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Otoya I, Valdiviezo N, Morante Z, Calle C, Ferreyra Y, Huarcaya-Chombo N, Polo-Mendoza G, Castañeda C, Vidaurre T, Neciosup SP, Calderón MJ, Gomez HL. Subcutaneous Trastuzumab: An Observational Study of Safety and Tolerability in Patients With Early HER2-Positive Breast Cancer. Int J Breast Cancer 2024; 2024:9551710. [PMID: 38962673 PMCID: PMC11222001 DOI: 10.1155/2024/9551710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/15/2024] [Accepted: 05/28/2024] [Indexed: 07/05/2024] Open
Abstract
Purpose: In Peru, breast cancer (BC) stands as the most predominant malignancy neoplasm among women. Trastuzumab has marked a significant milestone in the management of this disease. It has been shown to improve prognosis in human epidermal growth factor receptor 2 (HER2)-expressing female patients, but its repercussions and efficacy are yet to be analyzed in a context with limited resources. Methods: The study population is made of woman patients aged 18 years and older diagnosed with HER2-positive BC at Instituto Nacional de Enfermedades Neoplásicas (INEN, Lima, Peru) during 2019-2021 and treated with at least one dose of subcutaneous trastuzumab. We reviewed medical records to register treatment characteristics, adverse events (AEs), disease progression, and survival status. We considered a median follow-up time of 36 and 45 months for progression and survival status. Results: The majority of patients were over 50 years old (54.29%). Tumor size averaged 19.7 ± 16.1 mm. Lymph nodes were present in 44.78% of patients. Most patients received adjuvant chemotherapy (63.8%) as first-line treatment. Descriptive analyses of treatment outcomes revealed a 30% toxicity rate, primarily attributed to arthralgia (47.62%), followed by diarrhea, fatigue, and injection site reactions, with relatively lower discontinuation rates compared to larger scale studies. Differences in demographic, clinical, and treatment characteristics were not statistically significant concerning the emergence of AEs (p > 0.05). Progression appeared in nine patients, and the overall survival (OS) rate stood at 98.6% and 92.8%, respectively, during a median follow-up of 36 and 45 months. Conclusion: The research suggests that subcutaneous trastuzumab is comparable in effectiveness and safety to the intravenous administration. Regional-specific studies may provide valuable insights into demographic factors influencing treatment outcomes in Peru or other countries. Furthermore, it could represent a more accessible alternative, potentially enhancing patient adherence and optimizing healthcare resource logistics.
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Affiliation(s)
- Iris Otoya
- Department of Medical OncologyInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Natalia Valdiviezo
- Department of Medical OncologyInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Zaida Morante
- Department of Medical OncologyInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Cindy Calle
- Department of Medical OncologyInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Yomali Ferreyra
- Department of BioengineeringUniversidad de Ingeniería y Tecnología, Lima, Peru
| | | | | | - Carlos Castañeda
- Department of Medical OncologyInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Tatiana Vidaurre
- Department of Medical OncologyInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Silvia P. Neciosup
- Department of Medical OncologyInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Mónica J. Calderón
- Department of Medical OncologyInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
- Institute of Investigations in Biomedical Sciences (INICIB)Universidad Ricardo Palma, Lima, Peru
| | - Henry L. Gomez
- Department of Medical OncologyInstituto Nacional de Enfermedades Neoplásicas, Lima, Peru
- Institute of Investigations in Biomedical Sciences (INICIB)Universidad Ricardo Palma, Lima, Peru
- OncosaludAuna Ideas, Lima, Peru
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Chatelut E, Hendrikx JJMA, Martin J, Ciccolini J, Moes DJAR. Unraveling the complexity of therapeutic drug monitoring for monoclonal antibody therapies to individualize dose in oncology. Pharmacol Res Perspect 2021; 9:e00757. [PMID: 33745217 PMCID: PMC7981594 DOI: 10.1002/prp2.757] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 12/13/2022] Open
Abstract
Monoclonal antibodies (Mabs) have become key drugs in cancer treatment, either as targeted therapies or more recently as immune checkpoint inhibitors (ICIs). The fact that only some patients benefit from these drugs poses the usual question in the field of onco-hematology: that of the benefit of individual dosing and the potential of therapeutic drug monitoring (TDM) to carry out this individualization. However, Mabs present unique pharmacological characteristics for TDM, and the pharmacokinetic-pharmacodynamic relationship observed should be interpreted differently than that observed for conventional drugs and small molecules. This pharmacology practice review has been summarized from a public debate between the authors at the International TDM and Clinical Toxicology meeting in Banff, 2020, regarding the potential roles of TDM in the Mab/ICI setting.
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Affiliation(s)
- Etienne Chatelut
- CRCTUniversité de ToulouseInserm, and Institut Claudius‐RegaudIUCT‐OncopoleToulouseFrance
| | - Jeroen J. M. A. Hendrikx
- Department of Pharmacy and Pharmacology and Department of Nuclear MedicineThe Netherlands Cancer InstituteAmsterdamThe Netherlands
| | - Jennifer Martin
- Centre for Drug Repurposing and Medicines ResearchThe University of NewcastleCallaghanNSWAustralia
| | - Joseph Ciccolini
- SMARTcCRCM Inserm U1068Aix Marseille University and La Timone university Hospital of MarseilleMarseilleFrance
| | - Dirk Jan A. R. Moes
- Department of Clinical Pharmacy and ToxicologyLeiden University Medical CenterLeidenThe Netherlands
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Cost-minimization analysis of subcutaneous versus intravenous trastuzumab administration in Chilean patients with HER2-positive early breast cancer. PLoS One 2020; 15:e0227961. [PMID: 32023267 PMCID: PMC7001963 DOI: 10.1371/journal.pone.0227961] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 01/03/2020] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Trastuzumab (TZM) improves survival and the risk of recurrence among patients with early-stage HER2+ breast cancer (BC). TZM treatment can be given intravenously (IV-TZM) or subcutaneously (SC-TZM). Although both methods have similar efficacy and safety, they differ in dosage and administration. Previous studies of cost minimization determined that SC-TZM is associated with lower costs than IV-TZM; however, those studies did not include the costs associated with body weight-based dosage and the treatment of adverse drug reactions (ADRs). METHODS/PATIENTS We performed a model-based cost-minimization analysis. The analysis included direct and indirect medical costs associated with TZM preparation (adjusted by body weight) and administration and also costs due to severe ADRs and non-medical costs that occurred during the total treatment course (18 cycles). We performed a sensitivity analysis to test the robustness of the results across various TZM costs and patient body weights. RESULTS The overall cost (in USD) of IV-TZM treatment was $83,309.1 per patient compared with $77,067.7 per patient for SC-TZM. Thus, one year of SC-TZM treatment cost $6,241.4 less per patient than one year of IV-TZM treatment. The sensitivity analysis revealed that the results were mainly driven by the price of each TZM vial and body weight. CONCLUSION SC-TZM is a cost-saving therapy for Chilean patients with early-stage HER2+ BC. Given their similar efficacy and safety, we suggest the use of SC formulations rather than IV formulations. The use of SC-TZM instead of IV-TZM may have a significant economic impact on public/private healthcare systems.
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Nadiradze G, Horvath P, Sautkin Y, Archid R, Weinreich FJ, Königsrainer A, Reymond MA. Overcoming Drug Resistance by Taking Advantage of Physical Principles: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC). Cancers (Basel) 2019; 12:cancers12010034. [PMID: 31877647 PMCID: PMC7016575 DOI: 10.3390/cancers12010034] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/24/2022] Open
Abstract
Theoretical considerations as well as comprehensive preclinical and clinical data suggest that optimizing physical parameters of intraperitoneal drug delivery might help to circumvent initial or acquired resistance of peritoneal metastasis (PM) to chemotherapy. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a novel minimally invasive drug delivery system systematically addressing the current limitations of intraperitoneal chemotherapy. The rationale behind PIPAC is: (1) optimizing homogeneity of drug distribution by applying an aerosol rather than a liquid solution; (2) applying increased intraperitoneal hydrostatic pressure to counteract elevated intratumoral interstitial fluid pressure; (3) limiting blood outflow during drug application; (4) steering environmental parameters (temperature, pH, electrostatic charge etc.) in the peritoneal cavity for best tissue target effect. In addition, PIPAC allows repeated application and objective assessment of tumor response by comparing biopsies between chemotherapy cycles. Although incompletely understood, the reasons that allow PIPAC to overcome established chemoresistance are probably linked to local dose intensification. All pharmacological data published so far show a superior therapeutic ratio (tissue concentration/dose applied) of PIPAC vs. systemic administration, of PIPAC vs. intraperitoneal liquid chemotherapy, of PIPAC vs. Hyperthermic Intraperitoneal Chemotherapy (HIPEC) or PIPAC vs. laparoscopic HIPEC. In the initial introduction phase, PIPAC has been used in patients who were quite ill and had already failed multiple treatment regimes, but it may not be limited to that group of patients in the future. Rapid diffusion of PIPAC in clinical practice worldwide supports its potential to become a game changer in the treatment of chemoresistant isolated PM of various origins.
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Van den Nest M, Glechner A, Gold M, Gartlehner G. The comparative efficacy and risk of harms of the intravenous and subcutaneous formulations of trastuzumab in patients with HER2-positive breast cancer: a rapid review. Syst Rev 2019; 8:321. [PMID: 31829250 PMCID: PMC6905114 DOI: 10.1186/s13643-019-1235-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 11/14/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Trastuzumab is a monoclonal antibody for patients with HER2 (human epidermal growth factor receptor 2)-positive breast cancer, which is added to regular treatment and reduces mortality. Originally, trastuzumab had to be administered intravenously (IV) over 30 min every 3 weeks for 1 year. Since 2012, a formulation for the subcutaneous (SC) administration of trastuzumab has been available, which has not yet been approved in the USA. Advocates claim that the SC formulation saves time and money, despite higher costs. The purpose of this study is to review existing literature concerning the comparative efficacy and risk of harms of trastuzumab IV and SC concerning patient-relevant health outcomes. METHODS We conducted searches in the Cochrane Library and MEDLINE for articles published through May 2018 in English or German. In addition, we searched ClinicalTrials.gov to identify unpublished studies. We dually reviewed the abstracts and full-text articles based on a priori defined inclusion criteria, rated the risk of bias of included studies, and assessed the strength of the evidence for each outcome of interest. Because data was insufficient for quantitative synthesis, we summarized results narratively. RESULTS We identified three RCTs (randomized controlled trials) meeting our eligibility criteria, which included data on 1003 patients. We found moderate evidence for similar event rates (20.05% vs. 18%, HR (hazard ratio) 0.88, CI 95% = 0.62-1.27), and mortality rates (10% vs. 8%, HR 0.76, CI 95% = 0.44-1.32) after 1.7 years for patients receiving trastuzumab IV and for patients receiving SC. Results remained similar after 3.3 years, though evidence lacked strength due to a high dropout rate. All trials reported more adverse events among the SC group than in the IV group. Evidence for these findings was of moderate strength. Nevertheless, more than 85% of the patients preferred trastuzumab SC over IV. Results concerning serious adverse events appeared to be heterogeneous. CONCLUSION Results of studies indicate similar efficacy between the two routes of administration. The higher rates of adverse events for SC administration were mainly attributable to injection site-related events. The clinical decision of whether to administer trastuzumab SC or IV requires the consideration of several factors and should be determined individually.
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Affiliation(s)
- Miriam Van den Nest
- Department for Evidence-based Medicine and Clinical Epidemiology, Donau-Universität Krems, Dr.-Karl-Dorrek-Straße 30, 3500, Krems, Austria.
| | - Anna Glechner
- Department for Evidence-based Medicine and Clinical Epidemiology, Donau-Universität Krems, Dr.-Karl-Dorrek-Straße 30, 3500, Krems, Austria
| | - Maria Gold
- Department for Oncology, University Hospital, 3100 St, Pölten, Austria
| | - Gerald Gartlehner
- Department for Evidence-based Medicine and Clinical Epidemiology, Donau-Universität Krems, Dr.-Karl-Dorrek-Straße 30, 3500, Krems, Austria.,RTI International, 3040 Cornwallis Rd, Research Triangle Park, Durham, NC, 27709, USA
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Richards R, Keating E, Boucher J. Targeted Therapies: Treatment Options for Patients With Metastatic Breast Cancer. Clin J Oncol Nurs 2019; 23:434-438. [DOI: 10.1188/19.cjon.434-438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Pimentel FF, Morgan G, Tiezzi DG, de Andrade JM. Development of New Formulations of Biologics: Expectations, Immunogenicity, and Safety for Subcutaneous Trastuzumab. Pharmaceut Med 2018; 32:319-325. [PMID: 30363808 PMCID: PMC6182492 DOI: 10.1007/s40290-018-0247-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Subcutaneous (SC) trastuzumab has long been approved as a cancer treatment for early and advanced HER2-positive (HER2+) breast cancer by both the European Medicines Agency (EMA) and Agência Nacional de Vigilância Sanitária (ANVISA), the Brazilian National Health Surveillance Agency. A pivotal non-inferiority phase III trial, which aimed to provide a more convenient and cost-effective treatment in the HER2+ breast cancer neoadjuvant setting, showed that the SC group met prespecified efficacy endpoints and the SC formulation was considered as safe as the intravenous (IV) formulation. Considering the recent approval of several biosimilars, new SC formulations are also an interesting manufacturer strategy as these drugs can obtain patent protection. Despite being considered non-inferior to the IV formulation of trastuzumab, in clinical development, the SC formulation elicited higher immunogenicity, mainly related to overall anti-drug antibodies (ADAs); however, this finding was classified as clinically non-significant. In this article, we explore different aspects of the benefits and risks of the SC trastuzumab formulation according to published data.
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Affiliation(s)
- Franklin Fernandes Pimentel
- Breast Disease Division, Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of Sao Paulo, São Paulo, Brazil
| | - Gilberto Morgan
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - Daniel Guimarães Tiezzi
- Breast Disease Division, Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of Sao Paulo, São Paulo, Brazil
| | - Jurandyr Moreira de Andrade
- Breast Disease Division, Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of Sao Paulo, São Paulo, Brazil
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Hendrikx JJMA, Haanen JBAG, Voest EE, Schellens JHM, Huitema ADR, Beijnen JH. Fixed Dosing of Monoclonal Antibodies in Oncology. Oncologist 2017; 22:1212-1221. [PMID: 28754722 PMCID: PMC5634778 DOI: 10.1634/theoncologist.2017-0167] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 06/29/2017] [Indexed: 01/09/2023] Open
Abstract
Most monoclonal antibodies in oncology are administered in body-size-based dosing schedules. This is believed to correct for variability in both drug distribution and elimination between patients. However, monoclonal antibodies typically distribute to the blood plasma and extracellular fluids only, which increase less than proportionally with the increase in body weight. Elimination takes place via proteolytic catabolism, a nonspecific immunoglobulin G elimination pathway, and intracellular degradation after binding to the target. The latter is the primary route of elimination and is related to target expression levels rather than body size. Taken together, the minor effects of body size on distribution and elimination of monoclonal antibodies and their usually wide therapeutic window do not support body-size-based dosing. We evaluated effects of body weight on volume of distribution and clearance of monoclonal antibodies in oncology and show that a fixed dose for most of these drugs is justified based on pharmacokinetics. A survey of the savings after fixed dosing of monoclonal antibodies at our hospital showed that fixed dosing can reduce costs of health care, especially when pooling of preparations is not possible (which is often the case in smaller hospitals). In conclusion, based on pharmacokinetic parameters of monoclonal antibodies, there is a rationale for fixed dosing of these drugs in oncology. Therefore, we believe that fixed dosing is justified and can improve efficiency of the compounding. Moreover, drug spillage can be reduced and medication errors may become less likely. IMPLICATIONS FOR PRACTICE The currently available knowledge of elimination of monoclonal antibodies combined with the publicly available data from clinical trials and extensive population pharmacokinetic (PopPK) modeling justifies fixed dosing. Interpatient variation in exposure is comparable after body weight and fixed dosing and most monoclonal antibodies show relatively flat dose-response relationships. For monoclonal antibodies, this results in wide therapeutic windows and no reduced clinical efficacy after fixed dosing. Therefore, we believe that fixed dosing at a well-selected dose can increase medication safety and help in reduction of costs of health care without the loss of efficacy or safety margins.
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Affiliation(s)
- Jeroen J M A Hendrikx
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute and MC Slotervaart, Amsterdam, The Netherlands
| | - John B A G Haanen
- Department of Medical Oncology and Immunology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Emile E Voest
- Department of Molecular Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan H M Schellens
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute and MC Slotervaart, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute and MC Slotervaart, Amsterdam, The Netherlands
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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Sanford M. Subcutaneous trastuzumab: a review of its use in HER2-positive breast cancer. Target Oncol 2014; 9:85-94. [PMID: 24664187 DOI: 10.1007/s11523-014-0313-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 02/27/2014] [Indexed: 12/14/2022]
Abstract
Trastuzumab (Herceptin®) is a humanized IgG1 monoclonal antibody that is an efficacious treatment for HER2-positive breast and gastric cancers. Subcutaneous trastuzumab is a new formulation approved in the European Union for use in patients with early or metastatic breast cancer. In the randomized, open-label, multinational HannaH (enHANced treatment with NeoAdjuvant Herceptin) study of neoadjuvant/adjuvant trastuzumab in patients with early HER2-positive breast cancer, the pharmacokinetics of neoadjuvant subcutaneous trastuzumab were similar to those after intravenous administration, meeting the noninferiority criterion for mean predose trough concentrations, as assessed prior to surgery (primary pharmacokinetic endpoint). Trastuzumab blood concentrations throughout the dosing interval remained above those considered necessary for anticancer activity. In this study, the pathologic complete response rates (primary efficacy endpoint) were 45.4 and 40.7 % in the subcutaneous and intravenous administration groups, respectively, meeting a study noninferiority criterion. In the randomized, open-label, crossover, multinational PrefHer study of neoadjuvant/adjuvant or adjuvant trastuzumab in early HER2-positive breast cancer, subcutaneous administration of trastuzumab was preferred over intravenous administration by >85 % of patients, most commonly because it was time saving and induced less pain and discomfort. In the HannaH study, the tolerability profile of subcutaneous trastuzumab was similar to that of intravenous trastuzumab, except that the rate of serious adverse events was 21 % (vs. 12 % with intravenous administration), partly because of more infections with subcutaneous administration. Whether this finding is of any clinical significance should emerge from ongoing studies. On the evidence, subcutaneous trastuzumab is an effective and generally well-tolerated treatment option that is preferred by patients over intravenous administration.
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Affiliation(s)
- Mark Sanford
- Adis, Springer Healthcare, 41 Centorian Drive, Private Bag 65901, Mairangi Bay, North Shore, 0754, Auckland, New Zealand,
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