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Nag S. Duration of trastuzumab use in patients with early breast cancer. THE NATIONAL MEDICAL JOURNAL OF INDIA 2021; 34:285-286. [PMID: 35593237 DOI: 10.25259/nmji_338_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Shona Nag
- Department of Oncology, Sahyadri Hospitals, Pune, Maharashtra, India
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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.
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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
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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.
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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
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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.
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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
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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.
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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
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Chiec L, Shah AN. Risk-based Approaches for Optimizing Treatment in HER2-Positive Early Stage Breast Cancer. Semin Oncol 2020; 47:249-258. [PMID: 32928586 DOI: 10.1053/j.seminoncol.2020.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/09/2020] [Indexed: 11/11/2022]
Abstract
Advancements in the care for patients with early stage HER2-positive breast cancer is a story of incremental successes aimed at optimizing efficacy and reducing the toxicities of administered therapies. HER2 drives an aggressive breast cancer subtype that represents 15%-20% of breast cancers, for which HER2-targeted therapy is very active. In addition to trastuzumab, pertuzumab, neratinib, and ado-trastuzumab emtansine have been approved in recent years for the treatment of high-risk early stage HER2-positive breast cancer. As a result of both a high response rate to neoadjuvant therapy and the opportunity for response-adapted adjuvant therapy, the treatment paradigm has evolved so that most patients with stage II and III disease now receive neoadjuvant therapy. Additionally, the efficacy of HER2-therapy allows for de-escalation of treatment in many patients with stage I disease. As a result, multidisciplinary evaluation is essential for the optimal care of patients with HER2-positive breast cancer. Important areas of further research include tailoring the duration and intensity of therapy based on disease risk and response to neoadjuvant therapy. This article will review the evaluation of patients with early stage HER2-positive breast cancer and provide an evidence- and guideline-based summary of risk-based treatment strategies.
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Affiliation(s)
- Lauren Chiec
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois
| | - Ami N Shah
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois.
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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.
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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.
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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
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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.
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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
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10
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Elsisi GH, Nada Y, Rashad N, Carapinha J, Noor AO, Almasri DM, Zaidy MA, Foad A, Khaled H. Cost-effectiveness of six months versus 1-year adjuvant trastuzumab in HER2 positive early breast cancer in Egypt. J Med Econ 2020; 23:575-580. [PMID: 32011199 DOI: 10.1080/13696998.2020.1724682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Breast cancer is the most prevalent cancer among women in Egypt. Trastuzumab is administered with chemotherapy for patients with HER2-positive advanced breast cancer (HER2 + ve ABC) in the metastatic and adjuvant settings resulting in improved treatment outcomes, and long-term follow-up. Some studies have evaluated whether equivalent outcomes can be achieved with reduced treatment duration. This study evaluates the cost-effectiveness of 6-month versus 1-year trastuzumab treatments from payer perspective over a 10 year time horizon.Methods: A half-cycle corrected Markov model was developed with five mutually exclusive health states; patient with HER2 +ve ABC, disease-free survival (DFS), local or regional relapse, metastatic relapse, and death. A cycle length of 6 months was applied, direct medical costs including cost of treatments, day-care, surgery, health states and follow-up visits were collected, and indirect costs such as lost productivity were not estimated. The transition probabilities and utilities were extracted from published literature, and deterministic sensitivity analyses were conducted.Results: Among the HER2 +ve ABC patient population in Egypt, the total QALYs of the 6-month trastuzumab were estimated to be 2.99 compared with 2.93 for the 1-year trastuzumab which resulted in a difference of 0.06 QALYs. The total costs were EGP 271,647 ($106,947) and EGP 381,248 ($150,097), respectively. These costs yielded an ICER of -109,600 EGP/QALY (-43,149 $/QALY) for the 6-month trastuzumab. The 6-month trastuzumab is a dominant strategy when compared to 1-year trastuzumab, resulting in improved effectiveness at a reduced cost. All analyses results confirmed the dominance of 6-month trastuzumab and our model robustness.Conclusions: This study concluded that 6-month trastuzumab is a cost-effective option when compared to 1-year trastuzumab in patients with HER2 +ve ABC in Egypt. Our findings provide health care decision makers with additional insights to best allocate available resources concurrently with the improvement of the Egyptian patient's outcomes.
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Affiliation(s)
- Gihan Hamdy Elsisi
- HTA Office, L.L.C., Cairo, Egypt
- Faculty of Pharmacy, Future University, Cairo, Egypt
| | - Yousery Nada
- Medical Oncology Department, Maadi Armed Forces Medical Compound, Oncology and Hematology Hospital, Cairo, Egypt
| | - Noha Rashad
- Medical Oncology Department, Maadi Armed Forces Medical Compound, Oncology and Hematology Hospital, Cairo, Egypt
| | - João Carapinha
- C&C, Inc., Boston, MA, USA
- School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Ahmad O Noor
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Diena M Almasri
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mostafa Al Zaidy
- Medical Oncology Department, Maadi Armed Forces Medical Compound, Oncology and Hematology Hospital, Cairo, Egypt
| | - Ahmed Foad
- Medical Oncology Department, Maadi Armed Forces Medical Compound, Oncology and Hematology Hospital, Cairo, Egypt
| | - Hussien Khaled
- Medical Oncology Department, National Cancer Institute, Cairo University, Giza, Egypt
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11
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Deng H, Du X, Wang L, Chen M. Six Months vs. 12 Months of Adjuvant Trastuzumab Among Women With HER2-Positive Early-Stage Breast Cancer: A Meta-Analysis of Randomized Controlled Trials. Front Oncol 2020; 10:288. [PMID: 32266131 PMCID: PMC7098966 DOI: 10.3389/fonc.2020.00288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 02/19/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose: Both 12 and 6 months of trastuzumab in combination with chemotherapy are effective for HER2+ early-stage breast cancer. This meta-analysis was performed to assess the effectiveness and the toxicity of the two durations. Methods and Materials: We acquired relevant randomized controlled trials (RCTs) from PubMed, the Cochrane Library, ScienceDirect, EMBASE, Ovid MEDLINE, Web of Science, Scopus, and Google Scholar. Our endpoints included disease-free survival (DFS), overall survival (OS), number of recurrences, mortality and early stopping of trastuzumab, and adverse events (AEs). Results: We included five good-quality studies. Both durations of trastuzumab were effective among women with HER2+ early-stage breast cancer, but 12 months of trastuzumab appeared to have better DFS [hazard ratio (HR) = 1.10, 95% confidence interval (CI): 0.99-1.23, P = 0.09] and better OS than 6 months of trastuzumab (HR = 1.14, 95% CI: 0.99-1.32, P = 0.07). However, the 12 month group had more AEs, especially cardiac events [risk ratio (RR) = 0.66, 95% CI: 0.56-0.77, P < 0.00001]. In our sub-analyses, the 12 months duration had better DFS among patients using trastuzumab concurrently than the 6 months duration (HR = 1.23, 95% CI: 1.06-1.44, P = 0.006). Additionally, the 12 months duration had superior OS in women with ER-negative breast cancer (HR = 1.51, 95% CI: 1.10-2.08, P = 0.01) and patients treated with trastuzumab concurrently than the 6 months duration (HR = 1.61, 95% CI: 1.13-2.29, P = 0.008). Conclusions: Twelve months was the standard duration of adjuvant trastuzumab among patients with HER2+ early-stage breast cancer, with a tendency toward superior survival. However, patients in the 12 month group had more significant cardiac toxicity than those in the 6 month group.
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Affiliation(s)
- Huan Deng
- Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Hangzhou, China
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China
- Department of Radiation Oncology, Zhejiang Key Laboratory of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, China
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing, China
| | - Xianghui Du
- Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Hangzhou, China
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China
- Department of Radiation Oncology, Zhejiang Key Laboratory of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, China
- Key Laboratory Diagnosis and Treatment Technology on Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Li Wang
- Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Ming Chen
- Institute of Cancer and Basic Medicine (ICBM), Chinese Academy of Sciences, Hangzhou, China
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China
- Department of Radiation Oncology, Zhejiang Key Laboratory of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, China
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12
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Eiger D, Franzoi MA, Pondé N, Brandão M, de Angelis C, Schmitt Nogueira M, de Hemptinne Q, de Azambuja E. Cardiotoxicity of trastuzumab given for 12 months compared to shorter treatment periods: a systematic review and meta-analysis of six clinical trials. ESMO Open 2020; 5:e000659. [PMID: 32079624 PMCID: PMC7046387 DOI: 10.1136/esmoopen-2019-000659] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/22/2020] [Accepted: 01/23/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Treatment de-escalation in early-stage, human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC) has been attempted in order to decrease costs and toxicities. One of the strategies pursued is decreasing trastuzumab treatment duration, with mixed results thus far. Trastuzumab-associated cardiotoxicity, however, may be more frequent with 12 months of trastuzumab compared with shorter treatment lengths. Therefore, we have conducted a meta-analysis to address this question. MATERIALS AND METHODS A meta-analysis of trials testing 12 months of adjuvant trastuzumab versus shorter regimens, reporting cardiac outcomes in patients with HER2-positive BC was performed with the random effects model with inverse variance weighting. RESULTS Clinical cardiac dysfunction associated with 12 months of trastuzumab versus shorter trastuzumab regimens, including 11 250 patients, showed a pooled OR (pOR) of 1.90 (95% CI 1.37 to 2.64; p value <0.001; I2=65.7%); in the subgroup comparison of 12 versus 6 months, the pOR was 1.57 (95% CI 1.30 to 1.90; p<0.001; I2=5.7%). pOR for low left ventricular ejection fraction was 1.45 (95% CI 1.19 to 1.75; p<0.001; I2=11.9%), 1.55 (95% CI 1.00 to 2.42; p=0.052; I2=0.0%) for congestive heart failure and 3.70 (95% CI 0.27 to 51.60; p=0.33; I2=78.8%) for premature trastuzumab discontinuation due to cardiotoxicity for 12 months versus shorter trastuzumab regimens. Funnel plot analyses indicated a low risk of publication bias. CONCLUSIONS Compared to shorter treatment durations, there is sufficient evidence that 12 months of trastuzumab yields higher odds for the occurrence of relevant cardiac events. An individual patient-level data meta-analysis is needed in order to provide adequate data on risk factors for cardiotoxicity.
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Affiliation(s)
- Daniel Eiger
- Clinical Trials Support Unit, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B), Bruxelles, Belgium
| | - Maria Alice Franzoi
- Clinical Trials Support Unit, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B), Bruxelles, Belgium
| | - Noam Pondé
- AC Camargo Cancer Center, São Paulo, Brazil
| | - Mariana Brandão
- Clinical Trials Support Unit, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B), Bruxelles, Belgium
| | - Claudia de Angelis
- Department of Translational Research and New Technologies in Medicine and Surgery, Pisa University Hospital, Pisa, Italy
| | - Melanie Schmitt Nogueira
- Department of Haematology, Oncology, Hemostasiology and Stem Cell Transplant (Medizinische Klinik IV), Uniklinik RWTH Aachen, Aachen, Germany
| | | | - Evandro de Azambuja
- Clinical Trials Support Unit, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B), Bruxelles, Belgium
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13
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Venniyoor A. Trastuzumab is not a one-man show: The sequence matters. CANCER RESEARCH, STATISTICS, AND TREATMENT 2020. [DOI: 10.4103/crst.crst_86_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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14
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Joensuu H, Fraser J, Wildiers H, Huovinen R, Auvinen P, Utriainen M, Nyandoto P, Villman KK, Halonen P, Granstam-Björneklett H, Lundgren L, Sailas L, Turpeenniemi-Hujanen T, Tanner M, Yachnin J, Ritchie D, Johansson O, Huttunen T, Neven P, Canney P, Harvey VJ, Kellokumpu-Lehtinen PL, Lindman H. Effect of Adjuvant Trastuzumab for a Duration of 9 Weeks vs 1 Year With Concomitant Chemotherapy for Early Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer: The SOLD Randomized Clinical Trial. JAMA Oncol 2019; 4:1199-1206. [PMID: 29852043 DOI: 10.1001/jamaoncol.2018.1380] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Importance Trastuzumab plus chemotherapy is the standard adjuvant treatment for patients with human epidermal growth factor receptor 2 (HER2)-positive early breast cancer. While the standard duration of trastuzumab treatment is 12 months, the benefits and harms of trastuzumab continued beyond the chemotherapy are unclear. Objective To evaluate the efficacy and safety of adjuvant trastuzumab continued beyond chemotherapy in women treated with up-front chemotherapy containing a taxane and trastuzumab. Design, Setting, and Participants Open-label, randomized (1:1) clinical trial including women with HER2-positive breast cancer. Chemotherapy was identical in the 2 groups, consisting of 3 cycles of 3-weekly docetaxel (either 80 or 100 mg/m2) plus trastuzumab for 9 weeks, followed by 3 cycles of fluorouracil, epirubicin, and cyclophosphamide. Thereafter, no trastuzumab was administered in the 9-week group, whereas controls received trastuzumab to complete 1 year of administration. Disease-free survival (DFS) was compared between the groups using a Cox model and the noninferiority approach. The estimated sample size was 2168 patients (1-sided testing, with a relative noninferiority margin of 1.3). From January 3, 2008, to December 16, 2014, 2176 patients were accrued from 7 countries. Intervention Docetaxel plus trastuzumab for 9 weeks, followed by 3 cycles of fluorouracil, epirubicin, and cyclophosphamide in both groups. Controls continued trastuzumab to 1 year. Main Outcomes and Measures The primary objective was DFS; secondary objectives included distant disease-free survival, overall survival, cardiac DFS, and safety. Results In the 2174 women analyzed, median age was 56 (interquartile range [IQR], 48-64) years. The median follow-up was 5.2 (IQR, 3.8-6.7) years. Noninferiority of the 9-week treatment could not be demonstrated for DFS (hazard ratio, 1.39; 2-sided 90% CI, 1.12-1.72). Distant disease-free survival and overall survival did not differ substantially between the groups. Thirty-six (3%) and 21 (2%) patients in the 1-year and the 9-week groups, respectively, had cardiac failure; the left ventricle ejection fraction was better maintained in the 9-week group. An interaction was detected between the docetaxel dose and DFS; patients in the 9-week group treated with 80 mg/m2 had inferior and those treated with 100 mg/m2 had similar DFS as patients in the 1-year group. Conclusions and Relevance Nine weeks of trastuzumab was not noninferior to 1 year of trastuzumab when given with similar chemotherapy. Cardiac safety was better in the 9-week group. The docetaxel dosing with trastuzumab requires further study. Trial Registration ClinicalTrials.gov Identifier: NCT00593697.
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Affiliation(s)
- Heikki Joensuu
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Judith Fraser
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | | | - Riikka Huovinen
- Department of Oncology, Turku University Central Hospital, Turku, Finland
| | - Päivi Auvinen
- Department of Oncology, Kuopio University Hospital, Kuopio, Finland
| | - Meri Utriainen
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | | | - Päivi Halonen
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | | | - Liisa Sailas
- Vaasa Central Hospital, Vaasa, Finland.,North Carelia Central Hospital, Joensuu, Finland
| | | | - Minna Tanner
- Department of Oncology, Tampere University Hospital, Tampere, Finland
| | | | - Diana Ritchie
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | | | | | | | - Peter Canney
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
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15
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Gouveia HS, Konsulova A, Cardoso F. New strategies for the precision treatment of HER2-driven tumours. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2019. [DOI: 10.1080/23808993.2019.1626713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Helena S. Gouveia
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| | - Assia Konsulova
- Department of Oncology, Complex Oncological Centre, Burgas, Bulgaria
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
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16
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Earl HM, Hiller L, Vallier AL, Loi S, McAdam K, Hughes-Davies L, Harnett AN, Ah-See ML, Simcock R, Rea D, Raj S, Woodings P, Harries M, Howe D, Raynes K, Higgins HB, Wilcox M, Plummer C, Mansi J, Gounaris I, Mahler-Araujo B, Provenzano E, Chhabra A, Abraham JE, Caldas C, Hall PS, McCabe C, Hulme C, Miles D, Wardley AM, Cameron DA, Dunn JA. 6 versus 12 months of adjuvant trastuzumab for HER2-positive early breast cancer (PERSEPHONE): 4-year disease-free survival results of a randomised phase 3 non-inferiority trial. Lancet 2019; 393:2599-2612. [PMID: 31178152 PMCID: PMC6615016 DOI: 10.1016/s0140-6736(19)30650-6] [Citation(s) in RCA: 190] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/21/2019] [Accepted: 03/05/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Adjuvant trastuzumab significantly improves outcomes for patients with HER2-positive early breast cancer. The standard treatment duration is 12 months but shorter treatment could provide similar efficacy while reducing toxicities and cost. We aimed to investigate whether 6-month adjuvant trastuzumab treatment is non-inferior to the standard 12-month treatment regarding disease-free survival. METHODS This study is an open-label, randomised phase 3 non-inferiority trial. Patients were recruited from 152 centres in the UK. We randomly assigned patients with HER2-positive early breast cancer, aged 18 years or older, and with a clear indication for chemotherapy, by a computerised minimisation process (1:1), to receive either 6-month or 12-month trastuzumab delivered every 3 weeks intravenously (loading dose of 8 mg/kg followed by maintenance doses of 6 mg/kg) or subcutaneously (600 mg), given in combination with chemotherapy (concurrently or sequentially). The primary endpoint was disease-free survival, analysed by intention to treat, with a non-inferiority margin of 3% for 4-year disease-free survival. Safety was analysed in all patients who received trastuzumab. This trial is registered with EudraCT (number 2006-007018-39), ISRCTN (number 52968807), and ClinicalTrials.gov (number NCT00712140). FINDINGS Between Oct 4, 2007, and July 31, 2015, 2045 patients were assigned to 12-month trastuzumab treatment and 2044 to 6-month treatment (one patient was excluded because they were double randomised). Median follow-up was 5·4 years (IQR 3·6-6·7) for both treatment groups, during which a disease-free survival event occurred in 265 (13%) of 2043 patients in the 6-month group and 247 (12%) of 2045 patients in the 12-month group. 4-year disease-free survival was 89·4% (95% CI 87·9-90·7) in the 6-month group and 89·8% (88·3-91·1) in the 12-month group (hazard ratio 1·07 [90% CI 0·93-1·24], non-inferiority p=0·011), showing non-inferiority of the 6-month treatment. 6-month trastuzumab treatment resulted in fewer patients reporting severe adverse events (373 [19%] of 1939 patients vs 459 [24%] of 1894 patients, p=0·0002) or stopping early because of cardiotoxicity (61 [3%] of 1939 patients vs 146 [8%] of 1894 patients, p<0·0001). INTERPRETATION We have shown that 6-month trastuzumab treatment is non-inferior to 12-month treatment in patients with HER2-positive early breast cancer, with less cardiotoxicity and fewer severe adverse events. These results support consideration of reduced duration trastuzumab for women at similar risk of recurrence as to those included in the trial. FUNDING UK National Institute for Health Research, Health Technology Assessment Programme.
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Affiliation(s)
- Helena M Earl
- Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Cambridge Breast Cancer Research Unit, Cambridge University Hospitals National Health Service (NHS) Foundation Trust, Cambridge, UK; National Institute for Health Research 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 National Health Service (NHS) Foundation Trust, Cambridge, UK
| | - Shrushma Loi
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Karen McAdam
- Department of Oncology, Cambridge University Hospitals National Health Service (NHS) Foundation Trust, Cambridge, UK; Department of Oncology, North West Anglia NHS Foundation Trust, Peterborough City Hospital, Peterborough, UK
| | - Luke Hughes-Davies
- Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Department of Oncology, Cambridge University Hospitals National Health Service (NHS) Foundation Trust, Cambridge, UK
| | - Adrian N Harnett
- Department of Oncology, James Paget University Hospital, Norfolk, UK; Department of Oncology, Norfolk & Norwich University Hospital, Norwich, UK
| | - Mei-Lin Ah-See
- Medical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Richard Simcock
- Sussex Cancer Centre, Brighton and Sussex University Hospitals NHS, Brighton, UK
| | - Daniel Rea
- Cancer Research UK Clinical Trials Unit and Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Sanjay Raj
- Department of Oncology, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | | | - Mark Harries
- Department of Medical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, 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
- Department of Cardiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Freeman Hospital, Newcastle upon Tyne, UK
| | - Janine Mansi
- Department of Medical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Betania Mahler-Araujo
- Metabolic Research Laboratories, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Department of Histopathology, Cambridge University Hospitals National Health Service (NHS) Foundation Trust, Cambridge, UK
| | - Elena Provenzano
- Department of Histopathology, Cambridge University Hospitals National Health Service (NHS) Foundation Trust, Cambridge, UK; National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, UK
| | - Anita Chhabra
- Pharmacy, Cambridge University Hospitals National Health Service (NHS) Foundation Trust, Cambridge, UK
| | - Jean E Abraham
- Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK; Cambridge Breast Cancer Research Unit, Cambridge University Hospitals National Health Service (NHS) Foundation Trust, Cambridge, UK; National Institute for Health Research 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 National Health Service (NHS) Foundation Trust, Cambridge, UK; National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, UK; Cancer Research UK Cambridge Institute, University of Cambridge Li Ka Shing Centre, Cambridge, UK
| | - Peter S Hall
- Cancer Edinburgh Research Centre, The Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | | | - Claire Hulme
- Academic Unit of Health Economics, University of Leeds, Leeds, UK; Health Economics Group, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - David Miles
- Medical Oncology, Mount Vernon Cancer Centre, Northwood, UK
| | - Andrew M Wardley
- Research & Development, The NIHR Manchester Clinical Research Facility at The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, Faculty of Biology, Medicine and Health, ManchesterAcademic Health Science Centre, University of Manchester, Manchester, UK
| | - David A Cameron
- Cancer Edinburgh Research Centre, The 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
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17
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Goldvaser H, Korzets Y, Shepshelovich D, Yerushalmi R, Sarfaty M, Ribnikar D, Thavendiranathan P, Amir E. Deescalating Adjuvant Trastuzumab in HER2-Positive Early-Stage Breast Cancer: A Systemic Review and Meta-Analysis. JNCI Cancer Spectr 2019; 3:pkz033. [PMID: 31360906 PMCID: PMC6649709 DOI: 10.1093/jncics/pkz033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/18/2019] [Accepted: 04/26/2019] [Indexed: 12/30/2022] Open
Abstract
Background One year of adjuvant trastuzumab in combination with chemotherapy is the standard of care in early-stage human epidermal growth factor receptor 2 (HER2)-positive breast cancer. Existing data on shortening trastuzumab treatment show conflicting results. Methods A search of PubMed and abstracts from key conferences identified randomized trials that compared abbreviated trastuzumab therapy to 1 year of treatment in early-stage HER2-positive breast cancer. Hazard ratios (HRs) and 95% confidence intervals (CIs) were extracted for disease-free survival (DFS) and overall survival (OS). Subgroup analyses evaluated the effect of nodal involvement, estrogen receptor expression, and the duration of abbreviated trastuzumab (9–12 weeks vs 6 months). Odds ratios (ORs) and 95% confidence intervals were computed for prespecified cardiotoxicity events including cardiac dysfunction and congestive heart failure. P values were two-sided. Results Analysis included six trials comprising 11 603 patients. Shorter trastuzumab treatment was associated with worse DFS (HR = 1.14, 95% CI = 1.05 to 1.25, P = .002) and OS (HR = 1.15, 95% CI = 1.02 to 1.29. P = .02). The effect on DFS was not influenced by estrogen receptor status (P for the subgroup difference = .23), nodal involvement (P = .44), or the different duration of trastuzumab in the experimental arm (P = .09). Shorter trastuzumab treatment was associated with lower odds of cardiac dysfunction (OR = 0.67, 95% CI = 0.55 to 0.81, P < .001) and congestive heart failure (OR = 0.66, 95% CI = 0.50 to 0.86, P = .003). Conclusions Compared with 1 year, shorter duration of adjuvant trastuzumab is associated with statistically significantly worse DFS and OS despite favorable cardiotoxicity profile. One year of targeted HER2 treatment should remain the standard adjuvant treatment in early-stage HER2-positive disease with appropriate cardiac monitoring.
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Affiliation(s)
- Hadar Goldvaser
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada.,Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Yasmin Korzets
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel.,Department of Radiation Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada
| | - Daniel Shepshelovich
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada.,Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel
| | - Rinat Yerushalmi
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Michal Sarfaty
- Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Domen Ribnikar
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Toronto General Hospital, Peter Munk Cardiac Center, University of Toronto, Toronto, Canada
| | - Eitan Amir
- Division of Medical Oncology, University of Toronto and Princess Margaret Cancer Centre, Toronto, Canada
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18
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Saad ED, Squifflet P, Burzykowski T, Quinaux E, Delaloge S, Mavroudis D, Perez E, Piccart-Gebhart M, Schneider BP, Slamon D, Wolmark N, Buyse M. Disease-free survival as a surrogate for overall survival in patients with HER2-positive, early breast cancer in trials of adjuvant trastuzumab for up to 1 year: a systematic review and meta-analysis. Lancet Oncol 2019; 20:361-370. [PMID: 30709633 PMCID: PMC7050571 DOI: 10.1016/s1470-2045(18)30750-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/25/2018] [Accepted: 10/03/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Although frequently used as a primary endpoint, disease-free survival has not been validated as a surrogate for overall survival in early breast cancer. We investigated this surrogacy in the adjuvant setting of treatment with anti-HER2 antibodies. METHODS In a systematic review and meta-analysis, we identified published and non-published randomised controlled trials with completed accrual and available disease-free survival and overall survival results for the intention-to-treat population as of September 2016. Bibliographic databases (MEDLINE, Embase, and Cochrane Central Register of Controlled Trials), clinical trial registries (Clinicaltrials.gov, EU Clinical Trials Register, WHO International Clinical Trials Registry Platform, and PharmNet.Bund), and trial registries from relevant pharmaceutical companies were searched. Eligibility for treatment of HER2-positive early breast cancer required at least one group to have an anti-HER antibody treatment (ie, trastuzumab, pertuzumab, or trastuzumab emtansine) planned for 12 months, and at least one control arm with chemotherapy without the antibody, a lower total dose or duration of the antibody, or observation alone. Units of analysis were contrasts: two-group trials gave rise to one contrast, whereas trials with more than two groups gave rise to more than one contrast. We excluded trials enrolling patients with recurrent, metastatic, or non-invasive disease, and those testing neoadjuvant therapy exclusively. Our primary objective was to estimate patient-level and trial-level correlations between disease-free survival and overall survival. We measured the association between disease-free survival and overall survival using Spearman's correlation coefficient (rs), and the association between hazard ratios (HRs) for disease-free survival and overall survival using R2. We computed the surrogate threshold effect, the maximum HR for disease-free survival that statistically predicts an HR for overall survival less than 1·00 in a future trial. FINDINGS Eight trials (n=21 480 patients) gave rise to a full set (12 contrasts). Patient-level associations between disease-free and overall survival were strong (rs=0·90 [95% CI 0·89-0·90]). Trial-level associations gave rise to values of R2 of 0·75 (95% CI 0·50-1·00) for the full set. Subgroups defined by nodal status and hormone receptor status yielded qualitatively similar results. Depending on the expected number of deaths in a future trial, the surrogate threshold effects ranged from 0·56 to 0·81, based on the full set. INTERPRETATION These findings suggest that it is appropriate to continue to use disease-free survival as a surrogate for overall survival in trials in HER-2-positive, early breast cancer. The key limitation of this study is the dependence of its results on the trials included and on the existence of an outlying trial. FUNDING Roche Pharma AG.
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Affiliation(s)
- Everardo D Saad
- International Drug Development Institute, Louvain-la-Neuve, Belgium.
| | - Pierre Squifflet
- International Drug Development Institute, Louvain-la-Neuve, Belgium
| | - Tomasz Burzykowski
- International Drug Development Institute, Louvain-la-Neuve, Belgium; Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt University, Diepenbeek, Belgium
| | - Emmanuel Quinaux
- International Drug Development Institute, Louvain-la-Neuve, Belgium
| | | | | | | | | | | | - Dennis Slamon
- University of California, Los Angeles (UCLA), Los Angeles, CA, USA
| | | | - Marc Buyse
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt University, Diepenbeek, Belgium; International Drug Development Institute, San Francisco, CA, USA
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Short-duration versus 1-year adjuvant trastuzumab in early HER2 positive breast cancer: A meta-analysis of randomized controlled trials. Cancer Treat Rev 2019; 75:12-19. [PMID: 30856373 DOI: 10.1016/j.ctrv.2019.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 02/23/2019] [Accepted: 02/27/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND One year of adjuvant trastuzumab treatment is the standard of care for early stage human epidermal growth factor receptor 2 (HER2)-positive breast cancer patients; however, controversy remains regarding the optimal schedule of trastuzumab because the selection of the 1-year schedule was arbitrary. After the remarkable results of the PERSEPHONE trial as well as the updated final results of the PHARE trial, we performed an updated meta-analysis to reassess the efficacy and safety of shorter durations of trastuzumab. METHODS A literature search of databases was conducted to identify randomized controlled trials reporting the efficacy and cardiotoxicity of shorter-duration and standard 1-year trastuzumab treatment. The hazard ratios (HRs) of disease-free survival (DFS) and overall survival (OS), and the odds ratios (ORs) of cardiac events were also estimated and pooled. RESULTS Six studies were eligible, including a total of 11,496 patients. Both DFS (HR = 1.13; 95% confidence interval [CI] = 1.03-1.25; p = 0.01) and OS (HR = 1.16; 95% CI = 1.01-1.32; p = 0.03) were significantly improved with conventional 1-year trastuzumab treatment compared with shorter treatments. The more pronounced survival benefits observed in patients with negative estrogen receptor (ER) tumor and nodal involvement should be interpreted cautiously because of the lack of interaction between the survival benefit and ER, as well as the nodal status (interaction test, ER status: p = 0.26; nodal status: p = 0.60). One year of trastuzumab treatment resulted in a substantial DFS benefit compared with shorter schedules when administered concurrently with chemotherapy (HR = 1.22; 95% CI = 1.09-1.38; p = 0.0008; p = 0.02 for the interaction test). Patients in the shorter duration group experienced significantly fewer cardiac events (OR = 0.52; 95% CI = 0.43-0.62; p < 0.00001). CONCLUSIONS Though correlated with an increasing risk of cardiotoxicity, 1 year of adjuvant trastuzumab treatment conferred substantial survival benefits and should remain as the preferred treatment for early stage HER2-positive breast cancer. Shorter durations of trastuzumab may serve as an alternative choice for patients with cardiac disease and those at lower risk of recurrence.
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20
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Aktas BY, Guven DC, Dizdar O. Noninferiority for Short-HER or short-chemotherapy? Ann Oncol 2019; 30:147. [PMID: 30395162 DOI: 10.1093/annonc/mdy491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- B Y Aktas
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey.
| | - D C Guven
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | - O Dizdar
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
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21
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El-Enbaby AM, Moneim NAAE, Khedr GAEA, Elwany YMN. Nine months versus 12 months of adjuvant trastuzumab for patients with HER2-positive breast cancer. KOREAN JOURNAL OF CLINICAL ONCOLOGY 2018; 14:108-115. [DOI: 10.14216/kjco.18019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/12/2018] [Indexed: 09/01/2023]
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22
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Esposito A, Viale G, Criscitiello C, Curigliano G. A clinical perspective on escalating or de-escalating adjuvant therapy in HER2+ breast cancer. Expert Rev Clin Pharmacol 2018; 12:9-16. [PMID: 30466330 DOI: 10.1080/17512433.2019.1552134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Patients with early HER2-positive breast cancer (BC) benefit from HER2-targeted systemic therapy. The endorsed standard adjuvant treatment for patients with early HER2-positive breast cancer is chemotherapy plus trastuzumab administered for 1 year. Areas covered: Several trials have investigated modifications of the standard treatment in terms of de-escalation by either shortening the duration or giving less resource-demanding regimens and in terms of escalation by either adding a second anti-HER2 agent or extending the duration of HER2-targeted treatment for more than 12 months. In this perspective, we would offer a comprehensive view of these trials and discuss their findings. Expert commentary: At the current state of knowledge, there are still open questions regarding the management of HER2+ BC patients, such as the most adequate duration of trastuzumab therapy, the optimal chemotherapy regimen that should be combined with trastuzumab, and the addition of a second anti-HER2 agent. Growing evidences suggest that some HER2+ BC patients may not need chemotherapy. If these patients could be recognized upfront, optimal response could potentially be reached with HER2-targeted therapy alone.
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Affiliation(s)
- Angela Esposito
- a Division of Early Drug Development for Innovative Therapies , IEO, European Institute of Oncology, IRCCS Milano , Milano , Italy
| | - Giulia Viale
- a Division of Early Drug Development for Innovative Therapies , IEO, European Institute of Oncology, IRCCS Milano , Milano , Italy.,b Department of Oncology and Hemato-Oncology , University of Milano , Milano , Italy
| | - Carmen Criscitiello
- a Division of Early Drug Development for Innovative Therapies , IEO, European Institute of Oncology, IRCCS Milano , Milano , Italy
| | - Giuseppe Curigliano
- a Division of Early Drug Development for Innovative Therapies , IEO, European Institute of Oncology, IRCCS Milano , Milano , Italy.,b Department of Oncology and Hemato-Oncology , University of Milano , Milano , Italy
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23
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Wilson FR, Coombes ME, Brezden-Masley C, Yurchenko M, Wylie Q, Douma R, Varu A, Hutton B, Skidmore B, Cameron C. Herceptin® (trastuzumab) in HER2-positive early breast cancer: a systematic review and cumulative network meta-analysis. Syst Rev 2018; 7:191. [PMID: 30428932 PMCID: PMC6237027 DOI: 10.1186/s13643-018-0854-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 10/23/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Originator trastuzumab (Herceptin®; H) is an antibody-targeted therapy to treat patients with human epidermal growth factor receptor 2-positive (HER2+) early breast cancer (EBC). We investigated the overall survival (OS) advantage conferred by the addition of H to chemotherapy for HER2+ EBC patients and how the OS advantage changed over time. METHODS A systematic literature review (SLR) identified randomized controlled trials (RCTs) and non-randomized studies (NRSs) published from January 1, 1990 to January 19, 2017, comparing systemic therapies used in the neoadjuvant/adjuvant settings to treat HER2+ EBC patients. Bayesian cumulative network meta-analyses (cNMAs) of OS were conducted to assess the published literature over time. Heterogeneity was assessed through sensitivity and subgroup analyses. RESULTS The SLR identified 31 unique studies (28 RCTs, 3 NRSs) included in the OS analyses from 2008 to 2016. In the reference case cNMA (RCTs alone), initial evidence demonstrated an OS advantage for H/chemotherapy compared with chemotherapy alone in HER2+ EBC patients. As additional OS data were published, the precision around this survival benefit strengthened over time. Both H/anthracycline-containing chemotherapy and H/non-anthracycline-containing chemotherapy regimens provided similar OS advantages for HER2+ EBC patients. CONCLUSION This analysis represents the most comprehensive SLR/cNMA to date of published OS data in HER2+ EBC studies. These findings demonstrate why H/chemotherapy is now the established standard of care in HER2+ EBC. In the case of H, the benefits of early patient access far outweighed the risk of waiting for more precise information. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017055763.
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Affiliation(s)
- Florence R Wilson
- Cornerstone Research Group Inc., Suite 204, 3228 South Service Road, Burlington, ON, L7N 3H8, Canada
| | | | | | | | - Quinlan Wylie
- Cornerstone Research Group Inc., Suite 204, 3228 South Service Road, Burlington, ON, L7N 3H8, Canada
| | - Reuben Douma
- Cornerstone Research Group Inc., Suite 204, 3228 South Service Road, Burlington, ON, L7N 3H8, Canada
| | - Abhishek Varu
- Cornerstone Research Group Inc., Suite 204, 3228 South Service Road, Burlington, ON, L7N 3H8, Canada
| | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Public Health and Preventative Medicine, University of Ottawa School of Epidemiology, Ottawa, ON, Canada
| | | | - Chris Cameron
- Cornerstone Research Group Inc., Suite 204, 3228 South Service Road, Burlington, ON, L7N 3H8, Canada.
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24
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Murthy RK, Chavez-MacGregor M, Hortobagyi GN. Adjuvant HER2-Targeted Therapy Update in Breast Cancer: Escalation and De-escalation of Therapy in 2018. CURRENT BREAST CANCER REPORTS 2018. [DOI: 10.1007/s12609-018-0290-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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25
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Basho RK, McArthur HL. Optimizing (neo)adjuvant treatment of HER2-positive breast cancer. Ther Adv Med Oncol 2018; 10:1758835918775697. [PMID: 30034547 PMCID: PMC6048669 DOI: 10.1177/1758835918775697] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 04/12/2017] [Indexed: 01/03/2023] Open
Abstract
The development of human epidermal growth factor 2 (HER2)-directed therapy has resulted in significant improvement in outcomes for patients with early-stage HER2-overexpressing (HER2+) breast cancer. In recent years, newer HER2-directed agents and novel treatment strategies have been developed with ongoing improvements in overall outcomes. However, with the addition of newer agents, there is an increasing need to risk stratify patients to maximize efficacy and minimize toxicity of treatment. De-escalation of therapy with the potential to shorten the duration of adjuvant therapy and minimize chemotherapy administration in patients with favorable disease can be considered. On the other hand, escalation of therapy with the addition of novel HER2-directed agents and extended duration of therapy in patients at high risk of relapse can help improve long-term cure rates. Herein, we discuss recent developments in neoadjuvant and adjuvant strategies for the treatment of potentially curable HER2+ breast cancer.
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Affiliation(s)
- Reva K. Basho
- Breast Medical Oncology, Samuel Oschin
Comprehensive Cancer Institute, Cedars-Sinai Medical Center, 8700 Beverly
Boulevard AC 1053, Los Angeles, CA 90048, USA
| | - Heather L. McArthur
- Breast Medical Oncology, Samuel Oschin
Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles,
CA, USA
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26
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Effectiveness of trastuzumab as adjuvant therapy in patients with early stage breast cancer: A systematic review and meta-analysis. Med J Islam Repub Iran 2017; 31:88. [PMID: 29951389 PMCID: PMC6014767 DOI: 10.14196/mjiri.31.88] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Indexed: 02/02/2023] Open
Abstract
Background: Trastuzumab in combination with chemotherapy has long been established as a standard treatment for HER2-positive patients in early stage breast cancer (BC). The present study aimed at assessing the effectiveness of trastuzumab adjuvant therapy in early stage BC in overall survival (OS) and disease-free survival (DFS). Methods: A systematic review and meta-analysis was performed to evaluate the effectiveness of trastuzumab adjuvant therapy. PubMed, Cochrane library, Scopus, Web of Science, and Embase databases were searched for relevant RCTs from the beginning to February 2017. Quality assessment of studies was conducted using the Cochrane Risk of Bias Tool. The desired outcomes were OS and DFS. Results: A total of 1818 articles were identified first, however, only 11 studies were eligible to be included in this study. Our findings and meta-analysis results revealed that trastuzumab is effective in increasing OS (OS hazard ratio: -0.286 ± 0.049, 95%CI (-0.381, - 0.191)) and improving DFS (DFS hazard ratio: -0.419± 0.077, 95%CI (-0.569, -0.269)). The most serious but negligible side effect of trastuzumab is congestive heart failure. Conclusion: Adding trastuzumab as adjuvant therapy in early stages of BC in HER2 positive patients could increase OS and DFS of the patients effectively.
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27
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Zhen Z, Yang K, Ye L, You Z, Chen R, Liu Y, He Y. Suberoylanilide hydroxamic acid sensitizes neuroblastoma to paclitaxel by inhibiting thioredoxin-related protein 14-mediated autophagy. Cancer Sci 2017; 108:1485-1492. [PMID: 28498513 PMCID: PMC5497723 DOI: 10.1111/cas.13279] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/01/2017] [Accepted: 05/08/2017] [Indexed: 12/21/2022] Open
Abstract
Paclitaxel is not as effective for neuroblastoma as most of the front‐line chemotherapeutics due to drug resistance. This study explored the regulatory mechanism of paclitaxel‐associated autophagy and potential solutions to paclitaxel resistance in neuroblastoma. The formation of autophagic vesicles was detected by scanning transmission electron microscopy and flow cytometry. The autophagy‐associated proteins were assessed by western blot. Autophagy was induced and the autophagy‐associated proteins LC3‐I, LC3‐II, Beclin 1, and thioredoxin‐related protein 14 (TRP14), were found to be upregulated in neuroblastoma cells that were exposed to paclitaxel. The inhibition of Beclin 1 or TRP14 by siRNA increased the sensitivity of the tumor cells to paclitaxel. In addition, Beclin 1‐mediated autophagy was regulated by TRP14. Furthermore, the TRP14 inhibitor suberoylanilide hydroxamic acid (SAHA) downregulated paclitaxel‐induced autophagy and enhanced the anticancer effects of paclitaxel in normal control cancer cells but not in cells with upregulated Beclin 1 and TRP14 expression. Our findings showed that paclitaxel‐induced autophagy in neuroblastoma cells was regulated by TRP14 and that SAHA could sensitize neuroblastoma cells to paclitaxel by specifically inhibiting TRP14.
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Affiliation(s)
- Zijun Zhen
- State Key Laboratory of Oncology in South China, Guangzhou, China.,Department of Pediatric Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Kaibin Yang
- State Key Laboratory of Oncology in South China, Guangzhou, China.,Sun Yat-sen University Zhongshan School of Medicine, Guangzhou, China
| | - Litong Ye
- State Key Laboratory of Oncology in South China, Guangzhou, China.,Sun Yat-sen University Zhongshan School of Medicine, Guangzhou, China
| | - Zhiyao You
- State Key Laboratory of Oncology in South China, Guangzhou, China.,Sun Yat-sen University Zhongshan School of Medicine, Guangzhou, China
| | - Rirong Chen
- State Key Laboratory of Oncology in South China, Guangzhou, China.,Sun Yat-sen University Zhongshan School of Medicine, Guangzhou, China
| | - Ying Liu
- State Key Laboratory of Oncology in South China, Guangzhou, China.,Sun Yat-sen University Zhongshan School of Medicine, Guangzhou, China
| | - Youjian He
- State Key Laboratory of Oncology in South China, Guangzhou, China.,Collaborative Innovation Center of Cancer Medicine, Guangzhou, China.,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
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28
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Clarke CS, Hunter RM, Shemilt I, Serra-Sastre V. Multi-arm Cost-Effectiveness Analysis (CEA) comparing different durations of adjuvant trastuzumab in early breast cancer, from the English NHS payer perspective. PLoS One 2017; 12:e0172731. [PMID: 28248984 PMCID: PMC5383006 DOI: 10.1371/journal.pone.0172731] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 02/07/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Trastuzumab improves survival in HER2+ breast cancer patients, with some evidence of adverse cardiac side effects. Current recommendations are to give adjuvant trastuzumab for one year or until recurrence, although trastuzumab treatment for only 9 or 10 weeks has shown similar survival rates to 12-month treatment. We present here a multi-arm joint analysis examining the relative cost-effectiveness of different durations of adjuvant trastuzumab. METHODS AND FINDINGS Network meta-analysis (NMA) was used to examine which trials' data to include in the cost-effectiveness analysis (CEA). A network using FinHer (9 weeks vs. zero) and BCIRG006 (12 months vs. zero) trials offered the only jointly randomisable network so these trials were used in the CEA. The 3-arm CEA compared costs and quality-adjusted life-years (QALYs) associated with zero, 9-week and 12-month adjuvant trastuzumab durations in early breast cancer, using a decision tree followed by a Markov model that extrapolated the results to a lifetime time horizon. Pairwise incremental cost-effectiveness ratios (ICERs) were also calculated for each pair of regimens and used in budget impact analysis, and the Bucher method was used to check face validity of the findings. Addition of the PHARE trial (6 months vs. 12 months) to the network, in order to create a 4-arm CEA including the 6-month regimen, was not possible as late randomisation in this trial resulted in recruitment of a different patient population as evidenced by the NMA findings. The CEA results suggest that 9 weeks' trastuzumab is cost-saving and leads to more QALYs than 12 months', i.e. the former dominates the latter. The cost-effectiveness acceptability frontier (CEAF) favours zero trastuzumab at willingness-to-pay levels below £2,500/QALY and treatment for 9 weeks above this threshold. The combination of the NMA and Bucher investigations suggests that the 9-week duration is as efficacious as the 12-month duration for distant-disease-free survival and overall survival, and safer in terms of fewer adverse cardiac events. CONCLUSIONS Our CEA results suggest that 9-week trastuzumab dominates 12-month trastuzumab in cost-effectiveness terms at conventional thresholds of willingness to pay for a QALY, and the 9-week regimen is also suggested to be as clinically effective as the 12-month regimen according to the NMA and Bucher analyses. This finding agrees with the results of the E2198 head-to-head study that compared 10 weeks' with 14 months' trastuzumab and found no significant difference. Appropriate trial design and reporting is critical if results are to be synthesisable with existing evidence, as selection bias can lead to recruitment of a different patient population from existing trials. Our analysis was not based on head-to-head trials' data, so the results should be viewed with caution. Short-duration trials would benefit from recruiting larger numbers of participants to reduce uncertainty in the synthesised results.
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Affiliation(s)
- Caroline S Clarke
- UCL Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Rachael M Hunter
- UCL Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Ian Shemilt
- UCL Institute of Education, University College London, London, United Kingdom
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Joensuu H. Escalating and de-escalating treatment in HER2-positive early breast cancer. Cancer Treat Rev 2016; 52:1-11. [PMID: 27866067 DOI: 10.1016/j.ctrv.2016.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/30/2016] [Accepted: 11/03/2016] [Indexed: 01/26/2023]
Abstract
The current standard adjuvant systemic treatment of early HER2-positive breast cancer consists of chemotherapy plus 12months of trastuzumab, with or without endocrine therapy. Several trials have investigated modifications of the standard treatment that are shorter and less resource-demanding (de-escalation) or regimens that aim at dual HER2 inhibition or include longer than 12months of HER2-targeted treatment (escalation). Seven randomized trials investigate shorter than 12months of trastuzumab treatment duration. The shorter durations were not statistically inferior to the 1-year duration in the 3 trials with survival results available, but 2 of the trials were small and 1 had a relatively short follow-up time of the patients at the time of reporting. The pathological complete response (pCR) rates were numerically higher in all 9 randomized trials that compared chemotherapy plus dual HER2 inhibition consisting of trastuzumab plus either lapatinib, neratinib, or pertuzumab with chemotherapy plus trastuzumab as neoadjuvant treatments, but the superiority of chemotherapy plus dual HER2-inhibition over chemotherapy plus trastuzumab remains to be demonstrated in the adjuvant setting. One year of adjuvant trastuzumab was as effective as 2years of trastuzumab in the HERA trial, and was associated with fewer side-effects. Extending 1-year adjuvant trastuzumab treatment with 1year of neratinib improved disease-free survival in the ExteNET trial, but the patient follow-up times are still short, and no overall survival benefit was reported. Several important trials are expected to report results in the near future and may modify the current standard.
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Affiliation(s)
- Heikki Joensuu
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
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30
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Abstract
PURPOSE OF REVIEW One-year duration of adjuvant trastuzumab is the gold standard since 2005. During the last decade many attempts have been made to both increase and reduce the treatment duration. The purpose of this article is to review the current available evidence regarding alternative anti-HER2 therapy durations in the (neo)adjuvant treatment of HER2-positive localized breast cancer patients. RECENT FINDINGS According to the majority of published data, shorter trastuzumab schedule has shown a decreased benefit in the overall HER2 population, whereas extending adjuvant trastuzumab, beyond 1 year, does not improve the outcome and is associated with increased cardiac toxicity. However, new challenging questions are raised by the recent results of ExteNet trial, in which sequential introduction of 1 year neratinib after standard trastumab-based therapy improved the outcome, especially in the estrogen receptor-positive subset of patients. SUMMARY To date the standard duration of adjuvant trastuzumab remains 1 year in the adjuvant setting. It is likely that ongoing trials will clarify which patients could benefit from a shorter or a longer treatment. Taking into account patient's specific risk/benefit ratio and new biomarkers, in future, a 'personalized' treatment duration would be warranted.
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