cell viability.
Collapse
Affiliation(s)
- Naser Hameed Saleh
- Department of Animal Biology, Faculty of Natural Sciences, University of Tabriz, Tabriz, Iran
| | | | - Esmaeil Babaei
- Department of Animal Biology, Faculty of Natural Sciences, University of Tabriz, Tabriz, Iran
| |
Collapse
|
6
|
Sposito M, Belluomini L, Pontolillo L, Tregnago D, Trestini I, Insolda J, Avancini A, Milella M, Bria E, Carbognin L, Pilotto S. Adjuvant Targeted Therapy in Solid Cancers: Pioneers and New Glories. J Pers Med 2023; 13:1427. [PMID: 37888038 PMCID: PMC10608226 DOI: 10.3390/jpm13101427] [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: 08/24/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/28/2023] Open
Abstract
Targeted therapy (TT) has revolutionized cancer treatment, successfully applied in various settings. Adjuvant TT in resected early-stage gastrointestinal stromal tumors (GIST), melanoma, non-small cell lung cancer (NSCLC), and breast cancer has led to practice-changing achievements. In particular, standard treatments include BRAF inhibitors for melanoma, osimertinib for NSCLC, hormone therapy or HER2 TT for breast cancer, and imatinib for GIST. Despite the undeniable benefit derived from adjuvant TT, the optimal duration of TT and the appropriate managing of the relapse remain open questions. Furthermore, neoadjuvant TT is emerging as valuable, particularly in breast cancer, and ongoing studies evaluate TT in the perioperative setting for early-stage NSCLC. In this review, we aim to collect and describe the large amount of data available in the literature about adjuvant TT across different histologies, focusing on epidemiology, major advances, and future directions.
Collapse
Affiliation(s)
- Marco Sposito
- Section of Innovation Biomedicine—Oncology Area, Department of Engineering for Innovation Medicine (DIMI), University of Verona and University and Hospital Trust (AOUI) of Verona, 37134 Verona, Italy; (M.S.); (L.B.); (D.T.); (I.T.); (J.I.); (A.A.); (M.M.)
| | - Lorenzo Belluomini
- Section of Innovation Biomedicine—Oncology Area, Department of Engineering for Innovation Medicine (DIMI), University of Verona and University and Hospital Trust (AOUI) of Verona, 37134 Verona, Italy; (M.S.); (L.B.); (D.T.); (I.T.); (J.I.); (A.A.); (M.M.)
| | - Letizia Pontolillo
- Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (L.P.); (E.B.)
- Medical Oncology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Daniela Tregnago
- Section of Innovation Biomedicine—Oncology Area, Department of Engineering for Innovation Medicine (DIMI), University of Verona and University and Hospital Trust (AOUI) of Verona, 37134 Verona, Italy; (M.S.); (L.B.); (D.T.); (I.T.); (J.I.); (A.A.); (M.M.)
| | - Ilaria Trestini
- Section of Innovation Biomedicine—Oncology Area, Department of Engineering for Innovation Medicine (DIMI), University of Verona and University and Hospital Trust (AOUI) of Verona, 37134 Verona, Italy; (M.S.); (L.B.); (D.T.); (I.T.); (J.I.); (A.A.); (M.M.)
| | - Jessica Insolda
- Section of Innovation Biomedicine—Oncology Area, Department of Engineering for Innovation Medicine (DIMI), University of Verona and University and Hospital Trust (AOUI) of Verona, 37134 Verona, Italy; (M.S.); (L.B.); (D.T.); (I.T.); (J.I.); (A.A.); (M.M.)
| | - Alice Avancini
- Section of Innovation Biomedicine—Oncology Area, Department of Engineering for Innovation Medicine (DIMI), University of Verona and University and Hospital Trust (AOUI) of Verona, 37134 Verona, Italy; (M.S.); (L.B.); (D.T.); (I.T.); (J.I.); (A.A.); (M.M.)
| | - Michele Milella
- Section of Innovation Biomedicine—Oncology Area, Department of Engineering for Innovation Medicine (DIMI), University of Verona and University and Hospital Trust (AOUI) of Verona, 37134 Verona, Italy; (M.S.); (L.B.); (D.T.); (I.T.); (J.I.); (A.A.); (M.M.)
| | - Emilio Bria
- Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy; (L.P.); (E.B.)
- Medical Oncology, Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Luisa Carbognin
- Gynecology Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, 00168 Roma, Italy;
| | - Sara Pilotto
- Section of Innovation Biomedicine—Oncology Area, Department of Engineering for Innovation Medicine (DIMI), University of Verona and University and Hospital Trust (AOUI) of Verona, 37134 Verona, Italy; (M.S.); (L.B.); (D.T.); (I.T.); (J.I.); (A.A.); (M.M.)
| |
Collapse
|
7
|
Jacobson SI, Kacew AJ, Knoebel RW, Hsieh PH, Ratain MJ, Strohbehn GW. Alternative Trastuzumab Dosing Schedules Are Associated With Reductions in Health Care Greenhouse Gas Emissions. JCO Oncol Pract 2023; 19:799-807. [PMID: 37450776 PMCID: PMC10538895 DOI: 10.1200/op.23.00227] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/24/2023] [Accepted: 06/15/2023] [Indexed: 07/18/2023] Open
Abstract
PURPOSE Cancer care-related greenhouse gas (GHG) emissions harm human health. Many cancer drugs are administered at greater-than-necessary doses, frequencies, and durations. Alternative dosing strategies may enable reductions in cancer care GHG emissions without compromising patient outcomes. MATERIALS AND METHODS We used streamlined life-cycle analysis in a case-control simulation to estimate the relative reductions in GHG emissions that would be expected to result from using each of three alternative dosing strategies of trastuzumab (6-month adjuvant treatment duration, once every 4-week dosing, and both) in human epidermal growth factor receptor 2 (HER2)+ breast cancer. Using primary data and conversion factors from the environmental science literature, we estimated per-patient relative reduction in GHG emissions and, using SEER data, health impacts (in terms of disability-adjusted life-years [DALYs] and excess mortality per kg CO2) on bystanders for each alternative dosing strategy. RESULTS Compared with the trastuzumab dosing strategy commonly used at baseline (12-month duration of adjuvant therapy and once every 3-week dosing in all settings), adoption of both 6-month adjuvant trastuzumab and once every 4-week trastuzumab dosing would reduce GHG emissions by 4.5%, 18.7%, and 14.6% in the neoadjuvant, adjuvant, and metastatic settings, respectively. We estimate that US-based adoption of alternative trastuzumab dosing would reduce annual DALYs and excess lives lost due to environmental impact of US-based trastuzumab therapy for HER2+ breast cancer by 1.5 and 0.9, respectively. CONCLUSION Alternative dosing strategies may materially reduce the population health impacts of cancer care by reducing environmental impact. Regulatory decision making and health technology assessments should consider a treatment's environmental and population health impacts. Clinical trials of alternative dosing strategies are justified on the basis of environmental and population health impacts.
Collapse
Affiliation(s)
| | - Alec J. Kacew
- University of Chicago Pritzker School of Medicine, Chicago, IL
| | | | - Po-Hung Hsieh
- Committee on Clinical Pharmacology and Pharmacogenomics, University of Chicago, Chicago, IL
- United States Food and Drug Administration, Silver Spring, MD
| | - Mark J. Ratain
- Committee on Clinical Pharmacology and Pharmacogenomics, University of Chicago, Chicago, IL
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, IL
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL
| | - Garth W. Strohbehn
- University of Michigan Rogel Cancer Center, Ann Arbor, MI
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI
- Division of Medical Oncology, LTC Charles S Kettles VA Medical Center, Ann Arbor, MI
- Division of Hematology/Oncology, Department of Medicine, University of Michigan, Ann Arbor, MI
- Center for Global Health Equity, University of Michigan, Ann Arbor, MI
| |
Collapse
|
8
|
Giffoni de Mello Morais Mata D, Chehade R, Hannouf MB, Raphael J, Blanchette P, Al-Humiqani A, Ray M. Appraisal of Systemic Treatment Strategies in Early HER2-Positive Breast Cancer-A Literature Review. Cancers (Basel) 2023; 15:4336. [PMID: 37686612 PMCID: PMC10486709 DOI: 10.3390/cancers15174336] [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: 06/08/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND The overexpression of the human epidermal growth factor receptor 2 (HER2+) accounts for 15-20% of all breast cancer phenotypes. Even after the completion of the standard combination of chemotherapy and trastuzumab, relapse events occur in approximately 15% of cases. The neoadjuvant approach has multiple benefits that include the potential to downgrade staging and convert previously unresectable tumors to operable tumors. In addition, achieving a pathologic complete response (pCR) following preoperative systemic treatment is prognostic of enhanced survival outcomes. Thus, optimal evaluation among the suitable strategies is crucial in deciding which patients should be selected for the neoadjuvant approach. METHODS A literature search was conducted in the Embase, Medline, and Cochrane electronic libraries. CONCLUSION The evaluation of tumor and LN staging and, hence, stratifying BC recurrence risk are decisive factors in guiding clinicians to optimize treatment decisions between the neoadjuvant versus adjuvant approaches. For each individual case, it is important to consider the most likely postsurgical outcome, since, if the patient does not obtain pCR following neoadjuvant treatment, they are eligible for adjuvant T-DM1 in the case of residual disease. This review of HER2-positive female BC outlines suitable neoadjuvant and adjuvant systemic treatment strategies for guiding clinical decision making around the selection of an appropriate therapy.
Collapse
Affiliation(s)
- Danilo Giffoni de Mello Morais Mata
- Division of Medical Oncology, London Regional Cancer Program, London Health Sciences Centre, Western University, London, ON N6A 5W9, Canada; (J.R.); (P.B.)
| | - Rania Chehade
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (R.C.); (A.A.-H.)
| | - Malek B. Hannouf
- Department of Internal Medicine, Western University, London, ON N6A 3K7, Canada;
| | - Jacques Raphael
- Division of Medical Oncology, London Regional Cancer Program, London Health Sciences Centre, Western University, London, ON N6A 5W9, Canada; (J.R.); (P.B.)
| | - Phillip Blanchette
- Division of Medical Oncology, London Regional Cancer Program, London Health Sciences Centre, Western University, London, ON N6A 5W9, Canada; (J.R.); (P.B.)
| | - Abdullah Al-Humiqani
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M4N 3M5, Canada; (R.C.); (A.A.-H.)
| | - Monali Ray
- Division of Medical Oncology, Markham Stouffville Hospital, Markham, ON L3P 7P3, Canada;
| |
Collapse
|
9
|
Batista JDL, Alves RJV, Cardoso TB, Moreno M, Tiscoski KA, Polanczyk CA. Effectiveness of adjuvant trastuzumab in women with HER-2+ breast cancer in the SUS. CIENCIA & SAUDE COLETIVA 2023; 28:1819-1830. [PMID: 37255158 DOI: 10.1590/1413-81232023286.15092022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/04/2022] [Indexed: 06/01/2023] Open
Abstract
The aim of this study was to evaluate the effectiveness in a real-world study of adjuvant trastuzumab in women with HER-2+ initial breast cancer in overall survival and recurrence-free survival. A retrospective cohort study was conducted with women who had HER-2+ breast cancer treated with trastuzumab from July 2012 to May 2017 and followed up until July 2021. The death rate was 2.62 per 100 persons/year, and the incidence rate of recurrence was 7.52 per 100 persons/year. The probability of survival at 8.7 years was 85.9%, while the probability of recurrence-free survival in the same period was 62.8%. The use of trastuzumab proved to be effective in the adjuvant treatment of breast cancer in a public health service in southern Brazil. Prognostic factors associated with worse overall survival or relapse did not influence the natural history of the disease, except locally advanced disease at the beginning of treatment. The data presented may prove to be useful in helping to make decisions about whether to use trastuzumab in the treatment of initial or locally advanced breast cancer in the Brazilian SUS.
Collapse
Affiliation(s)
- Joanna d'Arc Lyra Batista
- Universidade Federal da Fronteira Sul. Rodovia SC 459, Km 02, Sala 317, Fronteira Sul. 89801-001 Chapecó SC Brasil.
- Instituto de Avaliação de Tecnologia em Saúde. Porto Alegre RS Brasil
| | | | | | - Marcelo Moreno
- Universidade Federal da Fronteira Sul. Rodovia SC 459, Km 02, Sala 317, Fronteira Sul. 89801-001 Chapecó SC Brasil.
| | | | | |
Collapse
|
10
|
Chianca M, L'Abbate S, Fabiani I, Aimo A, Emdin M, Passino C, Fedele A, Cipolla CM, Cardinale DM. Clinical management of drug-induced cardiotoxicity in patients with HER-2+ breast cancer: current recommendations and future outlook. Expert Opin Drug Metab Toxicol 2023; 19:109-119. [PMID: 36989398 DOI: 10.1080/17425255.2023.2197589] [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: 03/31/2023]
Abstract
INTRODUCTION Human epidermal growth factor receptor two (HER2) target therapies have drastically revolutionised the treatment of HER2-positive breast cancer. Starting with trastuzumab, early phase III trials have already highlighted its significant cardiotoxicity, which is also present, albeit to a lesser extent, in the new generation drugs. Also given the growing population of patients with cardiovascular diseases, it is vital to set up proper long-term follow-up to prevent morbidity related to the development of cardiotoxicity. AREAS COVERED This review discusses the mechanisms of action underlying the cardiotoxicity of HER2 targeted therapies and the main clinical evidence on the toxicity of these drugs. In addition, the patterns of patient assessment prior to the initiation of therapy with HER2 targeted therapies are discussed, as well as the main evidence concerning the follow-up and management of cardiotoxicity. EXPERT OPINION the mechanisms of cardiotoxicity of new HER2 drugs need further study and, likewise, methods to prevent, monitor and identify HER-2-induced cardiotoxicity need to be implemented. Although some studies highlight the validity of cardiac biomarkers as predictive factors for cardiotoxicity, their actual usefulness and timing is still debated. Further studies are needed to assess the effectiveness of possible pharmacological primary prevention.
Collapse
Affiliation(s)
- Michela Chianca
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Piazza Martiri della libertà 33, Pisa, 56127, Italy
| | - Serena L'Abbate
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Piazza Martiri della libertà 33, Pisa, 56127, Italy
| | - Iacopo Fabiani
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, via Giuseppe Moruzzi 1, Pisa, 56124, Italy
| | - Alberto Aimo
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Piazza Martiri della libertà 33, Pisa, 56127, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, via Giuseppe Moruzzi 1, Pisa, 56124, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Piazza Martiri della libertà 33, Pisa, 56127, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, via Giuseppe Moruzzi 1, Pisa, 56124, Italy
| | - Claudio Passino
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Piazza Martiri della libertà 33, Pisa, 56127, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, via Giuseppe Moruzzi 1, Pisa, 56124, Italy
| | - Antonella Fedele
- Cardioncology Unit, Cardioncology and Second Opinion Division, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Via Ripamonti 435, Milan, 20141, Italy
| | - Carlo Maria Cipolla
- Cardioncology Unit, Cardioncology and Second Opinion Division, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Via Ripamonti 435, Milan, 20141, Italy
| | - Daniela Maria Cardinale
- Cardioncology Unit, Cardioncology and Second Opinion Division, European Institute of Oncology, Istituto di Ricovero e Cura a Carattere Scientifico, Via Ripamonti 435, Milan, 20141, Italy
| |
Collapse
|
11
|
Breast cancer: emerging principles of metastasis, adjuvant and neoadjuvant treatment from cancer registry data. J Cancer Res Clin Oncol 2023; 149:721-735. [PMID: 36538148 PMCID: PMC9931789 DOI: 10.1007/s00432-022-04369-4] [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: 12/13/2021] [Accepted: 09/17/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Growing primary breast cancers (PT) can initiate local recurrences (LR), regional lymph nodes (pLN) and distant metastases (MET). Components of these progressions are initiation, frequency, growth duration, and survival. These characteristics describe principles which proposed molecular concepts and hypotheses must align with. METHODS In a population-based retrospective modeling approach using data from the Munich Cancer Registry key steps and factors associated with metastasis were identified and quantified. Analysis of 66.800 patient datasets over four time periods since 1978, reliable evidence is obtained even in small subgroups. Together with results of clinical trials on prevention and adjuvant treatment (AT) principles for the MET process and AT are derived. RESULTS The median growth periods for PT/MET/LR/pLN comes to 12.5/8.8/5/3.5 years, respectively. Even if 30% of METs only appear after 10 years, a pre-diagnosis MET initiation principle not a delayed one should be true. The growth times of PTs and METs vary by a factor of 10 or more but their ratio is robust at about 1.4. Principles of AT are 50% PT eradication, the selective and partial eradication of bone and lung METs. This cannot be improved by extending the duration of the previously known ATs. CONCLUSION A paradigm of ten principles for the MET process and ATs is derived from real world data and clinical trials indicates that there is no rationale for the long-term application of endocrine ATs, risk of PTs by hormone replacement therapies, or cascading initiation of METs. The principles show limits and opportunities for innovation also through alternative interpretations of well-known studies. The outlined MET process should be generalizable to all solid tumors.
Collapse
|
12
|
Barot SV, Roesch E, Abraham J. Optimizing adjuvant and post-neoadjuvant therapy in HER2-positive early breast cancer. Expert Rev Anticancer Ther 2022; 22:1289-1299. [PMID: 36373394 DOI: 10.1080/14737140.2022.2146580] [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: 11/16/2022]
Abstract
INTRODUCTION Treatment advances have improved outcomes in human epidermal growth factor receptor 2 (HER2)-positive early-stage breast cancer (eBC) but certain patients remain at high risk of recurrence. Neoadjuvant therapy (NAT) has comparable outcomes to adjuvant therapy with the advantage of surgical down-staging, response assessment, informing prognosis, and tailoring adjuvant treatment. Thus, the standard of care for the majority of HER2-positive eBC has become a combination of chemotherapy and HER2-targeted agents given in the neoadjuvant setting. AREAS COVERED Mounting evidence suggests that pathologic complete response after NAT translates to a favorable long-term prognosis. The efficacy and tolerability of post-NAT are key, particularly for patients with residual disease. This is demonstrated, for example, by the use of trastuzumab emtansine in the appropriate clinical setting and various new drugs under investigation. This review summarizes the current clinical management and exciting future directions to optimize outcomes in HER2-positive eBC. EXPERT OPINION Targeted therapies such as trastuzumab deruxtecan, tucatinib, and immunotherapy have demonstrated impressive responses in metastatic breast cancer, including CNS disease. Incorporating these agents in the post-neoadjuvant space may improve the prognosis of HER2-positive eBC. Future research should prioritize the identification of biomarkers that personalize treatments to achieve maximum benefit and less toxicity.
Collapse
Affiliation(s)
- Shimoli V Barot
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erin Roesch
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jame Abraham
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
13
|
Fedele P, Sanna V, Santoro AN, Iaia ML, Fancellu A. Tailoring antiHer2 treatment strategies in breast cancer and beyond. Curr Probl Cancer 2022; 46:100892. [DOI: 10.1016/j.currproblcancer.2022.100892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/04/2022] [Accepted: 05/23/2022] [Indexed: 11/03/2022]
|
14
|
Sasaki R, Kurebayashi N, Eguchi H, Horimoto Y, Shiga T, Miyazaki S, Kashiyama T, Akamatsu W, Saito M. Involvement of kallikrein-PAR2-proinflammatory pathway in severe trastuzumab-induced cardiotoxicity. Cancer Sci 2022; 113:3449-3462. [PMID: 35879248 PMCID: PMC9530879 DOI: 10.1111/cas.15508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 11/28/2022] Open
Abstract
Trastuzumab‐induced cardiotoxicity interferes with continued treatment in approximately 10% of patients with ErbB2‐positive breast cancer, but its mechanism has not been fully elucidated. In this study, we recruited trastuzumab‐treated patients with ≥30% reduction in left ventricular ejection fraction (SP) and noncardiotoxic patients (NP). From each of these patients, we established three cases of induced pluripotent stem cell‐derived cardiomyocytes (pt‐iPSC‐CMs). Reduced contraction and relaxation velocities following trastuzumab treatment were more evident in SP pt‐iPSC‐CMs than NP pt‐iPSC‐CMs, indicating the cardiotoxicity phenotype could be replicated. Differences in ATP production, reactive oxygen species, and autophagy activity were observed between the two groups. Analysis of transcripts revealed enhanced kallikrein5 expression and pro‐inflammatory signaling pathways, such as interleukin‐1β, in SP pt‐iPSC‐CMs after trastuzumab treatment. The kallilkrein5‐protease‐activated receptor 2 (PAR2)‐MAPK signaling pathway was more activated in SP pt‐iPSC‐CMs, and treatment with a PAR2‐antagonist suppressed interleukin‐1β expression. Our data indicate enhanced pro‐inflammatory responses through kallikrein5‐PAR2 signaling and vulnerability to external stresses appear to be the cause of trastuzumab‐induced cardiotoxicity in SP.
Collapse
Affiliation(s)
- Ritsuko Sasaki
- Department of Breast Oncology, Juntendo University Graduate School of Medicine
| | - Nagomi Kurebayashi
- Department of Cellular and Molecular Pharmacology, Juntendo University Graduate School of Medicine
| | - Hidetaka Eguchi
- Intractable Disease Research Center, Juntendo University Graduate School of Medicine
| | - Yoshiya Horimoto
- Department of Breast Oncology, Juntendo University Graduate School of Medicine
| | - Takahiro Shiga
- Center for Genomic and Regenerative Medicine, Juntendo University Graduate School of Medicine
| | - Sakiko Miyazaki
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Taku Kashiyama
- Department of Cellular and Molecular Pharmacology, Juntendo University Graduate School of Medicine
| | - Wado Akamatsu
- Center for Genomic and Regenerative Medicine, Juntendo University Graduate School of Medicine
| | - Mitsue Saito
- Department of Breast Oncology, Juntendo University Graduate School of Medicine
| |
Collapse
|
15
|
Targeted Therapeutic Options and Future Perspectives for HER2-Positive Breast Cancer. Cancers (Basel) 2022; 14:cancers14143305. [PMID: 35884366 PMCID: PMC9320771 DOI: 10.3390/cancers14143305] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/01/2022] [Accepted: 07/03/2022] [Indexed: 02/07/2023] Open
Abstract
Simple Summary The development of several antiHuman Epidermal Growth Factor Receptor 2 (HER2) treatments over the last few years has improved the landscape of HER2-positive breast cancer. Despite this, relapse is still the main issue in HER2-positive breast cancer. The reasons for therapeutic failure lie in the heterogeneity of the disease itself, as well as in the drug resistance mechanisms. In this review, we intended to understand the milestones that have had an impact on this disease up to their implementation in clinical practice. In addition, understanding the underlying molecular biology of HER2-positive disease is essential for the optimization and personalization of the different treatment options. For this reason, we focused on two relevant aspects, which are triple-positive disease and the role that modulation of the immune response might play in treatment and prognosis. Abstract Despite the improvement achieved by the introduction of HER2-targeted therapy, up to 25% of early human epidermal growth factor receptor 2-positive (HER2+) breast cancer (BC) patients will relapse. Beyond trastuzumab, other agents approved for early HER2+ BC include the monoclonal antibody pertuzumab, the antibody-drug conjugate (ADC) trastuzumab-emtansine (T-DM1) and the reversible HER2 inhibitor lapatinib. New agents, such as trastuzumab-deruxtecan or tucatinib in combination with capecitabine and trastuzumab, have also shown a significant improvement in the metastatic setting. Other therapeutic strategies to overcome treatment resistance have been explored in HER2+ BC, mainly in HER2+ that also overexpress estrogen receptors (ER+). In ER+ HER2+ patients, target therapies such as phosphoinositide-3-kinase (PI3K) pathway inhibition or cyclin-dependent kinases 4/6 blocking may be effective in controlling downstream of HER2 and many of the cellular pathways associated with resistance to HER2-targeted therapies. Multiple trials have explored these strategies with some promising results, and probably, in the next years conclusive results will succeed. In addition, HER2+ BC is known to be more immunogenic than other BC subgroups, with high variability between tumors. Different immunotherapeutic agents such as HER-2 therapy plus checkpoint inhibitors, or new vaccines approaches have been investigated in this setting, with promising but controversial results obtained to date.
Collapse
|
16
|
Evolving Role of Risk Tailored Therapy in Early Stage HER2-Positive Breast Cancer: A Canadian Perspective. Curr Oncol 2022; 29:4125-4137. [PMID: 35735438 PMCID: PMC9221562 DOI: 10.3390/curroncol29060329] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 05/28/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022] Open
Abstract
The advent of HER2-targeted therapies has led to an important shift in the management of HER2-positive early breast cancer. However, initial treatment approaches apply uniform treatment regimens to all patients, with significant treatment-related and financial toxicities for both the patient and the health care system. Recent data demonstrates that for many patients, the chemotherapy backbone, duration and nature (mono- versus dual-targeted therapy) of the HER2 blockade can be better targeted to an individual patient’s risk of recurrence. We will provide a review of current data supporting risk tailored therapy in early stage HER2-positive breast cancer along with key completed and ongoing Canadian and international risk tailored trials. Neoadjuvant systemic therapy should now be considered for patients with clinical stage 2 disease, with greater use of non-anthracycline based chemotherapy regimens. Patients with residual disease following neoadjuvant therapy should be considered for escalated treatment with adjuvant T-DM1. Patients with stage I disease can often be managed with upfront surgery and evidence-based de-escalated adjuvant chemotherapy regimens. The modest benefit of 12- versus 6 months of adjuvant HER2 therapy and/or dual adjuvant HER2 therapy should be carefully weighed against the toxicities. All patients with HER2-positive breast cancer should be enrolled in ongoing risk tailored treatment trials whenever possible. Increasing data supports risk tailored therapy in early stage HER2-positive breast cancer in place of the routine application of aggressive and toxic systemic therapy regimens to all patients. While much progress has been made towards treatment de-escalation in appropriate patients, more is needed, as we highlight in this review. Indeed, Canadian-led clinical trials are helping to lead these efforts.
Collapse
|
17
|
Stucci LS, Pisino M, D’Addario C, Grassi T, Toss A. Management of HER2-Positive Early Breast Cancer in Italy: A Maze Presenting Opportunities and Challenges. Front Oncol 2022; 12:871160. [PMID: 35664788 PMCID: PMC9160375 DOI: 10.3389/fonc.2022.871160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
The management of human epidermal growth factor receptor 2 (HER2)-positive early-stage breast cancer (BC) has changed in recent years thanks to the introduction of anti-HER2 agents in clinical practice as standard of care in the neoadjuvant setting. In this scenario, we probed the issue of which HER2-positive BC patients are eligible for neoadjuvant or for adjuvant treatment, since these therapeutic strategies seem to be mutually exclusive in clinical practice according to an Italian drug surveillance system. We reviewed both alternatives to establish which is more suitable, considering the anti-HER2 drugs available in Italy. Randomized clinical trials demonstrated a similar clinical benefit for chemotherapy administered as neoadjuvant therapy or adjuvant therapy. A meta-analysis, including 11,955 patients treated with neoadjuvant therapy, demonstrated an improvement in event-free survival (EFS) and overall survival (OS). Moreover, the recent APHINITY trial, analyzed at 6 years follow-up, demonstrated the superiority of the combination pertuzumab–trastuzumab versus trastuzumab–placebo in previously untreated patients. A greater benefit was found in patients with positive lymph nodes treated in the adjuvant setting. Our analysis underlines the need for a therapeutic decision-making algorithm, which is still unavailable, to support clinicians in identifying patients suitable for neoadjuvant or adjuvant therapy. Further prospective clinical trials should be performed in collaboration with other Italian Breast Cancer Centers to establish the best strategy to be adopted in early HER2+ BC.
Collapse
Affiliation(s)
- Luigia Stefania Stucci
- Department of Biomedical Sciences and Human Oncology, Azienda Ospedaliero-Universitaria (A.O.U.), Consorziale Policlinico di Bari, Bari, Italy
- *Correspondence: Luigia Stefania Stucci,
| | - Marco Pisino
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Bari, Italy
| | - Claudia D’Addario
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Bari, Italy
| | - Teresa Grassi
- Department of Biomedical Sciences and Human Oncology, Azienda Ospedaliero-Universitaria (A.O.U.), Consorziale Policlinico di Bari, Bari, Italy
| | - Angela Toss
- Department of Oncology and Haematology, Genetic Oncology Unit, University Hospital of Modena, Modena, Italy
| |
Collapse
|
18
|
Lin M, Xiong W, Wang S, Li Y, Hou C, Li C, Li G. The Research Progress of Trastuzumab-Induced Cardiotoxicity in HER-2-Positive Breast Cancer Treatment. Front Cardiovasc Med 2022; 8:821663. [PMID: 35097033 PMCID: PMC8789882 DOI: 10.3389/fcvm.2021.821663] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/14/2021] [Indexed: 12/14/2022] Open
Abstract
In recent years, the incidence of breast cancer has been increasing on an annual basis. Human epidermal growth factor receptor-2 (HER-2) is overexpressed in 15-20% human breast cancers, which is associated with poor prognosis and a high recurrence rate. Trastuzumab is the first humanized monoclonal antibody against HER-2. The most significant adverse effect of trastuzumab is cardiotoxicity, which has become an important factor in limiting the safe use of the drug. Unfortunately, the mechanism causing this cardiotoxicity is still not completely understood, and the use of preventive interventions remains controversial. This article focuses on trastuzumab-induced cardiotoxicity, reviewing the clinical application, potential cardiotoxicity, mechanism and discussing the potential interventions through summarizing related researches over the past tens of years.
Collapse
Affiliation(s)
- Mengmeng Lin
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weiping Xiong
- Department of Cardiology, Shanghai Putuo District Liqun Hospital, Shanghai, China
| | - Shiyuan Wang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yingying Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunying Hou
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunyu Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guohui Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
19
|
Nouvelles stratégies thérapeutiques dans les cancers du sein HER2-surexprimé. Bull Cancer 2022; 108:11S8-11S18. [PMID: 34969516 DOI: 10.1016/s0007-4551(21)00632-9] [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: 11/21/2022]
Abstract
Breast cancer with HER2-amplification accounts for 20 % of breast cancers. The management of patients has dramatically changed with the advent of anti-HER2 treatment, especially the monoclonal antibodies since 2000 in the metastatic and (neo)-adjuvant setting, leading to an improvement of patient outcomes. If therapeutic arsenal has been gradually enhanced with the targeting of HER receptors family, resistances to these treatments are observed, hence the development of new therapeutic strategies. This review provides an updated look of novel therapeutic strategies in HER2-positive breast cancer, as well as future perspectives, both in the adjuvant and metastatic setting.
Collapse
|
20
|
Huang Z, Jin S, Zeng M, Shu J, Liu Y, Zhang J, Xu B, Niu M, Sun S, Nanding A, Li X, Shan M, Zhang G. Clinical and Therapeutic Factors Vary by Prognosis in Patients with Pathological Complete Response After Neoadjuvant Therapy for Breast Cancer. Cancer Manag Res 2021; 13:9235-9246. [PMID: 34955654 PMCID: PMC8694407 DOI: 10.2147/cmar.s338589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/03/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine clinical predictors of recurrence and metastasis in patients with pathological complete response (pCR) after neoadjuvant chemotherapy (NCT). Methods Patients treated with NCT who achieved pCR (n=285) were classified into three groups according to pre-NCT clinical stage (cStage): group I (IIa–IIb), group II (IIIa), and group III (IIIb–IIIc). Survival was analysed using the Kaplan–Meier method. The relationships between clinicopathological factors and recurrence were determined using Cox regression analysis. Results The median follow-up was 31 months. The 3-year disease-free survival and overall survival rates in groups I, II, and III were 92.7%, 87.8%, and 66.7% (P < 0.01) and 98.6%, 98.3%, and 90.6% (P=0.370), respectively. Lymph node status and tumour size were independent risk factors for recurrence and metastasis after NCT. In the human epidermal growth factor receptor 2-positive subgroup, advanced cStage and lymph node metastasis were associated with recurrence (P < 0.01). In the hormone receptor-positive subgroup, disease-free survival rates differed for cStages I–II compared to cStage III (P=0.049) and clinical node status 0–2 compared to clinical node status 3 (P=0.037). Conclusion Pre-NCT cStage predicted the prognosis of pCR for different breast cancer subtypes. Patients with advanced cStage, lymph node metastasis, and large tumour sizes had a higher risk of recurrence or metastasis.
Collapse
Affiliation(s)
- Zhenfeng Huang
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, 150081, People’s Republic of China
| | - Shiyang Jin
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, 150081, People’s Republic of China
| | - Mengyao Zeng
- Department of Gynecology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, 150081, People’s Republic of China
| | - Jing Shu
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, 150081, People’s Republic of China
| | - Yang Liu
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, 150081, People’s Republic of China
| | - Jinxing Zhang
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, 150081, People’s Republic of China
| | - Bingqi Xu
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, 150081, People’s Republic of China
| | - Ming Niu
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, 150081, People’s Republic of China
| | - Shanshan Sun
- Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, 150081, People’s Republic of China
| | - Abiyasi Nanding
- Department of Pathology, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, 150081, People’s Republic of China
| | - Xiaobo Li
- Department of Pathology, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang, 150081, People’s Republic of China
| | - Ming Shan
- 20th Floor Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, People’s Republic of China
- Correspondence: Ming Shan; Guoqiang Zhang Email ;
| | - Guoqiang Zhang
- 20th Floor Department of Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, People’s Republic of China
| |
Collapse
|
21
|
Gion M, Pérez-García JM, Llombart-Cussac A, Sampayo-Cordero M, Cortés J, Malfettone A. Surrogate endpoints for early-stage breast cancer: a review of the state of the art, controversies, and future prospects. Ther Adv Med Oncol 2021; 13:17588359211059587. [PMID: 34868353 PMCID: PMC8640314 DOI: 10.1177/17588359211059587] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/25/2021] [Indexed: 01/07/2023] Open
Abstract
Drug approval for early-stage breast cancer (EBC) has been historically granted in the context of registration trials based on adequate outcomes such as disease-free survival and overall survival. Improvements in long-term outcomes have made it more difficult to demonstrate the clinical benefit of a new cancer drug in large, randomized, comparative clinical trials. Therefore, the use of surrogate endpoints rather than traditional measures allows for cancer drug trials to proceed with smaller sample sizes and shorter follow-up periods, which reduces drug development time. Among surrogate endpoints for breast cancer, the increase in pathological complete response (pCR) rates was considered appropriate for accelerated drug approval. The association between pCR and long-term outcomes was strongest in patients with aggressive tumor subtypes, such as triple-negative and human epidermal growth factor receptor 2 (HER2)-positive/hormone receptor-negative breast cancers. Whereas in hormone receptor-positive/HER2-negative EBC, the most accepted surrogate markers for endocrine therapy-based trials include changes in Ki67 and the preoperative endocrine prognostic index. Beyond the classic endpoints, further prognostic tools are required to provide EBC patients with individualized and effective therapies, and the neoadjuvant setting provides an excellent platform for drug development and biomarker discovery. Nowadays, the availability of multigene signatures is offering a standardized quantitative and reproducible tool to potentiate the efficacy of standard treatment for high-risk patients and develop de-escalated treatments for patients at lower risk of relapse. In this article, we first evaluate the surrogacies used for long-term outcomes and the underlying evidence supporting the use of each surrogate endpoint for the accelerated or regular drug approval process in EBC. Next, we provide an overview of the most recent studies and innovative strategies in a (neo)adjuvant setting as a platform to accelerate new drug approval. Finally, we highlight some clinical trials aimed at tailoring systemic treatment of EBC using prognosis-related factors or early biomarkers of drug sensitivity or resistance.
Collapse
Affiliation(s)
- María Gion
- University Hospital Ramon y Cajal, Madrid, Spain
| | - José Manuel Pérez-García
- International Breast Cancer Center (IBCC), Quironsalud Group, Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Ridgewood, NJ, USA
| | - Antonio Llombart-Cussac
- Hospital Arnau de Vilanova, Valencia, Spain
- Universidad Catolica de Valencia San Vicente Martir, Valencia, Spain
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Ridgewood, NJ, USA
| | - Miguel Sampayo-Cordero
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Ridgewood, NJ, USA
| | - Javier Cortés
- International Breast Cancer Center (IBCC), Quironsalud Group, Carrer de Vilana, 12, 08022 Barcelona, SpainVall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Ridgewood, NJ, USA
- Department of Medicine, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - Andrea Malfettone
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- Medica Scientia Innovation Research (MEDSIR), Ridgewood, NJ, USA
| |
Collapse
|
22
|
Elsamany S, Elbaiomy M, Zeeneldin A, Tashkandi E, Hassanin F, Abdelhafeez N, O Al-Shamsi H, Bukhari N, Elemam O. Suggested Modifications to the Management of Patients With Breast Cancer During the COVID-19 Pandemic: Web-Based Survey Study. JMIR Cancer 2021; 7:e27073. [PMID: 34726611 PMCID: PMC8594736 DOI: 10.2196/27073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/23/2021] [Accepted: 07/19/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Management of patients with cancer in the current era of the COVID-19 pandemic poses a significant challenge to health care systems. Breast cancer is the most common cancer internationally. Breast cancer is a disease that involves surgery, chemotherapy, hormonal therapy, targeted therapy, radiotherapy, and, more recently, immunotherapy in its management plan. The immune system requires months to recover from these medications, and this condition is even worse in patients with metastatic breast cancer who need ongoing treatment with these drugs. Some of these drugs, such as inhibitors of cyclin-dependent kinases 4 and 6, can cause rare but life-threating lung inflammation. Patients with breast cancer who have metastatic disease to the lungs can experience deterioration of disease symptoms with COVID-19 infection. Oncologists treating patients with breast cancer are facing a difficult situation regarding treatment choice. The impact that COVID-19 has had on breast cancer care is unknown, including how to provide the best care possible without compromising patient and community safety. OBJECTIVE The aim of this study was to explore the views of oncologists regarding the management of patients with breast cancer during the COVID-19 pandemic. METHODS A web-based SurveyMonkey questionnaire was submitted to licensed oncologists involved in breast cancer management in Saudi Arabia, Egypt, and United Arab Emirates. The survey focused on characteristics of the participants, infection risk among patients with cancer, and possible treatment modifications related to different types of breast cancer. RESULTS The survey was completed by 82 participants. For early hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer, 61 of the 82 participants (74%) supported using neoadjuvant hormonal therapy in selected patients, and 58% (48/82) preferred giving 6 over 8 cycles of adjuvant chemotherapy when indicated. Only 43% (35/82) preferred inhibitors of cyclin-dependent kinases 4 and 6 with hormonal therapy as the first-line treatment in all patients with metastatic HR-positive disease. A total of 55 of the 82 participants (67%) supported using adjuvant trastuzumab for 6 instead of 12 months in selected patients with HER2-positive breast cancer. For metastatic HER2-positive, HR-positive breast cancer, 80% of participants (66/82) supported the use of hormonal therapy with dual anti-HER2 blockade in selected patients. The preferred choice of first-line treatment in metastatic triple negative patients with BRCA mutation and programmed cell death 1 ligand 1 (PD-L1) <1% was poly(adenosine diphosphate-ribose) polymerase inhibitor according to 41% (34/82) of the participants, and atezolizumab with nab-paclitaxel was preferred for PD-L1 >1% according to 71% (58/82) of the participants. CONCLUSIONS Several modifications in breast cancer management were supported by the survey participants. These modifications need to be discussed on a local basis, taking into account the local infrastructure and available resources.
Collapse
Affiliation(s)
- Shereef Elsamany
- Oncology Center, King Abdullah Medical City, Makkah, Saudi Arabia
- Oncology Center, Mansoura University, Mansoura, Egypt
| | | | - Ahmed Zeeneldin
- Oncology Center, King Abdullah Medical City, Makkah, Saudi Arabia
- National Cancer Institute, Cairo University, Cairo, Egypt
| | - Emad Tashkandi
- Oncology Center, King Abdullah Medical City, Makkah, Saudi Arabia
- College of Medicine, Umm AlQura University, Makkah, Saudi Arabia
| | - Fayza Hassanin
- Oncology Center, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Nafisa Abdelhafeez
- Oncology Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Humaid O Al-Shamsi
- Department of Oncology, Alzahra Hospital, Dubai, United Arab Emirates
- University of Sharjah, Sharjah, United Arab Emirates
| | - Nedal Bukhari
- Department of Medical Oncology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
- Department of Internal Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Omima Elemam
- Oncology Center, King Abdullah Medical City, Makkah, Saudi Arabia
- Oncology Center, Mansoura University, Mansoura, Egypt
| |
Collapse
|
23
|
Heart Failure Therapies for the Prevention of HER2-Monoclonal Antibody-Mediated Cardiotoxicity: A Systematic Review and Meta-Analysis of Randomized Trials. Cancers (Basel) 2021; 13:cancers13215527. [PMID: 34771689 PMCID: PMC8583665 DOI: 10.3390/cancers13215527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Monoclonal antibodies targeting HER2 are used for the management of early and metastatic HER2-positive breast cancer. Approximately 10–15% of patients diagnosed with breast cancer will be HER2-positive. The incidence of heart failure in breast cancer patients is becoming increasingly problematic, owing to the ageing of the population and the growing number of cancer survivors. The aim of our review was to assess the published evidence for the use of cardio-prevention strategies in HER2-monoclonal antibody-mediated cardiotoxicity. Whilst in the assessed trials the use of heart failure therapies did not reduce the risk of trastuzumab-associated cardiotoxicity, there was a reduction in the mean change in LVEF and in the rates of interruptions to HER2 therapy in patients treated with beta-blockers. This highlights the possible applications for neurohormonal therapies to prevent cardiotoxicity and mitigate interruption to vital HER2-monoclonal antibody treatment. Abstract Monoclonal antibodies including trastuzumab, pertuzumab, and antibody-drug conjugates, form the backbone of HER2-positive breast cancer therapy. Unfortunately, an important adverse effect of these agents is cardiotoxicity, occurring in approximately 10% of patients. There is increasing published data regarding prevention strategies for cardiotoxicity, though seldom used in clinical practice. We performed a systematic review and meta-analysis of randomized-controlled trials to evaluate pharmacotherapy for the prevention of monoclonal HER2-directed antibody-induced cardiotoxicity in patients with breast cancer. Online databases were queried from their inception until October 2021. Effects were determined by calculating risk ratios (RRs) and 95% confidence intervals (CI) or mean differences (MD) using random-effects models. We identified five eligible trials. In the three trials (n = 952) reporting data on the primary outcome of cardiotoxicity, there was no clear effect for patients assigned active treatment compared to control (RR = 0.90, 95% CI 0.63 to 1.29, p = 0.57). Effects were similar for ACE-I/ARB and beta-blockers (p homogeneity = 0.50). Active treatment reduced the risk of HER2 therapy interruptions (RR = 0.57, 95% CI 0.43 to 0.77, p < 0.001) with similar findings for ACE-I/ARB and beta-blockers (p homogeneity = 0.97). Prophylactic treatment with ACE-I/ARB or beta-blocker therapy may be of value for cardio-protection in patients with breast cancer prescribed monoclonal antibodies. Further, adequately powered randomized trials are required to define the role of routine prophylactic treatment in this patient group.
Collapse
|
24
|
Davey MG, Lowery AJ, Miller N, Kerin MJ. MicroRNA Expression Profiles and Breast Cancer Chemotherapy. Int J Mol Sci 2021; 22:10812. [PMID: 34639152 PMCID: PMC8509379 DOI: 10.3390/ijms221910812] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 02/06/2023] Open
Abstract
Breast cancer is the most common malignancy diagnosed in women. Traditionally, radical surgical resection was the cornerstone of breast cancer management, with limited exceptions. In recent times, our enhanced appreciation of the biomolecular characteristics of breast cancer has transformed the treatment paradigm to include prescription of chemotherapeutical agents, radiotherapies, targeted therapies, as well as more refined surgical approaches. While treatments with such modalities have enhanced clinico-oncological outcomes for breast cancer patients, the efforts of oncological and translational research have concentrated on the identification of novel biomarkers which may successfully inform prognosis and response to therapies, improve current therapeutic strategies, and enhance prognostication. Mi(cro)RNAs are small, non-coding molecules which are known to play regulatory roles in governing gene expression and cellular activity. Measurement of miRNA expression profiles have been illustrated to inform the response to therapies, such as conventional chemotherapy, and are currently undergoing assessment as means of enhancing treatment strategies with these cytotoxic agents. Herein, this review outlines how chemotherapy prescription has revolutionised breast cancer treatment and illustrates the novel role of miRNAs as biomarkers capable of enhancing current therapeutic strategies using chemotherapy in patients being treated with curative intent for breast cancer.
Collapse
Affiliation(s)
- Matthew G. Davey
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, H91 YR71 Galway, Ireland; (A.J.L.); (N.M.); (M.J.K.)
| | | | | | | |
Collapse
|
25
|
Battisti NML, Joshi K, Nasser MS, Ring A. Systemic therapy for older patients with early breast cancer. Cancer Treat Rev 2021; 100:102292. [PMID: 34536728 DOI: 10.1016/j.ctrv.2021.102292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/07/2021] [Indexed: 12/16/2022]
Abstract
Over a third of breast cancers are diagnosed in patients ≥70 years. With the ageing of the population, the number of older breast cancer patients will continue to rise. Older patients are under-represented in clinical studies underpinning breast cancer therapy, and frequently do not receive guideline-concordant care. This review outlines the evidence on the efficacy and the safety of systemic treatment options for the management of early-stage breast cancer (EBC) in older adults and identifies where critical data gaps exist. Chemotherapy is beneficial for older patients with oestrogen receptor (ER)-negative EBC, whilst the benefit for those with ER-positive disease is less certain. Careful consideration should be given to the side-effect profile of the treatment regimen chosen, owing to the risks of myelosuppression and cardiac damage, as well as toxicities, such as neuropathy, that may impact independence. The impact of chemotherapy on quality of life (QOL) outcomes appears significant but reversible in this population. Gene expression profiling, benefit and chemotherapy toxicity prediction tools integrating global health considerations hold promise to better inform chemotherapy decisions in this population. Benefits on targeted anti-human epidermal growth factor receptor 2 (HER2) agents is maintained in older EBC patients with a favourable safety profile. Endocrine therapy including aromatase inhibitors is the standard of care in this population, and extended treatment decisions should consider effects on bone health and life expectancy. More trials recruiting older adults with pragmatic designs and meaningful endpoints for this population are warranted to better inform systemic treatment decisions and discussion with patients.
Collapse
Affiliation(s)
- Nicolò Matteo Luca Battisti
- Department of Medicine - Breast Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, United Kingdom; Breast Cancer Research Division, The Institute of Cancer Research, 15 Cotswold Road, Sutton, London SM2 5NG, United Kingdom.
| | - Kroopa Joshi
- Department of Medicine - Breast Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, United Kingdom.
| | - Mariam Syeda Nasser
- Department of Medicine - Breast Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, United Kingdom.
| | - Alistair Ring
- Department of Medicine - Breast Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, United Kingdom.
| |
Collapse
|
26
|
Chen J, Colosimo M, Lim E. The management of HER2-positive early breast cancer: Current and future therapies. Asia Pac J Clin Oncol 2021; 17 Suppl 6:3-12. [PMID: 34490737 DOI: 10.1111/ajco.13655] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Advances in human epidermal growth factor receptor 2 (HER2)-directed therapies have revolutionised the care of patients with HER2-positive breast cancer. While adjuvant trastuzumab in combination with chemotherapy has dramatically improved the prognosis for patients with early-stage disease, up to a quarter of patients will develop recurrent disease. The standard-of-care treatment paradigm has evolved with the introduction of newer HER2-directed therapies and increasing use of neoadjuvant systemic therapy, the latter providing us with important functional data to HER2-directed therapies and impacting subsequent adjuvant therapy decisions. However, these new strategies come at a cost of increased toxicity and economic burden, and only a subset of patients benefit from such approaches. Thus, ongoing work is required to identify predictive biomarkers of response, to de-escalate treatment in patients who may do just as well with less therapy, and new therapeutic approaches for patients who do not respond to currently used therapies. In this review, we will examine the current therapeutic landscape, summarise the latest evidence, and list the current treatment algorithms for early stage HER2-positive breast cancer.
Collapse
Affiliation(s)
- Julia Chen
- Garvan Institute of Medical Research, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Maree Colosimo
- St Vincent's Private Hospital, Chermside, Queensland, Australia
| | - Elgene Lim
- Garvan Institute of Medical Research, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| |
Collapse
|
27
|
Tesch ME, Gelmon KA. Targeting HER2 in Breast Cancer: Latest Developments on Treatment Sequencing and the Introduction of Biosimilars. Drugs 2021; 80:1811-1830. [PMID: 33021725 DOI: 10.1007/s40265-020-01411-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Approximately 20% of all breast cancers overexpress the human epidermal growth factor receptor 2 (HER2). Targeting breast cancer through this vital oncogenic protein has been a major step towards improved patient outcomes. Today, several anti-HER2 agents are in clinical use including: the monoclonal antibodies trastuzumab and pertuzumab; the small molecule inhibitors lapatinib, neratinib, and tucatinib; and the antibody-drug conjugates ado-trastuzumab emtansine and trastuzumab deruxtecan, in some jurisdictions. In addition, several trastuzumab biosimilars have recently been granted regulatory approval in North America and the EU, and are enhancing patient access to HER2-directed therapy. The various agents differ greatly in their side-effect profiles and approved indications, from neoadjuvant and adjuvant use in early disease, to first- and later-line use in metastatic disease. This review discusses the current treatment recommendations for the use of anti-HER2 agents alone and in combination, examines the latest advances in HER2-targeted drugs and how they may be best applied in clinical practice, and provides guidance on optimal sequencing of the growing array of therapeutic options for HER2-positive breast cancer.
Collapse
Affiliation(s)
- Megan E Tesch
- Department of Medical Oncology, British Columbia Cancer, 600 W. 10th Avenue, Vancouver, BC, V5Z 4E6, Canada
| | - Karen A Gelmon
- Department of Medical Oncology, British Columbia Cancer, 600 W. 10th Avenue, Vancouver, BC, V5Z 4E6, Canada.
| |
Collapse
|
28
|
Systemic therapy for early breast cancer in older adults: current status and prospects. Curr Opin Oncol 2021; 33:574-583. [PMID: 34183493 DOI: 10.1097/cco.0000000000000768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In this review, we describe the evidence on the efficacy and the safety of systemic treatments for the management of early breast cancer (EBC) in older individuals. RECENT FINDINGS Chemotherapy has a temporary impact on quality of life (QoL) for older EBC patients and improves survival outcomes for those with oestrogen receptor (ER)-negative disease. Benefits were seen also in the context of comorbidities, although these may be influenced by selection bias. The Cancer and Aging Research Group-Breast Cancer tool can predict the risk of severe toxicities on chemotherapy in older patients. Gene expression profiling is less frequently used in older adults although it holds promise to better inform patient selection also in this age group.Postneoadjuvant systemic therapy and novel agents remain poorly described in older patients with EBC. No disease-free survival benefits were seen in older patients receiving abemaciclib plus adjuvant endocrine therapy. SUMMARY Chemotherapy is beneficial for selected older patients with high-risk, ER-negative EBC. Although its impact on QoL is temporary, preferences, higher risk of toxicity and competing risks need to be carefully considered. Open questions remain on novel therapeutic approaches and gene expression profile in older EBC patients and more real-world evidence is warranted.
Collapse
|
29
|
Mery B, Toussaint P, Heudel PE, Dufresne A, Carbonnaux M, Vanacker H, Bachelot T, Trédan O. [New therapeutic strategies in HER2-positive breast cancer]. Bull Cancer 2021:S0007-4551(21)00215-0. [PMID: 34144793 DOI: 10.1016/j.bulcan.2021.04.015] [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: 10/23/2020] [Revised: 04/13/2021] [Accepted: 04/23/2021] [Indexed: 11/17/2022]
Abstract
Breast cancer with HER2-amplification accounts for 20% of breast cancers. The management of patients has dramatically changed with the advent of anti-HER2 treatment, especially the monoclonal antibodies since 2000 in the metastatic and (neo)-adjuvant setting, leading to an improvement of patient outcomes. If therapeutic arsenal has been gradually enhanced with the targeting of HER receptors family, resistances to these treatments are observed, hence the development of new therapeutic strategies. This review provides an updated look of novel therapeutic strategies in HER2-positive breast cancer, as well as future perspectives, both in the adjuvant and metastatic setting.
Collapse
Affiliation(s)
- Benoîte Mery
- Centre Léon-Bérard, département de cancérologie médicale, 28, rue Laennec, 69008 Lyon, France
| | - Philippe Toussaint
- Centre Léon-Bérard, département de cancérologie médicale, 28, rue Laennec, 69008 Lyon, France
| | - Pierre-Etienne Heudel
- Centre Léon-Bérard, département de cancérologie médicale, 28, rue Laennec, 69008 Lyon, France
| | - Armelle Dufresne
- Centre Léon-Bérard, département de cancérologie médicale, 28, rue Laennec, 69008 Lyon, France
| | - Mélodie Carbonnaux
- Centre Léon-Bérard, département de cancérologie médicale, 28, rue Laennec, 69008 Lyon, France
| | - Hélène Vanacker
- Centre Léon-Bérard, département de cancérologie médicale, 28, rue Laennec, 69008 Lyon, France
| | - Thomas Bachelot
- Centre Léon-Bérard, département de cancérologie médicale, 28, rue Laennec, 69008 Lyon, France
| | - Olivier Trédan
- Centre Léon-Bérard, département de cancérologie médicale, 28, rue Laennec, 69008 Lyon, France.
| |
Collapse
|
30
|
Leighl NB, Nirmalakumar S, Ezeife DA, Gyawali B. An Arm and a Leg: The Rising Cost of Cancer Drugs and Impact on Access. Am Soc Clin Oncol Educ Book 2021; 41:1-12. [PMID: 33956494 DOI: 10.1200/edbk_100028] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Increasing cancer drug prices present global challenges to treatment access and cancer outcomes. Substantial variability exists in drug pricing across countries. In countries without universal health care, patients are responsible for treatment costs. Low- or middle-income countries are heavily impacted, with limited patient access to novel cancer treatments. Financial toxicity is seen across cancer types, countries, and health care systems. Those at highest risk include younger patients, new immigrants, visible minority groups, and those without private health coverage. Currently, cancer drug pricing does not correlate with value or clinical benefit. Value-based pricing of oncology drugs may incentivize development of higher-value medicines and eliminate excess spending on drugs that yield little benefit. Generics and biosimilars in oncology can also improve affordability and patient access, offering dramatic reductions in drug spending while maintaining patient benefit. Oncologists can promote value-based care by following evidence-based clinical guidelines that avoid low-value treatments. Researchers can also engage in value-based research that critically explores optimal cancer drug dosing, schedules, and treatment duration and defines patient populations most likely to benefit (e.g., through biomarker selection). Cancer Groundshot proposes that we improve outcomes for today's patients with cancer, including broader global access for high-value treatments, promotion of affordable cancer control strategies, and reduction of cancer morbidity and mortality through low-cost prevention and screening initiatives. Moving forward, major oncology societies recommend promoting uniform global access to essential cancer medicines and avoiding financial harm for patients as key principles in addressing the affordability of cancer drugs.
Collapse
Affiliation(s)
- Natasha B Leighl
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Sharon Nirmalakumar
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Doreen A Ezeife
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Bishal Gyawali
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
31
|
Jackisch C, Cortazar P, Geyer CE, Gianni L, Gligorov J, Machackova Z, Perez EA, Schneeweiss A, Tolaney SM, Untch M, Wardley A, Piccart M. Risk-based decision-making in the treatment of HER2-positive early breast cancer: Recommendations based on the current state of knowledge. Cancer Treat Rev 2021; 99:102229. [PMID: 34139476 DOI: 10.1016/j.ctrv.2021.102229] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 01/05/2023]
Abstract
Treatment of HER2-positive early breast cancer (EBC) continues to evolve with neoadjuvant (pre-operative) and adjuvant (post-operative) HER2-targeted therapies as standard of care. There are two important decision points. The first involves deciding between neoadjuvant therapy or proceeding directly to surgery. Neoadjuvant chemotherapy (NACT) plus pertuzumab-trastuzumab is appropriate for patients with high-risk HER2-positive EBC (tumour diameter ≥2 cm, and/or node-positive disease). Patients with node-negative disease and tumour diameter <2 cm are candidates for upfront surgery followed by paclitaxel for 12 weeks plus 18 cycles of trastuzumab, with the option to add pertuzumab (if pN+). The second decision point involves the pathohistological result at surgery after neoadjuvant therapy. Total pathological complete response (tpCR: ypT0/is, ypN0) is associated with improved survival endpoints. Patients with tumours ≥2 cm and/or node-positive disease at diagnosis who have a tpCR after dual blockade should continue pertuzumab-trastuzumab in the adjuvant setting to complete 1 year (18cycles) of treatment. For patients with invasive residual disease, 14cycles of post-neoadjuvant trastuzumab emtansine (T-DM1) therapy significantly increases invasive-DFS compared with trastuzumab. Extended adjuvant therapy with neratinib is an option in selected patients (HER2-positive and oestrogen receptor [ER]-positive) who have completed adjuvant trastuzumab-based therapy. Less aggressive chemotherapy regimens are recommended in populations with a lower risk of recurrence (patients with small tumours without axillary involvement; patients unlikely to tolerate anthracycline-taxane or taxane-carboplatin regimens). Ultimately, treatment recommendations should be consistent with local and international guidelines. Further studies will guide optimisation of treatment for patients with HER2-positive EBC according to the risk of disease recurrence.
Collapse
Affiliation(s)
| | | | - Charles E Geyer
- NSABP Foundation and Houston Methodist Cancer Center, Houston, TX, USA
| | | | - Joseph Gligorov
- Institut Universitaire de Cancérologie, APHP-Sorbonne Université, Hôpital Tenon, Paris, France
| | | | - Edith A Perez
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Andreas Schneeweiss
- National Center for Tumor Diseases, Heidelberg University Hospital and German Cancer Research Center, Heidelberg, Germany
| | - Sara M Tolaney
- Dana-Farber Cancer Institute, and Department of Hematology-Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Untch
- AGO-B and HELIOS Klinikum Berlin Buch, Berlin, Germany
| | - Andrew Wardley
- Outreach Research & Innovation Group and Manchester Breast Centre, Division of Cancer Sciences and University of Manchester, Manchester, UK; AstraZeneca PLC, UK
| | - Martine Piccart
- Institut Jules Bordet, Université Libre de Bruxelles (ULB), Brussels, Belgium
| |
Collapse
|
32
|
Loibl S, Poortmans P, Morrow M, Denkert C, Curigliano G. Breast cancer. Lancet 2021; 397:1750-1769. [PMID: 33812473 DOI: 10.1016/s0140-6736(20)32381-3] [Citation(s) in RCA: 679] [Impact Index Per Article: 226.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/29/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023]
Abstract
Breast cancer is still the most common cancer worldwide. But the way breast cancer is viewed has changed drastically since its molecular hallmarks were extensively characterised, now including immunohistochemical markers (eg, ER, PR, HER2 [ERBB2], and proliferation marker protein Ki-67 [MKI67]), genomic markers (eg, BRCA1, BRCA2, and PIK3CA), and immunomarkers (eg, tumour-infiltrating lymphocytes and PD-L1). New biomarker combinations are the basis for increasingly complex diagnostic algorithms. Neoadjuvant combination therapy, often including targeted agents, is a standard of care (especially in HER2-positive and triple-negative breast cancer), and the basis for de-escalation of surgery in the breast and axilla and for risk-adapted post-neoadjuvant strategies. Radiotherapy remains an important cornerstone of breast cancer therapy, but de-escalation schemes have become the standard of care. ER-positive tumours are treated with 5-10 years of endocrine therapy and chemotherapy, based on an individual risk assessment. For metastatic breast cancer, standard therapy options include targeted approaches such as CDK4 and CDK6 inhibitors, PI3K inhibitors, PARP inhibitors, and anti-PD-L1 immunotherapy, depending on tumour type and molecular profile. This range of treatment options reflects the complexity of breast cancer therapy today.
Collapse
Affiliation(s)
- Sibylle Loibl
- German Breast Group, Neu-Isenburg, Germany; Centre for Haematology and Oncology Bethanien, Frankfurt, Germany.
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carsten Denkert
- German Breast Group, Neu-Isenburg, Germany; Institute of Pathology, Philipps University of Marburg, Marburg, Germany; University Hospital Marburg, Marburg, Germany
| | - Giuseppe Curigliano
- European Institute of Oncology IRCCS, Milan, Italy; University of Milano, Milan, Italy
| |
Collapse
|
33
|
Pérez-García JM, Gebhart G, Ruiz Borrego M, Stradella A, Bermejo B, Schmid P, Marmé F, Escrivá-de-Romani S, Calvo L, Ribelles N, Martinez N, Albacar C, Prat A, Dalenc F, Kerrou K, Colleoni M, Afonso N, Di Cosimo S, Sampayo-Cordero M, Malfettone A, Cortés J, Llombart-Cussac A. Chemotherapy de-escalation using an 18F-FDG-PET-based pathological response-adapted strategy in patients with HER2-positive early breast cancer (PHERGain): a multicentre, randomised, open-label, non-comparative, phase 2 trial. Lancet Oncol 2021; 22:858-871. [DOI: 10.1016/s1470-2045(21)00122-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/11/2021] [Accepted: 02/18/2021] [Indexed: 10/21/2022]
|
34
|
Tarantino P, Morganti S, Curigliano G. Targeting HER2 in breast cancer: new drugs and paradigms on the horizon. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2021; 2:139-155. [PMID: 36046143 PMCID: PMC9400740 DOI: 10.37349/etat.2021.00037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/09/2021] [Indexed: 12/23/2022] Open
Abstract
About 15-20% of all breast cancers (BCs) are defined human epidermal growth factor receptor 2 (HER2)-positive, based on the overexpression of HER2 protein and/or amplification of ERBB2 gene. Such alterations lead to a more aggressive behavior of the disease, but also predict response to treatments targeting HER2. Indeed, several anti-HER2 compounds have been developed and approved in the last two decades, significantly improving our ability to cure patients in the early setting, and greatly extending their survival in the advanced setting. However, recent evolutions in this field promise to improve outcomes even further, through advancements in established HER2-targeting strategies, as well as the exploration of novel strategies. In particular, the engineering of new antibody-drug conjugates, with higher drug-to-antibody ratios (DARs) and cleavable linkers, has already led to the development of a highly effective drug, namely trastuzumab deruxtecan, recently approved by the Food and Drug Administration (FDA) and European Medicines Agency (EMA) for the treatment of advanced HER2-positive (HER2+) BC, and currently in study in the early setting. Moreover, the novel tyrosine kinase inhibitor tucatinib was recently approved by FDA and EMA, showing to improve survival of HER2+ advanced BC patients, particularly in those with brain metastasis. Immunotherapy is also being investigated in the HER2+ subtype, through immune-checkpoint inhibition, cancer vaccines and adoptive-cell therapies. Overall, the enlarging arsenal of promising anti-HER2 compounds is expected to deliver significant improvements in the prognosis of both early and advanced HER2+ BC in the years to come. Moreover, some of such agents are showing encouraging activity in the much wider population of HER2-low advanced BC patients, challenging current BC classifications. If confirmed, this new paradigm would potentially expand the population deriving benefit from HER2-targeted treatments to up to 70% of all advanced BC patients, leading to a revolution in current treatment algorithms, and possibly to a redefinition of HER2 classification.
Collapse
Affiliation(s)
- Paolo Tarantino
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, 20141 Milan, Italy
- Department of Oncology and Hematology, University of Milan, 20122 Milan, Italy
| | - Stefania Morganti
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, 20141 Milan, Italy
- Department of Oncology and Hematology, University of Milan, 20122 Milan, Italy
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, 20141 Milan, Italy
- Department of Oncology and Hematology, University of Milan, 20122 Milan, Italy
| |
Collapse
|
35
|
Ben Dhia S, Loap P, Loirat D, Vincent-Salomon A, Cao K, Escalup L, Fourquet A, Kirova Y. [Concurrent radiation therapy and dual HER2 blockade in breast cancer: Assessment of toxicity]. Cancer Radiother 2021; 25:424-431. [PMID: 33771453 DOI: 10.1016/j.canrad.2020.06.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 01/03/2023]
Abstract
PURPOSE The tolerance of the concurrent use of radiotherapy, pertuzumab and trastuzumab is unknown. The purpose of this study was to evaluate the toxicity of this association in patients treated for HER2 positive metastatic and/or locally recurrent unrespectable breast cancer. MATERIAL AND METHODS A retrospective study was performed in our institution for all consecutive patients treated with concurrent irradiation, pertuzumab and trastuzumab. The radiotherapy was performed while pertuzumab and trastuzumab were administrated as a maintenance treatment at the dose of 420mg (total dose) and 6mg/kg respectively every 3 weeks without chemotherapy. Toxicity was assessed according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. Left ventricular ejection fraction (LVEF) was measured at baseline and then every 3-4 months. RESULTS We studied 77 patients. treated in between 2013 and 2019 with median follow-up of 38 months (range 0-264 months). Median age was 53 years (33-86). There were 50 patients (64.9%) with metastatic and 27 patients (35.1%) with recurrent disease. All patients received docetaxel followed by P-T as first line treatment and they received 34 cycles (10-85) of pertuzumab and trastuzumab. All patients experienced partial or complete response according to RECIST criteria. Irradiation volumes were whole breast (41 patients, 53.2%) and chest wall (29 patients, 37.7%) at a dose of 50Gy with a median duration of 39 days. Radiotherapy of lymph nodes was performed in 53 patients (68.8%) as following: supraclavicular-infraclavicular and axillary lymph nodes in 52 patients (67.5%), and internal mammary nodes in 31 patients (40.3%). For 20 patients. (26.0%) radiotherapy was palliative: bone irradiation (12 patients, 15.6%), whole-brain radiotherapy (2 patients, 2.6%), cerebral metastasis irradiation (6 patients). As early toxicity we observed: radio dermatitis as following: 36 patients (46.8%) presented grade I, 17 patients (22.1%) presented grade II, and 3 patients (3.9%) presented grade III. One patient (1.3%) presented grade II esophagitis. One patient (1.3%) presented asymptomatic decrease of LVEF during treatment and 6 patients (7.7%) presented a decrease of LVEF. There was no radiation-induced pneumonitis. As late toxicity, we observed 1 (1.3%) case of grade I and 1 (1.3%) with grade II telangiectasia. There was 1 case (1.3%) of grade III cardiac toxicity, 8 months after the concurrent treatment. CONCLUSION The concurrent use of radiotherapy, pertuzumab and trastuzumab is feasible with good tolerance. Larger prospective data with longer follow-up is needed to confirm these results.
Collapse
Affiliation(s)
- S Ben Dhia
- Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - P Loap
- Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - D Loirat
- Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | | | - K Cao
- Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - L Escalup
- Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - A Fourquet
- Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - Y Kirova
- Institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| |
Collapse
|
36
|
Tannock IF, Ratain MJ, Goldstein DA, Lichter AS, Rosner GL, Saltz LB. Near-Equivalence: Generating Evidence to Support Alternative Cost-Effective Treatments. J Clin Oncol 2021; 39:950-955. [DOI: 10.1200/jco.20.02768] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
37
|
Joel A, Georgy JT, Thumaty DB, John AO, Chacko RT, Rebekah G, Sigamani E, Chandramohan J, Manipadam MT, Cherian AJ, Abraham DT, Jacob PM, Sebastian P, Backianathan S, Singh A. Neoadjuvant chemotherapy with biosimilar trastuzumab in human epidermal growth factor receptor 2 overexpressed non-metastatic breast cancer: patterns of use and clinical outcomes in India. Ecancermedicalscience 2021; 15:1207. [PMID: 33912232 PMCID: PMC8057782 DOI: 10.3332/ecancer.2021.1207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Human epidermal growth factor receptor 2 (HER2)-positive breast cancer is associated with poor prognosis and access to anti-HER2 treatment is still a challenge in lower-middle income countries. The availability of the biosimilar trastuzumab has improved access by lowering the costs. We report the pattern of use of neoadjuvant ± adjuvant trastuzumab and outcomes in patients with HER2-positive non-metastatic breast cancer treated with regimens incorporating shorter durations of therapy and the use of the biosimilar trastuzumab compared to the innovator. METHODS We conducted a retrospective analysis of patients with non-metastatic HER2-positive breast cancer treated with neoadjuvant ± adjuvant trastuzumab (innovator (n = 34 (33%)) and biosimilar (n = 70 (67%)) manufactured by Biocon Biologics) with chemotherapy. Information regarding chemotherapy regimens, duration of trastuzumab use (≤12 weeks and >12 weeks), pathological response (Miller Payne grade), disease free survival (DFS), overall survival (OS) and safety data were collected from electronic medical records. RESULTS A total of 135 patients were analysed with a median age of 51 years (range: 23-82); of these, 57% were postmenopausal, 31.8% were hormone receptor positive and 62.9% had stage III disease. The overall pathological complete response (p-CR) in both breast and axilla increased to 37.6% in patients treated with trastuzumab preoperatively as compared to 22.2% in patients who did not receive any trastuzumab. Patients receiving innovator trastuzumab and biosimilar trastuzumab showed a p-CR of 28.5% and 41.7%, respectively. At a median follow-up of 42 months (range: 3-114), there were 18 relapses and 11 deaths. The 3-year DFS was 87.1% and OS was 92.2%. Cardiac dysfunction developed in 4 of 78 (5.1%) evaluable patients. CONCLUSION Access to anti-HER2 therapy in the treatment of non-metastatic HER2-positive breast cancer in resource-constrained settings has improved significantly with the availability of the biosimilar trastuzumab. Imbalances in patient profiles at baseline in routine clinical practice led to inconclusive outcomes of ≤12 weeks versus >12 weeks trastuzumab treatment. However, on the basis of historical data, patients could be offered shorter duration of trastuzumab when a standard 1-year treatment of adjuvant trastuzumab is not feasible in resource-constrained settings. The p-CR using the biosimilar trastuzumab in neoadjuvant treatment has been observed to be comparable to the innovator trastuzumab.
Collapse
Affiliation(s)
- Anjana Joel
- Department of Medical Oncology, Christian Medical College, Vellore 632004, India
| | - Josh Thomas Georgy
- Department of Medical Oncology, Christian Medical College, Vellore 632004, India
| | - Divya Bala Thumaty
- Department of Medical Oncology, Christian Medical College, Vellore 632004, India
| | - Ajoy Oommen John
- Department of Medical Oncology, Christian Medical College, Vellore 632004, India
| | - Raju Titus Chacko
- Department of Medical Oncology, Christian Medical College, Vellore 632004, India
| | - Grace Rebekah
- Department of Biostatistics, Christian Medical College, Vellore 632004, India
| | | | - Jagan Chandramohan
- Department of Pathology, Christian Medical College, Vellore 632004, India
| | | | - Anish Jacob Cherian
- Department of Endocrine Surgery, Christian Medical College, Vellore 632004, India
| | | | | | - Patricia Sebastian
- Department of Radiation Therapy, Christian Medical College, Vellore 632004, India
| | | | - Ashish Singh
- Department of Medical Oncology, Christian Medical College, Vellore 632004, India
| |
Collapse
|
38
|
Wang BC, Xiao BY, Fan JQ, Lin GH, Wang C, Liu Q, Zhao YX. 6 versus 12 months of adjuvant trastuzumab in HER2+ early breast cancer: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24995. [PMID: 33725875 PMCID: PMC7969267 DOI: 10.1097/md.0000000000024995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Adjuvant trastuzumab improves survival outcomes of human epidermal receptor 2 positive early breast cancer patients. Currently, administration of 12 months adjuvant trastuzumab is the standard therapy. However, whether 6 months treatment is non-inferior to the standard 12 months treatment remains controversial. METHODS Relevant records were searched in PubMed, Cochrane Library, Web of Science, and EMBASE through Jan 14, 2020. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for disease-free survival (DFS) and overall survival (OS) were meta-analyzed. The primary endpoint was DFS with a non-inferiority hazard margin of 1.2 and the second was OS with 1.43. RESULTS Three randomized clinical studies met the inclusion criteria, including 3974 patients in 6 months group and 3976 in 12 months group. HR for DFS was 1.18 (95% CI 0.97-1.44, P = .09), with the non-inferiority margin comprised in the 95% CI. HR for OS was 1.14 (95% CI 0.98-1.32, P= .08), whereas the upper limit of 95% CI did not exceed the non-inferiority hazard margin. CONCLUSION Our analysis failed to show that 6 months treatment was non-inferior to 12 months treatment in improving the DFS. Although the non-inferiority of the 6-month adjuvant trastuzumab treatment was found for OS, considering that breast cancer patients should receive additional systematic therapies when disease progression or relapse happens, we suggest that 12 months adjuvant trastuzumab treatment should remain the standard therapeutic strategy for patients with early human epidermal receptor 2 positive breast cancer.
Collapse
Affiliation(s)
- Bi-Cheng Wang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Bo-Ya Xiao
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University
- Department of Medical Psychology, Faculty of Psychology, Naval Medical University (Second Military Medical University), Shanghai
| | - Ji-Quan Fan
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Guo-He Lin
- Department of Oncology, the Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chang Wang
- Institute of Anatomy, University of Bern, CH-3012 Bern, Switzerland
| | - Quentin Liu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Cancer Center, Sun Yat-sen University, Guangzhou, China
| | - Yan-Xia Zhao
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| |
Collapse
|
39
|
Rushton M, Lima I, Tuna M, Johnson C, Ivars J, Pritchard K, Hawken S, Dent S. Impact of Stopping Trastuzumab in Early Breast Cancer: A Population-Based Study in Ontario, Canada. J Natl Cancer Inst 2020; 112:1222-1230. [PMID: 32343801 PMCID: PMC7735777 DOI: 10.1093/jnci/djaa054] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/24/2020] [Accepted: 04/03/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Adjuvant trastuzumab for early-stage (I-III) HER2-positive breast cancer (BC) has led to statistically significant improvement in cancer outcomes but carries a risk of cardiotoxicity. Trastuzumab is discontinued early in many patients for asymptomatic changes in left ventricular ejection fraction. We evaluated the impact of early discontinuation of trastuzumab on cancer outcomes. METHODS We conducted a retrospective population-based cohort study of early BC patients treated with adjuvant trastuzumab in Ontario, Canada, 2007-2016. Four groups were analyzed: group A was full treatment, 17-18 cycles trastuzumab; group B was cardiac event (CE) within treatment period; group C was ≤16 cycles, no CEs, stopped within 30 days from last cardiac imaging; and group D was ≤16 cycles, no CEs, stopped more than 30 days from cardiac imaging. Primary outcome was disease-free survival (DFS); secondary outcomes were: overall survival, cancer-specific mortality, and cardiovascular mortality. Sensitivity analyses were performed 14 months after cycle 1 trastuzumab to control for early relapse. RESULTS A total of 5547 patients met the inclusion criteria: group A = 3921, group B = 309, group C = 362, and group D = 955. The 5-year DFS was 94.1% in group A, 80.1% in group B, 81.4% in group C, and 82.4% in group D. Using a Cox model, the hazard ratio for 5-year DFS was 3.15 (95% confidence interval [CI] = 2.13 to 4.65) for group B, 1.94 (95% CI = 1.30 to 2.89) for group C, and 1.92 (95% CI = 1.46 to 2.53) for group D. Overall, 26 patients (0.5%) died of cardiac causes. CONCLUSIONS BC patients in Ontario who did not complete adjuvant trastuzumab had a statistically significantly higher risk of BC relapse and death and low incidence of cardiac death. These findings support 1 year of adjuvant trastuzumab in early-stage BC.
Collapse
Affiliation(s)
- Moira Rushton
- The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, ON, Canada
- Canadian Cancer Trials Group, Queen’s University, Kingston, ON, Canada
| | - Isac Lima
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES uOttawa, Ottawa, ON, Canada
| | - Meltem Tuna
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES uOttawa, Ottawa, ON, Canada
| | - Chris Johnson
- Division of Cardiology, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Josee Ivars
- McMaster University, Faculty of Health Sciences, Hamilton, ON, Canada
| | - Kathy Pritchard
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Steven Hawken
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- ICES uOttawa, Ottawa, ON, Canada
| | - Susan Dent
- The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, ON, Canada
- Duke Cancer Institute, Duke University, Durham, NC, USA
| |
Collapse
|
40
|
Ban M, Petrić Miše B, Vrdoljak E. Early HER2-Positive Breast Cancer: Current Treatment and Novel Approaches. Breast Care (Basel) 2020; 15:560-569. [PMID: 33447229 PMCID: PMC7768133 DOI: 10.1159/000511883] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/25/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Trastuzumab significantly improves outcomes in early HER2-positive breast cancer, irrespectively of any prognostic or predictive factors. Unfortunately, about a quarter of patients receiving neoadjuvant trastuzumab experience disease recurrence, revealing the unquestionable need for further improvement of treatment outcomes. SUMMARY Adding HER2 blockade to adjuvant trastuzumab with pertuzumab and neratinib improves invasive disease-free survival (IDFS), particularly for those at highest risk of recurrence. A shift toward a neoadjuvant strategy for patients with a higher risk of recurrence could result in further treatment optimization. For patients without a pathological complete response (pCR) after the neoadjuvant part of the therapy, a switch to adjuvant trastuzumab emtansine significantly improves IDFS and distant recurrence-free survival and shows a trend towards improved overall survival (OS). On the other hand, for low-risk patients, chemotherapy deescalation should be strongly considered with the use of trastuzumab monotherapy as an anti-HER2 backbone. KEY MESSAGES Neoadjuvant therapy should be offered for a significant proportion of HER2-positive early breast cancer patients with a higher risk of recurrence. Postneoadjuvant treatment should be tailored according to the initial stage of disease and the response to neoadjuvant treatment.
Collapse
Affiliation(s)
- Marija Ban
- Department of Oncology, Clinical Hospital Centre Split, School of Medicine, University of Split, Split, Croatia
| | | | | |
Collapse
|
41
|
Piccart MJ, Hilbers FS, Bliss JM, Caballero C, Frank ES, Renault P, Naït Kaoudjt R, Schumacher E, Spears PA, Regan MM, Gelber RD, Davidson NE, Norton L, Winer EP. Road Map to Safe and Well-Designed De-escalation Trials of Systemic Adjuvant Therapy for Solid Tumors. J Clin Oncol 2020; 38:4120-4129. [PMID: 33052755 DOI: 10.1200/jco.20.01382] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 02/11/2024] Open
Abstract
An important challenge in the field of cancer is finding the balance between delivering effective treatments and avoiding adverse effects and financial toxicity caused by innovative, yet expensive, drugs. To address this, several treatment de-escalation trials have been conducted, but only a few of these have provided clear answers. A few trials had poor accrual or had design flaws that led to conflicting results. Members of the Breast International Group (BIG) and North American Breast Cancer Group (NABCG) believe the way forward is to understand the lessons from these trials and listen more carefully to what truly matters to our patients. We reviewed several adjuvant trials of different cancer types and developed a road map for improving the design and implementation of future de-escalation trials. The road map incorporates patients' insights obtained through focused group discussions across the BIG-NABCG networks. Considerations for the development of de-escalation trials for systemic adjuvant treatment, including noninferiority trial design, choice of end points, and prioritization of a patient's perspectives, are presented in this consensus article.
Collapse
Affiliation(s)
| | | | - Judith M Bliss
- The Institute of Cancer Research, Clinical Trials & Statistics Unit, London, United Kingdom
| | | | - Elizabeth S Frank
- Dana Farber Cancer Institute, Department of Medical Oncology, Boston, MA
| | | | | | | | - Patricia A Spears
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Meredith M Regan
- International Breast Cancer Study Group Statistical Center, Department of Data Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Richard D Gelber
- International Breast Cancer Study Group Statistical Center, Department of Data Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
- Harvard TH Chan School of Public Health, Boston, MA
- Frontier Science and Technology Research Foundation, Boston, MA
| | - Nancy E Davidson
- Fred Hutchinson Cancer Research Center, Seattle, WA
- University of Washington, Seattle, WA
| | - Larry Norton
- Memorial Sloan Kettering Cancer Center, Department of Medicine, New York, NY
| | - Eric P Winer
- Dana Farber Cancer Institute, Department of Medical Oncology, Boston, MA
| |
Collapse
|
42
|
Hu Q, Wang X, Chen Y, Li X, Luo T, Cao D. Optimum duration of adjuvant trastuzumab in treatment of human epidermal growth factor receptor-2 positive early breast cancer: protocol for a network meta-analysis of randomised controlled trials. BMJ Open 2020; 10:e035802. [PMID: 33444169 PMCID: PMC7682472 DOI: 10.1136/bmjopen-2019-035802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Controversy regarding optimum duration of trastuzumab treatment remains in patients with human epidermal growth factor receptor-2 (HER2) positive early breast cancer. The objective of applying network meta-analysis (NMA) is to integrate existing evidence based on direct and indirect comparisons of efficacy and safety, and then to determine the duration of trastuzumab treatments with the greatest impact on therapeutic outcomes in HER2-positive early breast cancers. METHODS AND ANALYSIS Electronic searching of trastuzumab treatments for early breast cancer by titles and abstracts will be conducted for the period from inception to 16 June 2019 in PubMed, Cochrane Library, Embase and ClinicalTrils.gov, as well as the annual meetings of San Antonio Breast Cancer Symposium (SABCS), European Society of Medical Oncology (ESMO) and American Society of Clinical Oncology (ASCO) online archives. The outcomes of interest are overall survival, disease-free survival, acceptability, cardiotoxicities and grade 3 to 4 non-haematological toxicities. Two independent reviewers will screen and extract eligible data based on the inclusion and exclusion criteria, and then assess the risk of bias and evidence quality of individual studies using Cochrane Collaboration's tool and Grades of Recommendation, Assessment, Development and Evaluation (GRADE). The heterogeneity, transitivity and inconsistency of NMA will be evaluated. In addition, we will perform subgroup and sensitivity analyses to assess the robustness and reliability of findings in our NMA. ETHICS AND DISSEMINATION Ethics approval is not required for our NMA. Findings from our NMA will be submitted as peer-reviewed journal manuscripts and international conference reports. TRIAL REGISTRATION NUMBER CRD42019139109.
Collapse
Affiliation(s)
- Qiancheng Hu
- Department of Abdominal Oncology, Cancer Center, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Xin Wang
- Department of Abdominal Oncology, Cancer Center, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Ye Chen
- Department of Abdominal Oncology, Cancer Center, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Xiaofen Li
- Department of Abdominal Oncology, Cancer Center, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Ting Luo
- Breast Medical Oncology, Clinical Research Center for Breast, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Dan Cao
- Department of Abdominal Oncology, Cancer Center, Sichuan University West China Hospital, Chengdu, Sichuan, China
| |
Collapse
|
43
|
Thanopoulou E, Khader L, Caira M, Wardley A, Ettl J, Miglietta F, Neven P, Guarneri V. Therapeutic Strategies for the Management of Hormone Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Positive (HR+/HER2+) Breast Cancer: A Review of the Current Literature. Cancers (Basel) 2020; 12:E3317. [PMID: 33182657 PMCID: PMC7696181 DOI: 10.3390/cancers12113317] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/22/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023] Open
Abstract
Enormous advances have been made in the understanding and treatment of human epidermal growth factor receptor 2-positive breast cancer (HER2+ BC) in the last 30 years that have resulted in survival gains for affected patients. A growing body of evidence suggests that hormone receptor-positive (HR+)/HER2+ BC and HR-negative (HR-)/HER2+ BC are biologically different, with complex molecular bidirectional crosstalk between the estrogen receptor and HER2 pathway potentially affecting sensitivity to both HER2-targeted and endocrine therapy in patients with HR+/HER2+ BC. Subgroup analyses from trials enrolling patients with HER2+ BC and the results of clinical trials specifically designed to evaluate therapy in patients with HR+/HER2+ BC are helping to guide treatment decisions. In this context, encouraging results with strategies aimed at delaying or reversing drug resistance, including extended adjuvant therapy and the addition of drugs targeting alternative pathways, such as cyclin-dependent kinase (CDK) 4 and 6 inhibitors, have recently emerged. We have reached the point where tailoring the treatment according to risk and biology has become the paradigm in early BC. However, further clinical trials are needed that integrate translational research principles and identify and consider specific patient subgroups and biomarkers.
Collapse
Affiliation(s)
- Eirini Thanopoulou
- Eli Lilly and Company Limited, Erl Wood Manor, Windlesham, Surrey GU20 6PH, UK;
| | - Leila Khader
- Eli Lilly Italia S.p.A., 50019 Comune di Sesto Fiorentino, Florence, Italy; (L.K.); (M.C.)
| | - Morena Caira
- Eli Lilly Italia S.p.A., 50019 Comune di Sesto Fiorentino, Florence, Italy; (L.K.); (M.C.)
| | - Andrew Wardley
- The NIHR Manchester Clinical Research Facility at The Christie NHS Foundation Trust, School of Medical Sciences, Faculty of Biology Medicine & Health, University of Manchester, Manchester M204BX, UK;
| | - Johannes Ettl
- Department of Obstetrics and Gynecology, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany;
| | - Federica Miglietta
- Medical Oncology 2, Istituto Oncologico Veneto IOV IRCCS, 35128 Padua, Italy;
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padua, Italy
| | - Patrick Neven
- Multidisciplinary Breast Center and Department of Gynecology and Obstetrics, UZ Leuven, 3000 Leuven, Belgium;
- Department of Oncology, KU Leuven, 3000 Leuven, Belgium
| | - Valentina Guarneri
- Medical Oncology 2, Istituto Oncologico Veneto IOV IRCCS, 35128 Padua, Italy;
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padua, Italy
| |
Collapse
|
44
|
Sardesai S, Sukumar J, Kassem M, Palettas M, Stephens J, Morgan E, Addison D, Baliga R, Stover DG, VanDeusen J, Williams N, Cherian M, Lustberg M, Wesolowski R, Ramaswamy B. Clinical impact of interruption in adjuvant Trastuzumab therapy in patients with operable HER-2 positive breast cancer. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2020; 6:26. [PMID: 33292843 PMCID: PMC7643282 DOI: 10.1186/s40959-020-00081-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Trastuzumab-induced cardiotoxicity (TIC) can lead to early discontinuation of adjuvant therapy, however there is limited evidence on long-term survival outcomes in patients with operable human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC) experiencing treatment interruption or discontinuation. METHODS The primary objective of the study was to evaluate disease-free survival (DFS) in non-metastatic, HER2-positive, female BC patients who experienced treatment interruption or early discontinuation of trastuzumab therapy. Clinical and histopathological data were collected on 400 patients at The Ohio State University, an NCI-designated comprehensive cancer center between January 2005 and December 2015. Treatment interruption was defined as any delay of ≥2 weeks during trastuzumab therapy, including permanent cessation prior to completing planned therapy. TIC was defined as LVEF < 50% or > 15 points decline from baseline as evaluated by 2D echocardiogram after initiation of (neo) adjuvant therapy. DFS was defined as the time from diagnosis to first recurrence (loco-regional or distant recurrence) including second primary BC or death. Overall survival (OS) was defined as the time from diagnosis to death or last known follow up. OS/DFS estimates were generated using Kaplan-Meier methods and compared using Log-rank tests. Cox proportional hazard models were used to calculate adjusted hazard ratios (aHR) for OS/DFS. RESULTS A total of 369 patients received trastuzumab therapy; 106 (29%) patients experienced treatment interruption at least once and 42 (11%) permanently discontinued trastuzumab prior to completing planned therapy. TIC was the most common reason for interruption (66 patients, 62%). The median duration of trastuzumab in patients with treatment interruption was 11.3 months (range: 0.5-16.9) with 24 (23%) patients receiving ≤6 months of therapy. This duration includes the time delay related to treatment interruption. Patients with any treatment interruption had worse DFS (aHR: 4.4, p = 0.001) and OS (aHR: 4.8, p < 0.001) after adjusting for age, stage, grade, ER, node status and TIC. CONCLUSIONS Treatment interruption or early discontinuation of trastuzumab therapy in early HER2-positive BC, most often from TIC, is an independent prognostic marker for worse DFS and OS in operable HER2-positive BC. Future prospective studies should consider targeting at-risk populations and optimizing cardiac function to avoid interruption in trastuzumab therapy.
Collapse
Affiliation(s)
- Sagar Sardesai
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA.
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA.
| | - Jasmine Sukumar
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Mahmoud Kassem
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Marilly Palettas
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Julie Stephens
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Evan Morgan
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Daniel Addison
- Division of Cardiology, The Ohio State University, Columbus, OH, USA
| | - Ragavendra Baliga
- Division of Cardiology, The Ohio State University, Columbus, OH, USA
| | - Daniel G Stover
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Jeffrey VanDeusen
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Nicole Williams
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Mathew Cherian
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Maryam Lustberg
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Robert Wesolowski
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| | - Bhuvaneswari Ramaswamy
- Stefanie Spielman Comprehensive Breast Cancer, The Ohio State University, Columbus, OH, 43210, USA
- Division of Medical Oncology, Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, 1204A Lincoln Tower, 1800 Cannon Dr, Columbus, OH, USA
| |
Collapse
|
45
|
Hensing W, Santa-Maria CA, Peterson LL, Sheng JY. Landmark trials in the medical oncology management of early stage breast cancer. Semin Oncol 2020; 47:278-292. [PMID: 32933761 PMCID: PMC7655597 DOI: 10.1053/j.seminoncol.2020.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 12/26/2022]
Abstract
With the advent of breast cancer screening programs, the majorities of patients with newly diagnosed breast cancer are diagnosed with early stage disease and are likely to experience cure with proper treatment. Significant advances have been made in the management of early-stage breast cancer to personalize treatment according to disease biology. This progress has led to improvement in survival outcomes and quality of life for our patients. In this review, we discuss landmark clinical trials in medical oncology that have shaped the current standard of care for early stage ER-positive, HER2-positive, and triple negative breast cancer.
Collapse
Affiliation(s)
- Whitney Hensing
- Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO
| | - Cesar A Santa-Maria
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore MD
| | - Lindsay L Peterson
- Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO
| | - Jennifer Y Sheng
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore MD.
| |
Collapse
|
46
|
Choong GM, Cullen GD, O'Sullivan CC. Evolving standards of care and new challenges in the management of HER2-positive breast cancer. CA Cancer J Clin 2020; 70:355-374. [PMID: 32813307 DOI: 10.3322/caac.21634] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/29/2020] [Accepted: 07/13/2020] [Indexed: 12/13/2022] Open
Abstract
The management of human epidermal growth factor receptor (HER2)-positive breast cancer (BC) has rapidly evolved over the last 20 years. Major advances have led to US Food and Drug Administration approval of 7 HER2-targeted therapies for the treatment of early-stage and/or advanced-stage disease. Although oncologic outcomes continue to improve, most patients with advanced HER2-positive BC ultimately die of their disease because of primary or acquired resistance to therapy, and patients with HER2-positive early BC who have residual invasive disease after preoperative systemic therapy are at a higher risk of distant recurrence and death. The concept of treatment de-escalation and escalation is increasingly important to optimally tailor therapy for patients with HER2-positive BC and is a major focus of the current review. Research efforts in this regard are discussed as well as updates regarding the evolving standard of care in the (neo)adjuvant and metastatic settings, including the use of novel combination therapies. The authors also briefly discuss ongoing challenges in the management of HER2-positive BC (eg, intrinsic vs acquired drug resistance, the identification of predictive biomarkers, the integration of imaging techniques to guide clinical practice), and the treatment of HER2-positive brain metastases. Research aimed at superseding these challenges will be imperative to ensure continued progress in the management of HER2-positive BC going forward.
Collapse
Affiliation(s)
- Grace M Choong
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Grace D Cullen
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
47
|
Paluch-Shimon S, Cherny NI, de Vries EGE, Dafni U, Piccart MJ, Latino NJ, Cardoso F. Application of the ESMO-Magnitude of Clinical Benefit Scale (V.1.1) to the field of early breast cancer therapies. ESMO Open 2020; 5:e000743. [PMID: 32893189 PMCID: PMC7476474 DOI: 10.1136/esmoopen-2020-000743] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/19/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022] Open
Abstract
Click here to listen to the Podcast BACKGROUND: The European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) is a validated value scale for solid tumour anticancer treatments. Form 1 of the ESMO-MCBS, used to grade therapies with curative intent including adjuvant therapies, has only been evaluated for a limited number of studies. This is the first large-scale field testing in early breast cancer to assess the applicability of the scale to this data set and the reasonableness of derived scores and to identify any shortcomings to be addressed in future modifications of the scale. METHOD Representative key studies and meta-analyses of the major modalities of adjuvant systemic therapy of breast cancer were identified for each of the major clinical scenarios (HER2-positive, HER2-negative, endocrine-responsive) and were graded with form 1 of the ESMO-MCBS. These generated scores were reviewed by a panel of experts for reasonableness. Shortcomings and issues related to the application of the scale and interpretation of results were identified and critically evaluated. RESULTS Sixty-five studies were eligible for evaluation: 59 individual studies and 6 meta-analyses. These studies incorporated 101 therapeutic comparisons, 61 of which were scorable. Review of the generated scores indicated that, with few exceptions, they generally reflected contemporary standards of practice. Six shortcomings were identified related to grading based on disease-free survival (DFS), lack of information regarding acute and long-term toxicity and an inability to grade single-arm de-escalation scales. CONCLUSIONS Form 1 of the ESMO-MCBS is a robust tool for the evaluation of the magnitude of benefit studies in early breast cancer. The scale can be further improved by addressing issues related to grading based on DFS, annotating grades with information regarding acute and long-term toxicity and developing an approach to grade single-arm de-escalation studies.
Collapse
Affiliation(s)
| | | | - Elisabeth G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Urania Dafni
- National and Kapodistrian University of Athens, Athens, Greece; Frontier Science Foundation-Hellas, Athens, Greece
| | - Martine J Piccart
- Université Libre de Bruxelles, Institut Jules Bordet, Bruxelles, Belgium
| | - Nicola Jane Latino
- ESMO-MCBS Working Group, European Society for Medical Oncology, Viganello, Switzerland
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| |
Collapse
|
48
|
Tailored duration of adjuvant trastuzumab for human epidermal growth factor receptor 2-positive breast cancer. NPJ Precis Oncol 2020; 4:23. [PMID: 32802960 PMCID: PMC7406512 DOI: 10.1038/s41698-020-00128-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 06/29/2020] [Indexed: 12/21/2022] Open
Abstract
We assumed that the effect of adjuvant trastuzumab on survival is mediated by the treatment time and we conducted this trial-level meta-regression to determine the appropriate length of treatment. Twelve adjuvant trastuzumab trials (from January 2000 to June 2019, consisting of 20,271 patients) were included. We considered 12-month trastuzumab treatment as the standard. The primary study endpoint was disease-free survival (DFS). By quantifying the relationship between shortened treatment time (month) and altered recurrence risk (expressed as hazard ratio), we found the regression coefficient β was 0.05 (95% confidence interval: 0.02–0.08, P = 0.002), indicating the recurrence risk would increase 5.1% for each month that treatment was shortened. Accordingly, 3, 6, and 9-month reductions in treatment time resulted in 16%, 35%, and 57% increases in recurrence risk, respectively. We revealed a significant linear association between shortened treatment time of trastuzumab and recurrence risk. The clinical duration of adjuvant trastuzumab should be tailored.
Collapse
|
49
|
Gulia S, Kannan S, Badwe R, Gupta S. Evaluation of 1-Year vs Shorter Durations of Adjuvant Trastuzumab Among Patients With Early Breast Cancer: An Individual Participant Data and Trial-Level Meta-analysis. JAMA Netw Open 2020; 3:e2011777. [PMID: 32833018 PMCID: PMC7445596 DOI: 10.1001/jamanetworkopen.2020.11777] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE The optimum duration of adjuvant trastuzumab among patients with early breast cancer is uncertain but of great therapeutic relevance. OBJECTIVE To compare shorter durations with 1 year of adjuvant trastuzumab for patients with early breast cancer. DATA SOURCES PubMed, Embase, Cochrane Central Register of Clinical Trials, and conference proceedings were searched from January 1, 2005, to June 30, 2019, for relevant randomized clinical trials (RCTs). STUDY SELECTION To be eligible, the trial had to be randomized, compare a shorter duration with 1 year of trastuzumab as adjuvant treatment, and include patients with early breast cancer. DATA EXTRACTION AND SYNTHESIS Individual patient data for disease-free survival (DFS) and overall survival (OS) were extracted from published survival curves of included RCTs; DFS and OS curves for each trial and the combined population were reconstructed. The DFS and OS hazard ratios (HRs) were estimated from the reconstructed survival curves as well as published estimates. The HR for DFS was used to test noninferiority using the median noninferiority margin of eligible RCTs. This study followed Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. MAIN OUTCOMES AND MEASURES The primary outcome was DFS; OS and cardiac toxic effects were secondary outcomes. RESULTS There were 6 eligible RCTs with a median DFS noninferiority margin of 1.3 (range, 1.15-1.53), 5 of which had extractable individual patient data for 11 376 patients, 1659 DFS events, and 871 deaths. For shorter duration vs 1 year of trastuzumab, the 5-year DFS was 85.42% (95% CI, 84.41%-86.38%) vs 87.12% (95% CI, 86.15%-88.02%) (HR, 1.14; 95% CI, 1.03-1.25, 1-sided P for noninferiority = .004), and OS was 92.39% (95% CI, 91.61%-93.10%) vs 93.46% (95% CI, 92.73%-94.13%) (HR, 1.17; 95% CI, 1.02-1.33). Using trial-level published estimates from 6 RCTs, including 11 603 patients, 1760 DFS events, and 930 deaths, the HR for DFS was 1.15 (95% CI, 1.04-1.26; 1-sided P for noninferiority = .002) and, for OS, 1.17 (95% CI, 1.03-1.33). There was significantly less risk of congestive heart failure with shorter-duration trastuzumab (relative risk, 0.53; 95% CI, 0.38-0.74). CONCLUSIONS AND RELEVANCE In this study, a shorter duration of adjuvant trastuzumab was noninferior to its 1-year administration and resulted in lower rates of cardiac toxic effects. These results suggest that a shorter duration may be the preferred option for patients with low-risk disease or a predisposition to cardiac toxic effects.
Collapse
Affiliation(s)
- Seema Gulia
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Sadhana Kannan
- Department of Biostatistics, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Rajendra Badwe
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| |
Collapse
|
50
|
Earl H, Hiller L, Vallier AL, Loi S, McAdam K, Hughes-Davies L, Rea D, Howe D, Raynes K, Higgins HB, Wilcox M, Plummer C, Mahler-Araujo B, Provenzano E, Chhabra A, Gasson S, Balmer C, Abraham JE, Caldas C, Hall P, Shinkins B, McCabe C, Hulme C, Miles D, Wardley AM, Cameron DA, Dunn JA. Six versus 12 months' adjuvant trastuzumab in patients with HER2-positive early breast cancer: the PERSEPHONE non-inferiority RCT. Health Technol Assess 2020; 24:1-190. [PMID: 32880572 PMCID: PMC7505360 DOI: 10.3310/hta24400] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The addition of adjuvant trastuzumab to chemotherapy has significantly improved outcomes for people with human epidermal growth factor receptor 2 (HER2)-positive, early, potentially curable breast cancer. Twelve months' trastuzumab, tested in registration trials, was adopted as standard adjuvant treatment in 2006. Subsequently, similar outcomes were demonstrated using 9 weeks of trastuzumab. Shorter durations were therefore tested for non-inferiority. OBJECTIVES To establish whether or not 6 months' adjuvant trastuzumab is non-inferior to 12 months' in the treatment of HER2-positive early breast cancer using a primary end point of 4-year disease-free survival. DESIGN This was a Phase III randomised controlled non-inferiority trial. SETTING The setting was 152 NHS hospitals. PARTICIPANTS A total of 4088 patients with HER2-positive early breast cancer who it was planned would receive both chemotherapy and trastuzumab took part. INTERVENTION Randomisation (1 : 1) to 6 months' or 12 months' trastuzumab treatment. MAIN OUTCOMES The primary end point was disease-free survival. The secondary end points were overall survival, cost-effectiveness and cardiac function during treatment with trastuzumab. Assuming a 4-year disease-free survival rate of 80% with 12 months' trastuzumab, 4000 patients were required to demonstrate non-inferiority of 6 months' trastuzumab (5% one-sided significance, 85% power), defining the non-inferiority limit as no worse than 3% below the standard arm. Costs and quality-adjusted life-years were estimated using a within-trial analysis and a lifetime decision-analytic model. RESULTS Between 4 October 2007 and 31 July 2015, 2045 patients were randomised to 12 months' trastuzumab and 2043 were randomised to 6 months' trastuzumab. Sixty-nine per cent of patients had ER-positive disease; 90% received anthracyclines (49% with taxanes; 41% without taxanes); 10% received taxanes without anthracyclines; 54% received trastuzumab sequentially after chemotherapy; and 85% received adjuvant chemotherapy (58% were node negative). At 6.1 years' median follow-up, with 389 (10%) deaths and 566 (14%) disease-free survival events, the 4-year disease-free survival rates for the 4088 patients were 89.5% (95% confidence interval 88.1% to 90.8%) in the 6-month group and 90.3% (95% confidence interval 88.9% to 91.5%) in the 12-month group (hazard ratio 1.10, 90% confidence interval 0.96 to 1.26; non-inferiority p = 0.01), demonstrating non-inferiority of 6 months' trastuzumab. Congruent results were found for overall survival (non-inferiority p = 0.0003) and landmark analyses 6 months from starting trastuzumab [non-inferiority p = 0.03 (disease-free-survival) and p = 0.006 (overall survival)]. Six months' trastuzumab resulted in fewer patients reporting adverse events of severe grade [365/1929 (19%) vs. 460/1935 (24%) for 12-month patients; p = 0.0003] or stopping early because of cardiotoxicity [61/1977 (3%) vs. 146/1941 (8%) for 12-month patients; p < 0.0001]. Health economic analysis showed that 6 months' trastuzumab resulted in significantly lower lifetime costs than and similar lifetime quality-adjusted life-years to 12 months' trastuzumab, and thus there is a high probability that 6 months' trastuzumab is cost-effective compared with 12 months' trastuzumab. Patient-reported experiences in the trial highlighted fatigue and aches and pains most frequently. LIMITATIONS The type of chemotherapy and timing of trastuzumab changed during the recruitment phase of the study as standard practice altered. CONCLUSIONS PERSEPHONE demonstrated that, in the treatment of HER2-positive early breast cancer, 6 months' adjuvant trastuzumab is non-inferior to 12 months'. Six months' treatment resulted in significantly less cardiac toxicity and fewer severe adverse events. FUTURE WORK Ongoing translational work investigates patient and tumour genetic determinants of toxicity, and trastuzumab efficacy. An individual patient data meta-analysis with PHARE and other trastuzumab duration trials is planned. TRIAL REGISTRATION Current Controlled Trials ISRCTN52968807, EudraCT 2006-007018-39 and ClinicalTrials.gov NCT00712140. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 40. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Helena Earl
- Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
- Cambridge Breast Cancer Research Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Louise Hiller
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Anne-Laure Vallier
- Cambridge Clinical Trials Unit - Cancer Theme, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Shrushma Loi
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Karen McAdam
- Department of Oncology, North West Anglia NHS Foundation Trust, Peterborough City Hospital, Peterborough, UK
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Luke Hughes-Davies
- Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Daniel Rea
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Donna Howe
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Kerry Raynes
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Helen B Higgins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | - Chris Plummer
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Betania Mahler-Araujo
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Metabolic Research Laboratories, University of Cambridge, Cambridge, UK
| | - Elena Provenzano
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anita Chhabra
- Pharmacy, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Sophie Gasson
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Claire Balmer
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Jean E Abraham
- Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
- Cambridge Breast Cancer Research Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Carlos Caldas
- Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
- Cambridge Breast Cancer Research Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Peter Hall
- Edinburgh University Cancer Research Centre, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Bethany Shinkins
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | | | - Claire Hulme
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
- Health Economics Group, University of Exeter Medical School, Exeter, UK
| | - David Miles
- Medical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Andrew M Wardley
- NIHR Manchester Clinical Research Facility at The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David A Cameron
- Edinburgh University Cancer Research Centre, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Janet A Dunn
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| |
Collapse
|