Hormone receptor-negative as a predictive factor for pathologic complete response to neoadjuvant therapy in breast cancer

HER2-positive is an independent indicator for predicting pathological complete response to neoadjuvant therapy and Ki67-changed after neoadjuvant chemotherapy predicts favorable prognosis in Chinese women with locally advanced breast cancer

The growing body of evidence suggests that breast cancer (BC) who achieve pathological complete response (pCR) after neoadjuvant chemotherapy (NAC) may experience a more favorable prognosis. The objective of this study is to investigate the correlation between clinicopathologic parameters of locally advanced breast cancer (LABC) patients and the outcomes of NAC, with the aim of identifying predictive indicators for pCR. Additionally, we seek to examine the conversion of IHC markers in pCR patients following NAC and its impact on the prognosis of BC patients. We conducted a study involving 126 patients with LABC. Clinicopathological parameters associated with pCR were subjected to univariate and multivariate analysis. Kaplan-Meier (KM) curves and the log-rank test were used to compare the statistical difference in prognosis in different groups of patients. Additionally, we used difference and consistency tests to examine the conversion of immunohistochemistry (IHC) markers following NAC. The status of estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2) and molecular subtypes of BC were associated with pCR in the univariate analysis (all P < .05), which may be potential markers to predict pCR. HER2 was identified as an independent factor for predicting pCR in the multivariate analysis. The pCR rate of HER2-positive patients who received NAC combined targeted therapy was higher than that of patients who only received NAC (P = .003). The disease-free survival (DFS) rate of TNBC patients who achieved pCR was significantly higher than that of non-pCR TNBC patients (P = .026). The IHC marker conversion after NAC mainly existed in PR (P = .041). Ki67 expression decreased in the luminal B subtype and increased in the HER2 enriched subtype after NAC (all P < .001). Patients with Ki67 expression change after NAC had longer overall survival (OS) and DFS than unchanged patients (all P < .05). HER2-positive is an independent indicator for predicting pCR, and HE2-positive patients who received NAC combined targeted therapy were favorable to achieving pCR. IHC markers of BC patients exhibit varying degrees of alterations after NAC, and changes in Ki67 expression after NAC could serve as a marker to predict a better prognosis.

Pertuzumab in Combination with Trastuzumab and Docetaxel in the Neoadjuvant Treatment for HER2-Positive Breast Cancer

Introduction

This study aims to assess safety and effectiveness of pertuzumab in combination with trastuzumab and docetaxel in the neoadjuvant treatment (NeoT) of HER2-positive breast cancer.

Methods

Two consecutive retrospective cohorts (n = 94, 2012-2015 and 2015-2017) of adult women with HER2-positive breast cancer, receiving NeoT at the breast clinic in Portugal (IPO-Porto), were followed. All patients had surgery and received trastuzumab as adjuvant therapy. The 2012-2015 cohort received doxorubicin, cyclophosphamide, docetaxel plus trastuzumab, whereas the 2015-2017 cohort was treated with the same protocol plus pertuzumab.

Results

The 2012-2015 cohort was older (median 53 years), with locally advanced tumors (48.1%), mostly hormone receptor positive (59.3%). The 2015-2017 cohort was younger (median 43 years) with 60% operable tumors. Pathologic complete response (pCR) improved in the second cohort, while maintaining a good safety profile and tolerability. Clinical staging (p = 0.001) and hormone receptor (p = 0.003) were significant predictors of pCR, but not treatment regimen (p = 0.304).

Conclusion

Further research with larger samples and longer follow-up is needed to understand the clinical differences. Clinical effectiveness of treatment should also be measured through overall and progression-free survival.

The addition of neoadjuvant pertuzumab for the treatment of HER2+ breast cancer: a cost estimate with real-world data

BACKGROUND

Breast cancer (BC) is largely prevalent worldwide. HER2-positive BC account for roughly 20-25% of all BC cases and has an overall survival lower than other BC. Innovation on BC therapeutics is a constant, but novel therapies have higher costs. Therefore, cost-effectiveness research is essential to provide healthcare decision-makers with solid foundations for a resource allocation. This study aims to estimate the average direct medical costs/patient and cost-effectiveness of adding pertuzumab in neoadjuvant treatment (NeoT) for HER2-positive breast cancer (BC).

METHODS

Two retrospective real-world consecutive cohorts of ≥18yo female patients diagnosed with HER2-positive BC treated with NeoT at the Breast Clinic of IPO-Porto were studied. The AC-DH regimen (2012-2015) comprised 8 cycles of neoadjuvant therapy (4 cycles of doxorubicin + cyclosphosphamide followed by 4 cycles ofdocetaxel + trastuzumab), while the AC-DHP regimen (2015-2017) included also pertuzumab as NeoT. NeoT was followed by surgery and adjuvant trastuzumab. Micro-costing technique and a bottom-up approach was used comprising all medical direct costs from the hospital perspective. Unit costs were obtained from government official prices or from IPO-Porto costing system. Costs were adjusted to 2017 and are expressed in euros. Multivariable logistic regression models were used for effectiveness assessment, while generalized linear models with gamma distribution were used for costs. ICER was calculated using the pathological complete response (pCR) as the preferential measure of effectiveness. Sensitivity analysis was also performed.

RESULTS

AC-DHP (n = 40) and AC-DH (n = 54) cohorts had heterogenous patient profiles (median age 43y/53y; 67.5%/59.3% positive HR; 60.0%/27.8% operable; 25.0%/24.1% inflammatory, respectively). The AC-DHP average total cost/patient was 56,375€, with pertuzumab accounting for 13,978€ (24.79%) and increasing in 15,982€ the average cost/patient (p < 0.001). Clinical staging and hormone receptors (HR) were significantly associated with pCR. ICER was 1.370€ per percentage point of pCR.

CONCLUSIONS

ICER was more favourable in stage III HR negative BC patients compared to other patient profiles. Innovative treatments access is critical to deliver high-quality healthcare, but sustainability must be considered. These results suggest the importance of establishing a cost-effectiveness profile of Pertuzumab in NeoT for HER2-positive BC.

Changes in Tumor Stem Cell Markers and Epithelial-Mesenchymal Transition Markers in Nonluminal Breast Cancer after Neoadjuvant Chemotherapy and Their Correlation with Contrast-Enhanced Ultrasound

Nonluminal breast cancer has high early metastasis and treatment resistance, and neoadjuvant chemotherapy (NAC) is needed. The presence of cancer stem cells (CSC) and epithelial-mesenchymal transition (EMT) leads to poor prognosis. This study investigated the changes in CSC markers and EMT markers after NAC in nonluminal breast cancer and their correlation with contrast-enhanced ultrasound (CEUS) features and chemotherapy efficacy. Before NAC, the range of nonluminal breast cancer on CEUS was larger than that of two-dimensional ultrasound, but after NAC, it was significantly smaller than that of two-dimensional ultrasound and closer to the postoperative pathological size. After NAC, the enlarged lesions and perfusion defects were significantly less than those before NAC. The time-intensity curve showed the characteristics of slow-in, low enhancement, and low perfusion. Nonluminal breast cancer downregulated the expression of CSC markers and EMT markers after NAC, but the epithelial phenotype of nonluminal breast cancer with good response to chemotherapy was upregulated. In nonluminal breast cancer with poor response to chemotherapy, markers of CSC and EMT were highly expressed before chemotherapy. In conclusion, CEUS is better than conventional ultrasound in estimating NAC efficacy in this mode. CEUS can also predict the prognosis of nonluminal breast cancer before NAC with the characteristics of enhanced enlargement and perfusion defects. The contrast-enhanced time-intensity curve of lesions with relatively poor blood supply may have more CSC and EMT characteristics.

Construction of Nomograms for Predicting Pathological Complete Response and Tumor Shrinkage Size in Breast Cancer

Purpose

Pathological complete response (pCR) is the goal of neoadjuvant chemotherapy (NAC) for the HER2-positive and triple-negative subtypes of breast cancer and is related to survival benefit; however, luminal breast cancer is not sensitive to NAC, and the size of tumor shrinkage is a more meaningful clinical indicator for the luminal breast cancer subtype. We wanted to use a nomogram or formula to develop and implement a series of prediction models for pCR or tumor shrinkage size.

Patients and Methods

We developed a prediction model in a primary cohort consisting of 498 patients with invasive breast cancer, and the data were gathered from July 2016 to September 2018. The endpoint was pCR and tumor shrinkage size. In the primary cohort, the HER2-positive cohort, and the triple-negative cohort, multivariate logistic regression analysis was used to screen the significant clinical features and clinicopathological features to develop nomograms. In the luminal group, multivariate linear regression analysis was used to test the risk factors that affect tumor shrinkage size. The area under the receiver operating characteristic curve (AUC) and calibration curves were adopted to evaluate and analyze the discrimination and calibration ability of nomograms. Furthermore, we also performed internal validation and independent validation in the primary cohort.

Results

ER status, KI67 status, HER2 status, number of NAC cycles, and tumor size were independent predictive factors of pCR in the primary cohort. These indicators had good discrimination and calibration in the primary and validation cohorts (AUC: 0.873, 0.820). The nomogram for HER2-positive and triple-negative breast cancer (TNBC) had an AUC of 0.820 and 0.785, respectively. Both the HER2 positive and TNBC nomogram calibration curves indicated significant agreement. Moreover, the luminal subtype prediction model was Y (tumor shrinkage size) = -0.576 × (age at diagnosis) + 2.158 × (number of NAC cycles) + 0.233 × (pre-NAC tumor size) + 51.662.

Conclusion

Utilizing this predictive model will enable us to identify patients at high probability for pCR after NAC. Clinicians can stratify these patients and make individualized and personalized recommendations for therapy.

Absence of estrogen receptor is associated with worse oncologic outcome in patients who were received neoadjuvant chemotherapy for breast cancer

BACKGROUND/OBJECTIVE

Neoadjuvant chemotherapy (NAC) is a standard treatment for locally advanced breast cancer, especially for HER2-positive or triple negative breast cancer which shows good response to chemotherapy. However, because a result of biomarkers is, occasionally, changed after NAC, the treatment strategy should be differently applied for patients with locally advanced breast cancer. We compared the results of biomarkers before and after NAC to evaluate the association with disease prognosis and oncologic results.

METHODS

Fifty-seven patients with locally advanced breast cancer underwent NAC and the immunohistochemical (IHC) staining results were compared between before and after NAC. And the association between oncologic outcomes and biomarkers was analyzed.

RESULTS

Negative status of estrogen receptor (ER) was associated with locoregional recurrence and distant metastasis both before and after NAC (p = 0.021, 0.019; p = 0.018, 0.036). And the negative status of progesterone receptor (PR) and triple negative status before neoadjuvant chemotherapy were also associated with death and distant metastasis, respectively. However, the changes of biomarkers after NAC in breast cancer were not directly associated with any oncologic outcomes.

CONCLUSION

The absence of ER in breast cancer before and after NAC would be a significant prognostic factor for local recurrence and distant metastasis. Therefore, the absence of ER should be considered as important factor in determining the treatment strategy.