Neoadjuvant Treatment with HER2-Targeted Therapies in HER2-Positive Breast Cancer: A Systematic Review and Network Meta-Analysis

The optimal neoadjuvant treatment strategy for HR+/HER2 + breast cancer: a network meta-analysis

The efficacy of neoadjuvant therapy varies significantly with hormone receptor (HR) status for patients with human epidermal growth factor receptor 2 (HER2) positive breast cancer (BC). Despite extensive research on HER2 + BC, the optimal neoadjuvant strategy for HR+/HER2 + BC remains inconclusive. This study aimed to identify the optimal neoadjuvant regimen for HR+/HER2 + BC treatment. We conducted a systematic search for trials comparing neoadjuvant regimens for HR+/HER2 + BC and a network meta-analysis. Odds ratios for pathological complete response (pCR) and hazard ratios for event-free survival (EFS) were calculated. Treatment regimens were ranked using the surface under the cumulative ranking curve. 20 trials with 2809 patients were included. In pCR analysis, three neoadjuvant regimens sequentially ranked at the top, namely those comprising T-DM1, pertuzumab with trastuzumab, and tyrosine kinase inhibitor with trastuzumab, demonstrating significantly higher pCR rates than monotherapies. In EFS analysis, pertuzumab with trastuzumab ranked the first while T-DM1 containing regimen ranked the last. Anthracycline-free regimens showed a marginally higher pCR rate than anthracycline-containing regimens, while carboplatin-containing regimens demonstrated a numerically higher pCR rate than carboplatin-free regimens. Significant heterogeneity was observed in endocrine therapy analysis, which may be caused by different strategies for incorporating endocrine therapy. In conclusion, trastuzumab plus pertuzumab stands out as the optimal neoadjuvant HER2-targeting regimen for HR+/HER2 + BC Furthermore, anthracycline-free carboplatin-containing chemotherapy emerges as a promising combination treatment. Further investigation is required to clarify the role of endocrine therapy in HR+/HER2 + BC to guide its clinical application.

An exploration of the optimal combination chemotherapy regimen based on neoadjuvant therapy containing pyrotinib for HER2-positive breast cancer: A multicenter real-world study

BACKGROUND

The combination of pyrotinib (Py) with cytotoxic agents proved to be effective in early human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC). However, the optimal chemotherapy regimen is unknown. This study attempts to explore it from real-world research data.

METHODS

Information was collected from patients with early-stage HER2-positive BC from 23 centers across the country. They were categorized into the anthracycline group (A group) and non-anthracycline group (non-A group). Patients in the non-A group were further categorized into the platinum group and non-platinum group and the short-cycle (≤4 cycles) taxane group and long-cycle (>4 cycles) taxane group. Total pathological complete response (tpCR, ypT0/is ypN0) and breast pathological complete response (bpCR, ypT0/is) rates were assessed.

RESULTS

A total of 107 patients were enrolled. Postoperative pathology indicated a tpCR rate of 36.8 %, a bpCR rate of 42.1 % in the A group, the non-A group had a tpCR rate of 47.8 %, and a bpCR rate of 53.6 %, with P-values of 0.273 and 0.254, respectively. In the long-cycle taxane group, the tpCR and bpCR rates were 60.8 % and 66.7 %, respectively. In the short-cycle taxane group, the tpCR and bpCR rates were 11.1 % and 16.7 %, respectively (both P<0.001). The platinum group had higher tpCR rate (62.9 % vs. 32.4 %, respectively; P = 0.011) and bpCR rate (65.7 % vs. 41.2 %, respectively; P = 0.041).

CONCLUSION

As for a neoadjuvant therapy regimen with Py, an anthracycline-free regimen is feasible. Besides, platinum-containing, long-cycle taxane regimens appear to achieve superior efficacy under anthracycline-removed conditions.

Efficacy and Safety of Neoadjuvant Pyrotinib for Human Epidermal Receptor 2-Positive Breast Cancer: A Meta-Analysis

Neoadjuvant pyrotinib shows the potential to improve treatment response in human epidermal receptor 2 (HER2)-positive breast cancer patients, but relevant meta-analyses are scarce. This meta-analysis intended to explore the efficacy and safety of neoadjuvant pyrotinib for HER2-positive breast cancer patients. Studies comparing the efficacy and safety between HER2-positive breast cancer patients receiving pyrotinib-containing neoadjuvant treatment (pyrotinib group) and those receiving other neoadjuvant treatments (control group), were searched in EMBASE, Web of Science, Cochrane, PubMed, China National Knowledge Infrastructure, Wanfang, and SinoMed until December 2023. Six randomized controlled trials (RCTs) and 4 cohort studies were included. The pyrotinib group and control group contained 540 and 684 patients, respectively. Pathological complete response (pCR) was higher in the pyrotinib group than in the control group [relative risk (RR)=1.93; 95% confidence interval (CI) = 1.63-2.29; P < 0.001]. Similar results were discovered in subgroup analyses of RCTs (RR = 1.89; 95% CI = 1.49-2.40; P < 0.001) and cohort studies (RR = 1.98; 95% CI = 1.55-2.53; P < 0.001). The objective response rate (ORR) was also higher in the pyrotinib group than in the control group (RR = 1.14; 95% CI = 1.07-1.21; P < 0.001). Regarding adverse events, only the incidence of diarrhea was increased in the pyrotinib group versus the control group (RR = 1.97; 95% CI = 1.31-2.96; P = 0.001), while others were not different, including nausea and vomiting, leukopenia, thrombocytopenia, hand-foot syndrome, and alopecia (all P > 0.05). No publication bias existed, and sensitivity analysis suggested the satisfactory robustness of this meta-analysis. In conclusion, compared with other neoadjuvant treatments, pyrotinib-containing neoadjuvant treatment achieves a better treatment response with a good safety profile in HER2-positive breast cancer patients.

Cost-utility and budget impact analysis of neoadjuvant dual HER2 targeted therapy for HER2-positive breast cancer in Sri Lanka

This study aimed to assess the cost-utility and budget impact of dual to single HER2 targeted neoadjuvant therapy for HER2-positive breast cancer in Sri Lanka. A five-health state Markov model with lifetime horizon was used to assess the cost-utility of neoadjuvant trastuzumab (T) plus pertuzumab (P) or lapatinib (L) compared to single therapy of T with chemotherapy (C), in public healthcare system and societal perspectives. Input parameters were estimated using local data, network meta-analysis, published reports and literature. Costs were adjusted to year 2021 (1USD = LKR194.78). Five-year budget impact for public healthcare system was assessed. Incremental cost-effectiveness ratios in societal perspective for neoadjuvantLTC plus adjuvantT (strategy 3), neoadjuvantPTC plus adjuvantT (strategy 2), neoadjuvantLTC plus adjuvantLT (strategy 5), and neoadjuvantPTC plus adjuvantPT (strategy 4) compared to neoadjuvantTC plus adjuvantT (strategy 1) were USD2716, USD5600, USD6878, and USD12127 per QALY gained, respectively. One GDP per-capita (USD3815) was considered as the cost-effectiveness threshold for the analysis. Even though only the ICER for strategy 3 was cost-effective, uncertainty of efficacy parameter was revealed. For strategy 2 neoadjuvant PTC plus adjuvant T, a 25% reduction of neoadjuvant regimen cost was required to be cost effective for use in early HER2 positive breast cancer.

Relative efficacy of antibody-drug conjugates and other anti-HER2 treatments on survival in HER2-positive advanced breast cancer: a systematic review and meta-analysis

BACKGROUND

Novel antibody-drug conjugates (ADCs) drugs present a promising anti-cancer treatment, although survival benefits for HER2-positive advanced breast cancer (BC) remain controversial. The aim of this meta-analysis was to evaluate the comparative effect of ADCs and other anti-HER2 therapy on progression-free survival (PFS) and overall survival (OS) for treatment of HER2-positive locally advanced or metastatic BC.

METHODS

Relevant randomized controlled trials (RCTs) were retrieved from five databases. The risk of bias was assessed with the Cochrane Collaboration's tool for RCTs by RevMan5.4 software. The hazard ratio (HR) and 95% confidence intervals (CIs) were extracted to evaluate the benefit of ADCs on PFS and OS in HER2-positive advanced BC by meta-analysis.

RESULTS

Meta-analysis of six RCTs with 3870 patients revealed that ADCs significantly improved PFS (HR: 0.63, 95% CI: 0.49-0.80, P = 0.0002) and OS (HR: 0.79, 95% CI: 0.72-0.86, P < 0.0001) of patients with HER2-positive locally advanced or metastatic BC. Subgroup analysis showed that PFS and OS were obviously prolonged for patients who previously received HER2-targeted therapy. Sensitivity analysis and publication bias suggested that the results were stable and reliable.

CONCLUSION

Statistically significant benefits for PFS and OS were observed with ADCs in HER2-positive locally advanced or metastatic BC, especially for those who received prior anti-HER2 treatment.

Predictors of recurrence in breast cancer patients with pathological partial response

OBJECTIVE

Patients with residual disease after neoadjuvant chemotherapy have a relative risk of developing recurrence. This study investigates the risk factors for recurrence in locally advanced breast cancer patients with residual disease and evaluates survival analysis.

METHODS

This is a retrospective, single-center study. Breast cancer patients who failed to achieve a pathological complete response after neoadjuvant chemotherapy were included. Demographic, clinicopathological, and treatment characteristics were evaluated to identify predictive factors of recurrence and survival analysis.

RESULTS

We included 205 patients in this study. After a median of 31 months of follow-up, 10 patients died, and 20 developed distant metastasis. Disease-free survival and disease-specific survival were 73.8% and 83.1%, respectively. Lymphovascular invasion and non-luminal subtype were independent predictors of locoregional recurrence. In situ carcinoma, lymphovascular invasion, ypTIII stage, and non-luminal molecular subtypes were independent predictors of disease-free survival. The only independent factor affecting disease-specific survival was cNII-III. The number of involved lymph nodes was an independent predictor of disease-free survival in patients without complete axillary response.

CONCLUSION

Factors affecting disease-specific survival and disease-free survival were cNII-III and the number of involved lymph nodes, respectively. Patients with non-luminal, large residual tumors with in situ carcinoma, lymphovascular invasion, clinically positive axilla, and residual nodal involvement have a high relative risk for recurrence and may benefit from additional treatments.

Prediction of clinical response to neoadjuvant therapy in advanced breast cancer by baseline B-mode ultrasound, shear-wave elastography, and pathological information

Background

Neoadjuvant therapy (NAT) is the preferred treatment for advanced breast cancer nowadays. The early prediction of its responses is important for personalized treatment. This study aimed at using baseline shear wave elastography (SWE) ultrasound combined with clinical and pathological information to predict the clinical response to therapy in advanced breast cancer.

Methods

This retrospective study included 217 patients with advanced breast cancer who were treated in West China Hospital of Sichuan University from April 2020 to June 2022. The features of ultrasonic images were collected according to the Breast imaging reporting and data system (BI-RADS), and the stiffness value was measured at the same time. The changes were measured according to the Response evaluation criteria in solid tumors (RECIST1.1) by MRI and clinical situation. The relevant indicators of clinical response were obtained through univariate analysis and incorporated into a logistic regression analysis to establish the prediction model. The receiver operating characteristic (ROC) curve was used to evaluate the performance of the prediction models.

Results

All patients were divided into a test set and a validation set in a 7:3 ratio. A total of 152 patients in the test set, with 41 patients (27.00%) in the non-responders group and 111 patients (73.00%) in the responders group, were finally included in this study. Among all unitary and combined mode models, the Pathology + B-mode + SWE model performed best, with the highest AUC of 0.808 (accuracy 72.37%, sensitivity 68.47%, specificity 82.93%, P<0.001). HER2+, Skin invasion, Post mammary space invasion, Myometrial invasion and Emax were the factors with a significant predictive value (P<0.05). 65 patients were used as an external validation set. There was no statistical difference in ROC between the test set and the validation set (P>0.05).

Conclusion

As the non-invasive imaging biomarkers, baseline SWE ultrasound combined with clinical and pathological information can be used to predict the clinical response to therapy in advanced breast cancer.

Review of the status of neoadjuvant therapy in HER2-positive breast cancer

Purpose

The development of human epidermal growth factor receptor 2 (HER2)-directed therapies has revolutionized the treatment of HER2-positive breast cancer. The aim of this article is to review the continually evolving treatment strategies in the neoadjuvant setting of HER2-positive breast cancer, as well as the current challenges and future perspectives.

Methods

Searches were undertaken on PubMed and Clinicaltrials.gov for relevant publications and trials.

Findings

The current standard of care in high-risk HER2-positive breast cancer is to combine chemotherapy with dual anti-HER2 therapy, for a synergistic anti-tumor effect. We discuss the pivotal trials which led to the adoption of this approach, as well as the benefit of these neoadjuvant strategies for guiding appropriate adjuvant therapy. De-escalation strategies are currently being investigated to avoid over treatment, and aim to safely reduce chemotherapy, while optimizing HER2-targeted therapies. The development and validation of a reliable biomarker is essential to enable these de-escalation strategies and personalization of treatment. In addition, promising novel therapies are currently being explored to further improve outcomes in HER2-positive breast cancer.

Axillary Downstaging and the Impact of Clinical Axillary Status on Efficacy of Neoadjuvant Therapy for HER2-Positive Breast Cancer: A Network Meta-Analysis

Background: Lymph node downstaging and the achievement of total-pCR (ypT0/is ypN0) after neoadjuvant therapy are of great importance in HER-2 positive breast cancer. We aim to provide an overall review of neoadjuvant regimens for lymph node downstaging and to indirectly compare the total-pCR by various neoadjuvant regimens with network meta-analysis in HER2-positive patients according to their clinical lymph node status. Methods: Five English databases were searched comprehensively and systematically for relevant RCTs and case-control studies. The data extracted from the included studies were analyzed with the use of Review Manager 5.3 or STATA 15.0 software. Results: A total of 1508 published manuscripts were identified, and 17 studies including 4747 patients were finally included in our analysis. The network meta-analysis of total-pCR showed that dual-target therapy is significantly better than single-target therapy in clinically node-positive patients, and carboplatin performed significantly better than anthracycline in single-target condition. Lapatinib performed poorly in clinically node-positive patients. However, lapatinib in combination with trastuzumab was ranked at the top in the clinically node-negative group, and pertuzumab showed dissatisfied performance in contrast to the primacy of pertuzumab in clinically node-positive groups. Conclusion: In summary, different lymph node statuses led to the diverse first choice of neoadjuvant regimen. We highly recommended TCbHP as the first choice for the neoadjuvant treatment in clinically node-positive HER-2 positive breast cancer. Since lapatinib with trastuzumab ranked top in the clinically node-negative group, we looked forward to discovering the potential value of TKI in clinically node-negative patients, which needs further analysis in the future.