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Howard FM, Pearson AT, Nanda R. Clinical trials of immunotherapy in triple-negative breast cancer. Breast Cancer Res Treat 2022; 195:1-15. [PMID: 35834065 PMCID: PMC9338129 DOI: 10.1007/s10549-022-06665-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 06/23/2022] [Indexed: 01/12/2023]
Abstract
Purpose Immunotherapy has started to transform the treatment of triple-negative breast cancer (TNBC), in part due to the unique immunogenicity of this breast cancer subtype. This review summarizes clinical studies of immunotherapy in advanced and early-stage TNBC. Findings Initial studies of checkpoint blockade monotherapy demonstrated occasional responses, especially in patients with untreated programmed death-ligand 1 (PD-L1) positive advanced TNBC, but failed to confirm a survival advantage over chemotherapy. Nonetheless, pembrolizumab monotherapy has tumor agnostic approval for microsatellite instability-high or high tumor mutational burden cancers, and thus can be considered for select patients with advanced TNBC. Combination chemoimmunotherapy approaches have been more successful, and pembrolizumab is approved for PD-L1 positive advanced TNBC in combination with chemotherapy. This success has been translated to the curative setting, where pembrolizumab is now approved in combination with neoadjuvant chemotherapy for high-risk early-stage TNBC. Conclusion Immunotherapy has been a welcome addition to the growing armamentarium for TNBC, but responses remain limited to a subset of patients. Innovative strategies are under investigation in an attempt to induce immune responses in resistant tumors—with regimens incorporating small-molecule inhibitors, novel immune checkpoint targets, and intratumoral injections that directly alter the tumor microenvironment. As the focus shifts toward the use of immunotherapy for early-stage TNBC, it will be critical to identify those who derive the most benefit from treatment, given the potential for irreversible autoimmune toxicity and the lack of predictive accuracy of PD-L1 expression in the early-stage setting.
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Affiliation(s)
- Frederick M Howard
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine & Biological Sciences, 5841 S. Maryland Ave MC 2115, Chicago, IL, 60637, USA.
| | - Alexander T Pearson
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine & Biological Sciences, 5841 S. Maryland Ave MC 2115, Chicago, IL, 60637, USA
| | - Rita Nanda
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine & Biological Sciences, 5841 S. Maryland Ave MC 2115, Chicago, IL, 60637, USA
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Howard FM, Villamar D, He G, Pearson AT, Nanda R. The emerging role of immune checkpoint inhibitors for the treatment of breast cancer. Expert Opin Investig Drugs 2021; 31:531-548. [PMID: 34569400 DOI: 10.1080/13543784.2022.1986002] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Breast cancer has traditionally been viewed as immunogenically 'cold,' but two immune checkpoint inhibitors have been approved in combination with chemotherapy for PD-L1 positive advanced triple-negative breast cancer (TNBC), and pembrolizumab was also recently approved for early stage TNBC. As the landscape is rapidly evolving, a comprehensive review of checkpoint inhibitors in breast cancer is needed to aid clinicians in selecting appropriate candidates for therapy, and to highlight ongoing promising studies in this area and topics in need of further investigation. AREA COVERED This review summarizes the latest evidence from completed and ongoing trials of immune checkpoint inhibitors. Ongoing studies were identified using a search of ClinicalTrials.gov with the term 'breast cancer' along with specific checkpoint inhibitor agents. EXPERT OPINION A number of novel combination strategies are under investigation to enhance response and overcome resistance to immunotherapy, with promising preliminary data from checkpoint inhibitors targeting TIGIT, combinations with small molecule inhibitors such as lenvatinib, and injectable agents directly influencing the immune microenvironment. As immunotherapy enters into the curative setting, biomarkers predictive of immunotherapy benefit are needed, as PD-L1 status has not been a helpful discriminator in completed trials in early-stage breast cancer.
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Affiliation(s)
| | - Dario Villamar
- Department of Medicine, University of Chicago, Chicago, USA
| | - Gong He
- Department of Medicine, University of Chicago, Chicago, USA
| | | | - Rita Nanda
- Department of Medicine, University of Chicago, Chicago, USA
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Emens LA, Adams S, Cimino-Mathews A, Disis ML, Gatti-Mays ME, Ho AY, Kalinsky K, McArthur HL, Mittendorf EA, Nanda R, Page DB, Rugo HS, Rubin KM, Soliman H, Spears PA, Tolaney SM, Litton JK. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of breast cancer. J Immunother Cancer 2021; 9:e002597. [PMID: 34389617 PMCID: PMC8365813 DOI: 10.1136/jitc-2021-002597] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 12/17/2022] Open
Abstract
Breast cancer has historically been a disease for which immunotherapy was largely unavailable. Recently, the use of immune checkpoint inhibitors (ICIs) in combination with chemotherapy for the treatment of advanced/metastatic triple-negative breast cancer (TNBC) has demonstrated efficacy, including longer progression-free survival and increased overall survival in subsets of patients. Based on clinical benefit in randomized trials, ICIs in combination with chemotherapy for the treatment of some patients with advanced/metastatic TNBC have been approved by the United States (US) Food and Drug Administration (FDA), expanding options for patients. Ongoing questions remain, however, about the optimal chemotherapy backbone for immunotherapy, appropriate biomarker-based selection of patients for treatment, the optimal strategy for immunotherapy treatment in earlier stage disease, and potential use in histological subtypes other than TNBC. To provide guidance to the oncology community on these and other important concerns, the Society for Immunotherapy of Cancer (SITC) convened a multidisciplinary panel of experts to develop a clinical practice guideline (CPG). The expert panel drew upon the published literature as well as their clinical experience to develop recommendations for healthcare professionals on these important aspects of immunotherapeutic treatment for breast cancer, including diagnostic testing, treatment planning, immune-related adverse events (irAEs), and patient quality of life (QOL) considerations. The evidence-based and consensus-based recommendations in this CPG are intended to give guidance to cancer care providers treating patients with breast cancer.
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Affiliation(s)
- Leisha A Emens
- Department of Medicine, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sylvia Adams
- Perlmutter Cancer Center, New York University Langone, New York, New York, USA
| | - Ashley Cimino-Mathews
- Department of Pathology and Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mary L Disis
- Cancer Vaccine Institute, University of Washington, Seattle, Washington, USA
| | - Margaret E Gatti-Mays
- Pelotonia Institute for Immuno-Oncology, Division of Medical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Alice Y Ho
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kevin Kalinsky
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | | | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Breast Oncology Program, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Rita Nanda
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago Medicine Comprehensive Cancer Center, Chicago, Illinois, USA
| | - David B Page
- Earle A Chiles Research Institute, Portland, Oregon, USA
| | - Hope S Rugo
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA
| | - Krista M Rubin
- Center for Melanoma, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Hatem Soliman
- Department of Breast Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Patricia A Spears
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jennifer K Litton
- Department of Breast Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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