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Ferro A, Campora M, Caldara A, De Lisi D, Lorenzi M, Monteverdi S, Mihai R, Bisio A, Dipasquale M, Caffo O, Ciribilli Y. Novel Treatment Strategies for Hormone Receptor (HR)-Positive, HER2-Negative Metastatic Breast Cancer. J Clin Med 2024; 13:3611. [PMID: 38930141 PMCID: PMC11204965 DOI: 10.3390/jcm13123611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/11/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
Estrogen receptor (ER)-positive breast cancer (BC) is the most common BC subtype. Endocrine therapy (ET) targeting ER signaling still remains the mainstay treatment option for hormone receptor (HR)-positive BC either in the early or in advanced setting, including different strategies, such as the suppression of estrogen production or directly blocking the ER pathway through SERMs-selective estrogen receptor modulators-or SERDs-selective estrogen receptor degraders. Nevertheless, the development of de novo or acquired endocrine resistance still remains challenging for oncologists. The use of novel ET combined with targeted drugs, such as cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors, has significantly improved long-term outcome rates, thus changing the therapeutic algorithm for metastatic BC (MBC) and recently the therapeutic strategy in the adjuvant setting for early high-risk BC. Eluding the resistance to CDK4/6 inhibitors combined with ET is currently an unmet medical need, and there is disagreement concerning the best course of action for patients who continue to progress after this combination approach. Genetic changes in the tumor along its growth uncovered by genomic profiling of recurrent and/or metastatic lesions through tumor and/or liquid biopsies may predict the response or resistance to specific agents, suggesting the best therapeutic strategy for each patient by targeting the altered ER-dependent pathway (novel oral SERDs and a new generation of anti-estrogen agents) or alternative ER-independent signaling pathways such as PI3K/AKT/mTOR or tyrosine kinase receptors (HER2 mutations or HER2 low status) or by inhibiting pathways weakened through germline BRCA1/2 mutations. These agents are being investigated as single molecules and in combination with other target therapies, offering promising weapons to overcome or avoid treatment failure and propose increasingly more personalized treatment approaches. This review presents novel insights into ET and other targeted therapies for managing metastatic HR+/HER2- BC by exploring potential strategies based on clinical evidence and genomic profiling following the failure of the CDK4/6i and ET combination.
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Affiliation(s)
- Antonella Ferro
- Medical Oncology and Breast Unit, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy; (A.C.); (D.D.L.); (M.L.); (S.M.); (M.D.)
| | - Michela Campora
- Department of Pathology, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy;
| | - Alessia Caldara
- Medical Oncology and Breast Unit, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy; (A.C.); (D.D.L.); (M.L.); (S.M.); (M.D.)
| | - Delia De Lisi
- Medical Oncology and Breast Unit, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy; (A.C.); (D.D.L.); (M.L.); (S.M.); (M.D.)
| | - Martina Lorenzi
- Medical Oncology and Breast Unit, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy; (A.C.); (D.D.L.); (M.L.); (S.M.); (M.D.)
| | - Sara Monteverdi
- Medical Oncology and Breast Unit, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy; (A.C.); (D.D.L.); (M.L.); (S.M.); (M.D.)
| | - Raluca Mihai
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK;
| | - Alessandra Bisio
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, 38123 Trento, Italy; (A.B.); (Y.C.)
| | - Mariachiara Dipasquale
- Medical Oncology and Breast Unit, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy; (A.C.); (D.D.L.); (M.L.); (S.M.); (M.D.)
| | - Orazio Caffo
- Medical Oncology, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy;
| | - Yari Ciribilli
- Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, 38123 Trento, Italy; (A.B.); (Y.C.)
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Ashai N, Swain SM. Post-CDK 4/6 Inhibitor Therapy: Current Agents and Novel Targets. Cancers (Basel) 2023; 15:cancers15061855. [PMID: 36980743 PMCID: PMC10046856 DOI: 10.3390/cancers15061855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/30/2023] Open
Abstract
Front-line therapy for advanced and metastatic hormone receptor positive (HR+), HER2 negative (HER-) advanced or metastatic breast cancer (mBC) is endocrine therapy with a CDK4/6 inhibitor (CDK4/6i). The introduction of CDK4/6i has dramatically improved progression-free survival and, in some cases, overall survival. The optimal sequencing of post-front-line therapy must be personalized to patients' overall health and tumor biology. This paper reviews approved next lines of therapy for mBC and available data on efficacy post-progression on CDK4/6i. Given the success of endocrine front-line therapy, there has been an expansion in therapies under clinical investigation targeting the estrogen receptor in novel ways. There are also clinical trials ongoing attempting to overcome CDK4/6i resistance. This paper will review these drugs under investigation, review efficacy data when possible, and provide descriptions of the adverse events reported.
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Affiliation(s)
- Nadia Ashai
- Department of Medicine, Georgetown Lombardi Comprehensive Cancer Center and MedStar Health, Washington, DC 20007, USA
| | - Sandra M Swain
- Department of Medicine, Georgetown Lombardi Comprehensive Cancer Center and MedStar Health, Washington, DC 20007, USA
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Wong V, de Boer R, Baron-Hay S, Blum R, Boyle F, Chua S, Clarke K, Cuff K, Green M, Lim E, Mok K, Nott L, Nottage M, Tafreshi A, Tsoi D, Uccellini A, Hong W, Gibbs P, Lok SW. Real-World Outcomes of Ribociclib and Aromatase Inhibitor Use in First Line Hormone Receptor Positive, HER2-Negative Metastatic Breast Cancer. Clin Breast Cancer 2022; 22:792-800. [PMID: 36151018 DOI: 10.1016/j.clbc.2022.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 08/25/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND International guidelines recommend combining a CDK4/6 inhibitor and endocrine therapy (ET) as first line treatment for hormone receptor (HR) positive, HER2 negative metastatic breast cancer (MBC). Results from MONALEESA-2 demonstrate superior progression free survival (PFS) and overall survival (OS) with ribociclib (CDK4/6 inhibitor) and ET compared to ET alone. Real world outcomes have yet to be reported. MATERIALS AND METHODS KARMA is a non-interventional registry of Australian patients receiving first-line treatment with ribociclib and aromatase inhibitor (AI), obtained via a Medicine Access Program (MAP) for HR+, HER2- MBC. Outcomes were compared with the ribociclib/letrozole cohort in MONALEESA-2. RESULTS Data from 160 patients at 17 sites was analysed. Median follow-up is 36.5 months. Compared to MONALEESA-2, patients were numerically younger (54.3 vs. 62 years), with higher rates of bone-only metastases (31% vs. 21%). A total of 63 of 160 (39%) patients remain on treatment. A total of 56% of patients had at least 1 dose reduction, with neutropenia (68%) and abnormal liver enzymes (17%) the most common reasons. A total of 17 of 160 (11%) discontinued treatment due to toxicity, with no treatment related deaths. Median PFS was not reached (95% CI 29.9- NR), with PFS at 12 months and 18 months being 76% and 67% respectively versus 25.3 months, 73% and 63% in MONALEESA-2. CONCLUSION The ribociclib and AI combination was well tolerated in this real-world setting. The KARMA registry cohort achieved a superior PFS (>36.5 months) to MONALEESA-2, potentially due to more favourable baseline disease characteristics. Less frequent assessment scheduling in this non trial setting may also contribute.
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Affiliation(s)
- Vanessa Wong
- Personalised Oncology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.
| | - Richard de Boer
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Parkville, VIC, Australia; St Vincent's Private Hospital, Fitzroy, VIC, Australia
| | | | - Robert Blum
- Department of Medical Oncology, Bendigo Health, Bendigo, VIC, Australia
| | | | - Susan Chua
- Department of Medical Oncology, Eastern Health, Box Hill, VIC, Australia
| | - Kerrie Clarke
- Albury Wodonga Regional Cancer Centre, Albury Wodonga Health, East Albury, NSW, Australia
| | - Katharine Cuff
- Department of Medical Oncology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | | | - Elgene Lim
- St Vincent's Clinical School, University of New South Wales, NSW, Australia
| | - Kelly Mok
- Department of Medical Oncology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Louise Nott
- Department of Medical Oncology, Royal Hobart Hospital, Hobart, TAS, Australia
| | - Michelle Nottage
- Department of Medical Oncology, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Ali Tafreshi
- Wollongong Private Hospital, Wollongong, NSW, Australia
| | - Daphne Tsoi
- St John of God Subiaco Hospital, Subiaco, WA, Australia
| | - Anthony Uccellini
- Department of Medical Oncology, Olivia Newton-John Cancer and Wellness Centre, Austin Health, Heidelberg, VIC, Australia
| | - Wei Hong
- Personalised Oncology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Peter Gibbs
- Personalised Oncology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medical Oncology, Western Health, Footscray, VIC, Australia
| | - Sheau Wen Lok
- Personalised Oncology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medical Oncology, Peter MacCallum Cancer Centre, Parkville, VIC, Australia
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