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Geyer CE, Blum JL, Yothers G, Asmar L, Flynn PJ, Robert NJ, Hopkins JO, O'Shaughnessy JA, Rastogi P, Puhalla SL, Hilton CJ, Dang CT, Gómez HL, Vukelja SJ, Lyss AP, Paul D, Brufsky AM, Colangelo LH, Swain SM, Mamounas EP, Wolmark N. Long-Term Follow-Up of the Anthracyclines in Early Breast Cancer Trials (USOR 06-090, NSABP B-46-I/USOR 07132, and NSABP B-49 [NRG Oncology]). J Clin Oncol 2024; 42:1344-1349. [PMID: 38335467 DOI: 10.1200/jco.23.01428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/03/2023] [Accepted: 12/07/2023] [Indexed: 02/12/2024] Open
Abstract
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.The primary joint efficacy analysis of the Anthracyclines in Early Breast Cancer (ABC) trials reported in 2017 failed to demonstrate nonanthracycline adjuvant therapy was noninferior to anthracycline-based regimens in high-risk, early breast cancer. Full analyses of the studies had proceeded when the prespecified futility boundary was crossed at a planned futility analysis for the ability to demonstrate noninferiority of a nonanthracycline regimen with continued follow-up. These results were presented with 3.3 years of median follow-up. This manuscript reports results of the final analyses of the study efficacy end points conducted with 6.9 years of median follow-up. Long-term analysis of invasive disease-free survival (IDFS), the primary end point of the ABC trials, remains consistent with the original results, as noninferiority of the nonanthracycline regimens could not be declared on the basis of the original criteria. The secondary end point of recurrence-free interval, which excluded deaths not due to breast cancer as events, favored anthracycline-based regimens, and tests for heterogeneity were significant for hormone receptor status (P = .02) favoring anthracycline regimens for the hormone receptor-negative cohorts. There was no difference in overall survival, and review of the type of IDFS events in the groups suggested reductions in cancer recurrences achieved with anthracycline regimens were offset by late leukemias and deaths unrelated to breast cancer.
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Affiliation(s)
- Charles E Geyer
- NSABP Foundation/NRG Oncology, Pittsburgh, PA
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joanne L Blum
- Baylor-Sammons Cancer Center, Texas Oncology, US Oncology Research, Dallas, TX
| | - Greg Yothers
- NRG Oncology SDMC, Department of Biostatistics, and University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Lina Asmar
- USOR, McKesson Specialty Health, The Woodlands, TX
| | - Patrick J Flynn
- Minnesota Community Oncology Research Consortium (MSORC), Stone Lake, MI
| | | | - Judith O Hopkins
- Novant Health (Forsyth Medical) Cancer Institute, Southeast Clinical Oncology Research (SCOR) NCORP, Winston Salem, NC
| | | | - Priya Rastogi
- NSABP Foundation/NRG Oncology, Pittsburgh, PA
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
- UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - Shannon L Puhalla
- NSABP Foundation/NRG Oncology, Pittsburgh, PA
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Christie J Hilton
- NSABP Foundation/NRG Oncology, Pittsburgh, PA
- Allegheny Health Network, Pittsburgh, PA
| | - Chau T Dang
- Memorial Sloan Kettering Cancer Center, West Harrison, NY
| | | | | | - Alan P Lyss
- Heartland Cancer Research NCORP-Missouri Baptist Medical Center, St Louis, MO
| | | | - Adam M Brufsky
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
- UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - Linda H Colangelo
- NRG Oncology SDMC, Department of Biostatistics, and University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Sandra M Swain
- NSABP Foundation/NRG Oncology, Pittsburgh, PA
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, MedStar Health, Washington, DC
| | - Eleftherios P Mamounas
- NSABP Foundation/NRG Oncology, Pittsburgh, PA
- Orlando Health Cancer Institute, Orlando, FL
| | - Norman Wolmark
- NSABP Foundation/NRG Oncology, Pittsburgh, PA
- UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Scott JM, Lee J, Herndon JE, Michalski MG, Lee CP, O’Brien KA, Sasso JP, Yu AF, Rowed KA, Bromberg JF, Traina TA, Gucalp A, Sanford RA, Gajria D, Modi S, Comen EA, D'Andrea G, Blinder VS, Eves ND, Peppercorn JM, Moskowitz CS, Dang CT, Jones LW. Timing of exercise therapy when initiating adjuvant chemotherapy for breast cancer: a randomized trial. Eur Heart J 2023; 44:4878-4889. [PMID: 36806405 PMCID: PMC10702461 DOI: 10.1093/eurheartj/ehad085] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/10/2023] [Accepted: 02/03/2023] [Indexed: 02/23/2023] Open
Abstract
AIMS The most appropriate timing of exercise therapy to improve cardiorespiratory fitness (CRF) among patients initiating chemotherapy is not known. The effects of exercise therapy administered during, following, or during and following chemotherapy were examined in patients with breast cancer. METHODS AND RESULTS Using a parallel-group randomized trial design, 158 inactive women with breast cancer initiating (neo)adjuvant chemotherapy were allocated to receive (1:1 ratio): usual care or one of three exercise regimens-concurrent (during chemotherapy only), sequential (after chemotherapy only), or concurrent and sequential (continuous) (n = 39/40 per group). Exercise consisted of treadmill walking three sessions/week, 20-50 min at 55%-100% of peak oxygen consumption (VO2peak) for ≈16 (concurrent, sequential) or ≈32 (continuous) consecutive weeks. VO2peak was evaluated at baseline (pre-treatment), immediately post-chemotherapy, and ≈16 weeks after chemotherapy. In intention-to-treat analysis, there was no difference in the primary endpoint of VO2peak change between concurrent exercise and usual care during chemotherapy vs. VO2peak change between sequential exercise and usual care after chemotherapy [overall difference, -0.88 mL O2·kg-1·min-1; 95% confidence interval (CI): -3.36, 1.59, P = 0.48]. In secondary analysis, continuous exercise, approximately equal to twice the length of the other regimens, was well-tolerated and the only strategy associated with significant improvements in VO2peak from baseline to post-intervention (1.74 mL O2·kg-1·min-1, P < 0.001). CONCLUSION There was no statistical difference in CRF improvement between concurrent vs. sequential exercise therapy relative to usual care in women with primary breast cancer. The promising tolerability and CRF benefit of ≈32 weeks of continuous exercise therapy warrant further evaluation in larger trials.
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Affiliation(s)
- Jessica M Scott
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Jasme Lee
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - James E Herndon
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, 2424 Erwin Road, 8020 Hock Plaza, Durham, NC 27705, USA
| | - Meghan G Michalski
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Catherine P Lee
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Kelly A O’Brien
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - John P Sasso
- School of Health and Exercise Sciences, University of British Columbia, 1147 Research Road, Kelowna, BC V1V 1V7, Canada
| | - Anthony F Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Kylie A Rowed
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Jacqueline F Bromberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Tiffany A Traina
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Ayca Gucalp
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Rachel A Sanford
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Devika Gajria
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Shanu Modi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Elisabeth A Comen
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Gabriella D'Andrea
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Victoria S Blinder
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Neil D Eves
- School of Health and Exercise Sciences, University of British Columbia, 1147 Research Road, Kelowna, BC V1V 1V7, Canada
| | - Jeffrey M Peppercorn
- Division of Hematology/Oncology, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
| | - Chaya S Moskowitz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Chau T Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medical College, 418 E 71st St, New York, NY 10021, USA
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Yu AF, Lin I, Jorgensen J, Copeland‐Halperin R, Feldman S, Ibtida I, Assefa A, Johnson MN, Dang CT, Liu JE, Steingart RM. Nomogram for Predicting Risk of Cancer Therapy-Related Cardiac Dysfunction in Patients With Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer. J Am Heart Assoc 2023; 12:e029465. [PMID: 37750581 PMCID: PMC10727240 DOI: 10.1161/jaha.123.029465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 07/06/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Cancer therapy-related cardiac dysfunction (CTRCD) is an important treatment-limiting toxicity for patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer that adversely affects cancer and cardiovascular outcomes. Easy-to-use tools that incorporate readily accessible clinical variables for individual estimation of CTRCD risk are needed. METHODS AND RESULTS From 2004 to 2013, 1440 patients with stage I to III HER2-positive breast cancer treated with trastuzumab-based therapy were identified. A multivariable Cox proportional hazards model was constructed to identify risk factors for CTRCD and included the 1377 patients in whom data were complete. Nine clinical variables, including age, race, body mass index, left ventricular ejection fraction, systolic blood pressure, coronary artery disease, diabetes, arrhythmia, and anthracycline exposure were built into a nomogram estimating risk of CTRCD at 1 year. The nomogram was validated for calibration and discrimination using bootstrap resampling. A total of 177 CTRCD events occurred within 1 year of HER2-targeted treatment. The nomogram for prediction of 1-year CTRCD probability demonstrated good discrimination, with a concordance index of 0.687. The predicted and observed probabilities of CTRCD were similar, demonstrating good model calibration. CONCLUSIONS A nomogram composed of 9 readily accessible clinical variables provides an individualized 1-year risk estimate of CTRCD among women with HER2-positive breast cancer receiving HER2-targeted therapy. This nomogram represents a simple-to-use tool for clinicians and patients that can inform clinical decision-making on breast cancer treatment options, optimal frequency of cardiac surveillance, and role of cardioprotective strategies.
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Affiliation(s)
- Anthony F. Yu
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Weill Cornell Medical CollegeNew YorkNYUSA
| | - I‐Hsin Lin
- Department of Epidemiology and BiostatisticsMemorial Sloan Kettering CancerNew YorkNYUSA
| | - Justine Jorgensen
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | | | - Stephanie Feldman
- Department of Medicine, Division of CardiologyRutgers New Jersey Medical SchoolNewarkNJUSA
| | - Ishmam Ibtida
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Amare Assefa
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Michelle N. Johnson
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Weill Cornell Medical CollegeNew YorkNYUSA
| | - Chau T. Dang
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Weill Cornell Medical CollegeNew YorkNYUSA
| | - Jennifer E. Liu
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Weill Cornell Medical CollegeNew YorkNYUSA
| | - Richard M. Steingart
- Department of MedicineMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
- Weill Cornell Medical CollegeNew YorkNYUSA
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Pegram M, Pietras R, Dang CT, Murthy R, Bachelot T, Janni W, Sharma P, Hamilton E, Saura C. Evolving perspectives on the treatment of HR+/HER2+ metastatic breast cancer. Ther Adv Med Oncol 2023; 15:17588359231187201. [PMID: 37576607 PMCID: PMC10422890 DOI: 10.1177/17588359231187201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/21/2023] [Indexed: 08/15/2023] Open
Abstract
Breast cancer (BC) with expression of the estrogen receptor (ER) and/or progesterone receptor (PR) protein and with overexpression/amplification of the human epidermal growth factor receptor 2 (HER2), termed hormone receptor-positive (HR+)/HER2+ BC, represents ∼10% of all BCs in the United States. HR+/HER2+ BC includes HER2+ BCs that are ER+, PR+, or both ER+ and PR+ (triple-positive BC). Although the current guideline-recommended treatment combination of anti-HER2 monoclonal antibodies plus chemotherapy is an effective first-line therapy for many patients with HER2+ advanced disease, intratumoral heterogeneity within the HR+/HER2+ subtype and differences between the HR+/HER2+ subtype and the HR-/HER2+ subtype suggest that other targeted combinations could be investigated in randomized clinical trials for patients with HR+/HER2+ BC. In addition, published data indicate that crosstalk between HRs and HER2 can lead to treatment resistance. Dual HR and HER2 pathway targeting has been shown to be a rational approach to effective and well-tolerated therapy for patients with tumors driven by HER2 and HR, as it may prevent development of resistance by blocking receptor pathway crosstalk. However, clinical trial data for such approaches are limited. Treatments to attenuate other signaling pathways involved in receptor crosstalk are also under investigation for inclusion in dual receptor targeting regimens. These include cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors, based on the rationale that association of CDK4/6 with cyclin D1 may play a role in resistance to HER2-directed therapies, and others such as phosphatidylinositol-3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) pathway inhibitors. Herein, we will review the scientific and clinical rationale for combined receptor blockade targeting HER2 and ER for patients with advanced-stage HR+/HER2+ disease.
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Affiliation(s)
- Mark Pegram
- Stanford Comprehensive Cancer Institute, Stanford University School of Medicine, Lorry Lokey Building/SIM 1, 265 Campus Drive, Ste G2103, Stanford, CA 94305-5456, USA
| | - Richard Pietras
- Division of Hematology-Oncology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, CA, USA
| | - Chau T. Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Rashmi Murthy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas Bachelot
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Wolfgang Janni
- Department of Gynecology and Obstetrics, University Hospital Ulm, University of Ulm, Ulm, Germany
| | - Priyanka Sharma
- Department of Internal Medicine, Division of Medical Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Erika Hamilton
- Sarah Cannon Research Institute/Tennessee Oncology, Nashville, TN, USA
| | - Cristina Saura
- Vall d’Hebron University Hospital and Vall d’Hebron Institute of Oncology (VHIO), Medical Oncology Service, Barcelona, Spain
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Polito L, Shim J, Hurvitz SA, Dang CT, Knott A, Du Toit Y, Restuccia E, Sanglier T, Swain SM. Real-World First-Line Use of Pertuzumab With Different Taxanes for Human Epidermal Growth Factor Receptor 2-Positive Metastatic Breast Cancer: A Comparative Effectiveness Study Using US Electronic Health Records. JCO Oncol Pract 2023; 19:435-445. [PMID: 37167571 PMCID: PMC10337715 DOI: 10.1200/op.22.00565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 01/12/2023] [Accepted: 02/28/2023] [Indexed: 05/13/2023] Open
Abstract
PURPOSE On the basis of the results from CLEOPATRA, pertuzumab plus trastuzumab and chemotherapy is the first-line standard of care for human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC). However, discrepancies have been reported between clinical trial and real-world outcomes. We report real-world outcomes for patients with HER2-positive MBC treated with first-line pertuzumab plus trastuzumab and a taxane in routine clinical practice in the United States. METHODS A retrospective analysis was conducted using electronic health record-derived deidentified data from the Flatiron Health database. Patients were grouped according to the first taxane received (paclitaxel/nab-paclitaxel or docetaxel). Median real-world progression-free survival (rwPFS) and overall survival (rwOS) was estimated using Kaplan-Meier methodology. Subgroup analyses were conducted in patients treated with docetaxel who met CLEOPATRA's key eligibility criteria. RESULTS We included 1,065 patients; 313 patients received paclitaxel/nab-paclitaxel and 752 received docetaxel. Patients who received paclitaxel/nab-paclitaxel were older, had a worse Eastern Cooperative Oncology Group Performance Status, and had more recurrent metastatic disease compared with the docetaxel group. After adjustment for potential confounders, similar median rwPFS (inverse probability of treatment weighted average treatment effect for the treated [IPTW-ATT] hazard ratio [HR], 1.09; 95% CI, 0.9 to 1.3; P = .365) and rwOS (IPTW-ATT HR, 1.23; 95% CI, 0.96 to 1.58; P = .101) was observed between treatment groups. In the subgroup of CLEOPATRA-eligible patients, median rwPFS and rwOS were 16.9 months and 57.8 months, respectively. CONCLUSION There was no statistically significant difference in real-world outcomes between patients treated with paclitaxel/nab-paclitaxel and those treated with docetaxel. Selecting patients using key CLEOPATRA eligibility criteria resulted in rwPFS and rwOS similar to those observed in CLEOPATRA, highlighting the importance of ensuring similar patient populations when comparing clinical trial and real-world data.
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Affiliation(s)
- Letizia Polito
- Product Development Data Science, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Jinjoo Shim
- Product Development Data Science, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Sara A. Hurvitz
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Chau T. Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Adam Knott
- Product Development Oncology, Roche Products Limited, Welwyn, United Kingdom
| | - Yolande Du Toit
- US Medical Affairs, Genentech, Inc., South San Francisco, CA
| | - Eleonora Restuccia
- Product Development Oncology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Thibaut Sanglier
- Product Development Data Science, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Sandra M. Swain
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, MedStar Health, Washington, DC
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Yu AF, Moore ZR, Moskowitz CS, Liu JE, Dang CT, Ramanathan L, Oeffinger KC, Steingart RM, Schmitt AM. Association of Circulating Cardiomyocyte Cell-Free DNA With Cancer Therapy-Related Cardiac Dysfunction in Patients Undergoing Treatment for ERBB2-Positive Breast Cancer. JAMA Cardiol 2023; 8:697-702. [PMID: 37256614 PMCID: PMC10233452 DOI: 10.1001/jamacardio.2023.1229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 04/07/2023] [Indexed: 06/01/2023]
Abstract
Importance Cancer therapy-related cardiac dysfunction (CTRCD) is a potentially serious cardiotoxicity of treatments for ERBB2-positive breast cancer (formerly HER2). Identifying early biomarkers of cardiotoxicity could facilitate an individualized approach to cardiac surveillance and early pharmacologic intervention. Circulating cell-free DNA (cfDNA) of cardiomyocyte origin is present during acute cardiac injury but has not been established as a biomarker of CTRCD. Objective To determine whether circulating cardiomyocyte cfDNA is associated with CTRCD in patients with ERBB2-positive breast cancer treated with anthracyclines and ERBB2-targeted therapy. Design, Setting, and Participants A prospective cohort of 80 patients with ERBB2-positive breast cancer enrolled at an academic cancer center between July 2014 and April 2016 underwent echocardiography and blood collection at baseline, after receiving anthracyclines, and at 3 months and 6 months of ERBB2-targeted therapy. Participants were treated with doxorubicin-based chemotherapy followed by trastuzumab (+/- pertuzumab). The current biomarker study includes participants with sufficient biospecimen available for analysis after anthracycline therapy. Circulating cardiomyocyte-specific cfDNA was quantified by a methylation-specific droplet digital polymerase chain reaction assay. Data for this biomarker study were collected and analyzed from June 2021 through April 2022. Main Outcomes and Measures The outcome of interest was 1-year CTRCD, defined by symptomatic heart failure or an asymptomatic decline in left ventricular ejection fraction (≥10% from baseline to less than lower limit of normal or ≥16%). Values for cardiomyocyte cfDNA and high-sensitivity cardiac troponin I (hs-cTnI) measured after patients completed treatment with anthracyclines were compared between patients who later developed CTRCD vs patients who did not using the Wilcoxon rank sum test, and the association of post-anthracycline cardiomyocyte cfDNA level with CTRCD was estimated using logistic regression. Results Of 71 patients included in this study, median (IQR) age was 50 (44-58) years, all were treated with dose-dense doxorubicin, and 48 patients underwent breast radiotherapy. Ten of 71 patients (14%) in this analysis developed CTRCD. The level of cardiomyocyte cfDNA at the post-anthracycline time point was higher in patients who subsequently developed CTRCD (median, 30.5 copies/mL; IQR, 24-46) than those who did not (median, 7 copies/mL; IQR, 2-22; P = .004). Higher cardiomyocyte cfDNA level after completion of anthracycline chemotherapy was associated with risk of CTRCD (hazard ratio, 1.02 per 1-copy/mL increase; 95% CI, 1.00-1.03; P = .046). Conclusions and Relevance This study found that higher cardiomyocyte cfDNA level after completion of anthracycline chemotherapy was associated with risk of CTRCD. Cardiomyocyte cfDNA quantification shows promise as a predictive biomarker to refine risk stratification for CTRCD among patients with breast cancer receiving cardiotoxic cancer therapy, and its use warrants further validation. Trial Registration ClinicalTrials.gov Identifier: NCT02177175.
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Affiliation(s)
- Anthony F. Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Zachary R. Moore
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chaya S. Moskowitz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jennifer E. Liu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Chau T. Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Lakshmi Ramanathan
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Richard M. Steingart
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Adam M. Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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7
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Yu AF, Dang CT, Jorgensen J, Moskowitz CS, DeFusco P, Oligino E, Oeffinger KC, Liu JE, Steingart RM. Rationale and design of a cardiac safety study for reduced cardiotoxicity surveillance during HER2-targeted therapy. Cardiooncology 2023; 9:13. [PMID: 36895062 PMCID: PMC9996968 DOI: 10.1186/s40959-023-00163-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 02/15/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Echocardiograms are recommended every 3 months in patients receiving human epidermal growth factor 2 (HER2)-targeted therapy for surveillance of left ventricular ejection fraction (LVEF). Efforts to tailor treatment for HER2-positive breast cancer have led to greater use of non-anthracycline regimens that are associated with lower cardiotoxicity risk, raising into question the need for frequent cardiotoxicity surveillance for these patients. This study seeks to evaluate whether less frequent cardiotoxicity surveillance (every 6 months) is safe for patients receiving a non-anthracycline HER2-targeted treatment regimen. METHODS/DESIGN We will enroll 190 women with histologically confirmed HER2-positive breast cancer scheduled to receive a non-anthracycline HER2-targeted treatment regimen for a minimum of 12 months. All participants will undergo echocardiograms before and 6-, 12-, and 18-months after initiation of HER2-targeted treatment. The primary composite outcome is symptomatic heart failure (New York Heart Association class III or IV) or death from cardiovascular causes. Secondary outcomes include: 1) echocardiographic indices of left ventricular systolic function; 2) incidence of cardiotoxicity, defined by a ≥ 10% absolute reduction in left ventricular ejection fraction (LVEF) from baseline to < 53%; and 3) incidence of early interruption of HER2-targeted therapy. CONCLUSIONS To our knowledge, this will be the first prospective study of a risk-based approach to cardiotoxicity surveillance. We expect findings from this study will inform the development of updated clinical practice guidelines to improve cardiotoxicity surveillance practices during HER2-positive breast cancer treatment. TRIAL REGISTRATION The trial was registered in the ClinicalTrials.gov registry (identifier NCT03983382) on June 12, 2019.
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Affiliation(s)
- Anthony F Yu
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA. .,Weill Cornell Medical College, New York, NY, USA.
| | - Chau T Dang
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Justine Jorgensen
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Chaya S Moskowitz
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | | | - Jennifer E Liu
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Richard M Steingart
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.,Weill Cornell Medical College, New York, NY, USA
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Shamseddine A, Patel SH, Chavez V, Moore ZR, Adnan M, Di Bona M, Li J, Dang CT, Ramanathan LV, Oeffinger KC, Liu JE, Steingart RM, Piersigilli A, Socci ND, Chan AT, Yu AF, Bakhoum SF, Schmitt AM. Innate immune signaling drives late cardiac toxicity following DNA-damaging cancer therapies. J Exp Med 2023; 220:213768. [PMID: 36534085 PMCID: PMC9767651 DOI: 10.1084/jem.20220809] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/15/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022] Open
Abstract
Late cardiac toxicity is a potentially lethal complication of cancer therapy, yet the pathogenic mechanism remains largely unknown, and few treatment options exist. Here we report DNA-damaging agents such as radiation and anthracycline chemotherapies inducing delayed cardiac inflammation following therapy due to activation of cGAS- and STING-dependent type I interferon signaling. Genetic ablation of cGAS-STING signaling in mice inhibits DNA damage-induced cardiac inflammation, rescues late cardiac functional decline, and prevents death from cardiac events. Treatment with a STING antagonist suppresses cardiac interferon signaling following DNA-damaging therapies and effectively mitigates cardiac toxicity. These results identify a therapeutically targetable, pathogenic mechanism for one of the most vexing treatment-related toxicities in cancer survivors.
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Affiliation(s)
- Achraf Shamseddine
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Suchit H. Patel
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiation Oncology, Mary Bird Perkins Cancer Center, Baton Rouge, LA, USA
| | - Valery Chavez
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zachary R. Moore
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mutayyaba Adnan
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melody Di Bona
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jun Li
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chau T. Dang
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lakshmi V. Ramanathan
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin C. Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer E. Liu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard M. Steingart
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alessandra Piersigilli
- Laboratory of Comparative Pathology, Rockefeller University, Weill Cornell Medicine and Memorial Sloan-Kettering Cancer Center, New York, NY, USA
- Takeda Development Center Americas, Drug Safety Research Evaluation, Cambridge, MA, USA
| | - Nicholas D. Socci
- Marie-Josee & Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Angel T. Chan
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anthony F. Yu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Samuel F. Bakhoum
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Adam M. Schmitt
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Correspondence to Adam M. Schmitt:
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Ferraro E, Minmin SC, Safonov A, Barrio AV, Modi S, Seidman AD, Wen HY, Brogi E, Robson ME, Dang CT. Abstract P4-02-14: Gain of HER2 Amplification in Patients with HR+/HER2- and Triple Negative Early Breast Cancer Treated with Neoadjuvant Chemotherapy. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p4-02-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: Neoadjuvant chemotherapy (NAC) is standard of care for the majority of patients with clinical stage II-III triple negative breast cancer (TNBC) and is considered in high-risk patients with hormone receptor positive (HR+)/human epidermal growth factor receptor 2 (HER2) negative (-) tumors, with expected pathological complete response (pCR) rates of 40-60% and 10-12%, respectively. In HER2- patients with residual disease (RD) after NAC, there is limited data on rates of gain of HER2 amplification. The biological and clinical significance of this phenomenon is unknown and determining the best adjuvant therapy for these patients remains a challenge. We sought to determine the rate of HER2 gain in a cohort of consecutive patients with HER2- breast cancer (BC) treated with NAC.
Methods: From 01/2021 to 12/2021, we identified patients with HER2- breast cancer treated with NAC followed by surgery at our institution. Patients who received neoadjuvant endocrine therapy were excluded. The rates of pCR (ypT0/is ypN0) and HER2 status pre- and post-NAC were assessed. Estrogen receptor (ER), progesterone receptor (PR) and HER2 status on surgery specimens were internally determined for all patients using ASCO/CAP 2020 guidelines. ER-low was defined as ER expression by immunohistochemistry (IHC) 1-10%.
Results: We included 256 patients, 130 (51%) HR+/HER2- [13/130(10%) ER-low] and 126 (49%) TNBC. Median age was 48 years (range 25-82) and the majority presented with clinical T2 (57%) and N1 (59%). Of 130 patients with HR+/HER2-tumors, 120 (92%) received dose-dense (dd) doxorubicin/cyclophosphamide-paclitaxel (AC-T). Of 126 TNBC patients, 46 (37%) received ddAC followed by carboplatin in combination with paclitaxel +/- pembrolizumab. Centralized HER2 status assessment on the core biopsy was performed in 22% of samples. Overall, pCR was achieved in 40% of TNBC and 11% of HR+/HER2-. Among the 192 patients with RD, the rate of HER2 gain was 8/192 (4%), including 3% (2/76) of TNBC and 5% (6/116) of HR+/HER2- patients. 7 of the 8 patients (88%) converted from IHC 1+ or 2+ fluorescence in situ hybridization (FISH) not amplified on core biopsy to IHC 2+ FISH amplified on the surgical specimen. In only 1 case, the HER2 status converted from IHC2+ FISH not amplified to IHC3+. 3/8 patients had multifocal disease. All 6 patients with HR+/HER2- BC and HER2 gain had high (>90%) ER expression (Table 1). All but one patient with HER2 gain received adjuvant anti-HER2 therapy. After a median follow-up of 10 months, no recurrence events occurred in this group.12 of the remaining 184 patients experienced a recurrence [11 distant recurrences (8 and 3, in the TNBC and HR+/HER2- groups, respectively), and there was 1 local event (localized chest wall recurrence) in the HR+/HER2- group].
Conclusions: At a single center, we found that in patients with HER2- BC treated with NAC, HER2 gain in patients with RD was uncommon and occurred more frequently in those with HR+ tumors. Analysis of a larger cohort is ongoing to corroborate these results. It is remains to be determined if this phenomenon represents a true HER2 status conversion or tumor heterogeneity.
Table 1: Clinico-pathological characteristics of patients with HER2 gain on residual disease
Citation Format: Emanuela Ferraro, Sonya Chew Minmin, Anton Safonov, Andrea V. Barrio, Shanu Modi, Andrew D Seidman, Hanna Y Wen, Edi Brogi, Mark E. Robson, Chau T Dang. Gain of HER2 Amplification in Patients with HR+/HER2- and Triple Negative Early Breast Cancer Treated with Neoadjuvant Chemotherapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-02-14.
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Affiliation(s)
| | | | | | | | - Shanu Modi
- 5Memorial Sloan Cancer Center, New York, NY
| | | | | | - Edi Brogi
- 8Memorial Sloan Kettering Cancer Center
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10
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Tarantino P, Tayob N, Dang CT, Yardley D, Isakoff SJ, Valero V, Faggen M, Mulvey T, Bose R, Weckstein D, Wolff AC, Reeder-Hayes K, Rugo H, Ramaswamy B, Zuckerman D, Hart L, Gadi VK, Constantine M, Cheng K, Garrett AM, Marcom PK, Albain KS, DeFusco P, Tung N, Ardman B, Nanda R, Jankowitz RC, Rimawi M, Abramson V, Pohlmann PR, Van Poznak C, Forero-Torres A, Liu MC, Ruddy K, Zheng Y, Barroso-Sousa R, Waks A, DeMeo MK, DiLullo MK, Curigliano G, Burstein H, Partridge A, Winer E, Viale G, Hui W, Mittendorf EA, Schneider BP, Prat A, Krop I, Tolaney S. Abstract PD18-01: Adjuvant Trastuzumab Emtansine Versus Paclitaxel plus Trastuzumab for Stage I HER2+ Breast Cancer: 5-year results and correlative analyses from ATEMPT (TBCRC033). Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-pd18-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: The ATEMPT trial primary analysis found that one year of adjuvant trastuzumab emtansine (T-DM1) achieved a 3-year iDFS of 97.8% for patients with stage I HER2+ breast cancer, but was not associated with fewer clinically relevant toxicities (CRTs) compared with paclitaxel and trastuzumab (TH). In this end-of-study analysis, we report 5-year survival outcomes and correlative analyses from the trial. Methods: Patients with stage I centrally confirmed HER2+ breast cancer were randomly assigned 3:1 to adjuvant T-DM1 for one year or TH and received T-DM1 3.6 mg/kg IV every 3 weeks for 17 cycles or paclitaxel 80 mg/m2 IV with weekly trastuzumab IV followed by trastuzumab for 9 months. The co-primary objectives were to compare the incidence of CRTs between the 2 arms and to evaluate iDFS in patients receiving T-DM1. To investigate proteomic correlates of recurrence, spatial proteomic analyses were performed on samples from 13 patients experiencing iDFS events (cases) and 24 matched controls using the NanoString GeoMx Digital Spatial Profiler. The impact of HER2 heterogeneity on outcomes was investigated among 17 cases and 51 matched controls by fluorescence in-situ hybridization (FISH). HER2 genetic heterogeneity was assessed by scrutinizing the whole tumor area and defined as the occurrence of HER2 gene amplification in >5% but < 50% invasive tumor cells. The risk of recurrence was evaluated centrally with the HER2DX genomic assay from 225 primary tumor samples. Germline whole genome sequencing (WGS) was conducted among 55 patients experiencing T-DM1-induced thrombocytopenia and/or bleeding and 55 matched controls to identify genomic correlates for this side effect. Results: A total of 497 patients who initiated protocol therapy were included in this analysis (383 T-DM1 and 114 TH). After a median follow up 5.8 years, among patients receiving T-DM1 there were a total of 11 iDFS events, with 3 distant recurrences. The 5-year iDFS for T-DM1 was 97.0% (95% CI, 95.3-98.8%), the 5-year recurrence-free interval (RFI) was 98.6% (95% CI: 97.4-99.8%) and the 5-year overall survival (OS) for T-DM1 was 97.8 % (95% CI, 96.3-99.3%). Although the study was not powered to evaluate the efficacy of TH, among the 114 patients receiving TH, a total of 9 iDFS events were observed, including 2 distant events; the 5-year iDFS with TH was 91.3% (95% CI: 86.0-96.9%), 5-year RFI was 93.3% (95% CI: 88.6-98.2%) and 5-year OS was 97.9% (95% CI: 95.2-100%). A total of 56 samples were evaluable for heterogeneity analyses, among which 14% (n=8) harbored HER2 genetic heterogeneity. Spatial proteomic analyses found that NF1 (adjusted p=0.72 × 10-6) and CTLA-4 (adjusted p=0.15 × 10-3) were significantly upregulated in primary samples from cases, while cleaved caspase 9, CD25, GITR, ICOS, p53 and PD-L2 were significantly upregulated in controls (all with adjusted p< 0.05). Germline WGS found that the top gene associations with thrombocytopenia and thrombocytopenia or bleeding were ALMS1 (p=0,19 × 10-3) and APBA3 (p=0,23 × 10-3), respectively, although none reaching the threshold for genome wide significance. rs62143195 and rs114169776 were the top single nucleotide polymorphisms associated with thrombocytopenia and thrombocytopenia or bleeding, respectively. Data on the impact of HER2 heterogeneity and of HER2DX score on survival outcomes will be presented. Conclusion: With longer follow-up, adjuvant T-DM1 confirmed outstanding long-term outcomes among patients with stage I HER2+ breast cancer, demonstrating a 5-year RFI of 98.6%. Spatial proteomic analyses identified a potential association between NF1 and CTLA-4 expression with recurrence. Details on the impact of HER2 heterogeneity and HER2DX assay on prognosis will be presented.
Citation Format: Paolo Tarantino, Nabihah Tayob, Chau T Dang, Denise Yardley, Steven J. Isakoff, Vicente Valero, Meredith Faggen, Therese Mulvey, Ron Bose, Douglas Weckstein, Antonio C. Wolff, Katherine Reeder-Hayes, Hope Rugo, Bhuvaneswari Ramaswamy, Dan Zuckerman, Lowell Hart, Vijayakrishna K. Gadi, Michael Constantine, Kit Cheng, Audrey Merrill Garrett, Paul K. Marcom, Kathy S. Albain, Patricia DeFusco, Nadine Tung, Blair Ardman, Rita Nanda, Rachel C. Jankowitz, Mothaffar Rimawi, Vandana Abramson, Paula R. Pohlmann, Catherine Van Poznak, Andres Forero-Torres, Minetta C. Liu, Kathryn Ruddy, Yue Zheng, Romualdo Barroso-Sousa, Adrienne Waks, Michelle K. DeMeo, Molly K. DiLullo, Giuseppe Curigliano, Harold Burstein, Ann Partridge, Eric Winer, Giuseppe Viale, Winnie Hui, Elizabeth A. Mittendorf, Bryan P. Schneider, Aleix Prat, Ian Krop, Sara Tolaney. Adjuvant Trastuzumab Emtansine Versus Paclitaxel plus Trastuzumab for Stage I HER2+ Breast Cancer: 5-year results and correlative analyses from ATEMPT (TBCRC033) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD18-01.
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Affiliation(s)
- Paolo Tarantino
- 1Breast Oncology Program, Dana-Farber Cancer Institute; Harvard Medical School, Boston, Massachusetts
| | | | | | - Denise Yardley
- 4Sarah Cannon Research Institute, Tennessee Oncology, Nashville, TN, USA
| | | | - Vicente Valero
- 6Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Therese Mulvey
- 8Massachusetts General Hospital North Shore Cancer Center
| | - Ron Bose
- 9Washington University in St Louis School of Medicine
| | | | | | | | - Hope Rugo
- 13University of California San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | | | - Kathy S. Albain
- 22Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center
| | | | - Nadine Tung
- 24Beth Israel Deaconess Medical Center, Boston
| | | | - Rita Nanda
- 26University of Chicago, Chicago, Illinois
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Giuseppe Viale
- 44European Institute of Oncology IRCCS, and University of Milan, Milan, Italy
| | | | | | | | | | - Ian Krop
- 49Yale School of Medicine, New Haven, Connecticut
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Ferraro E, Safonov A, Chen Y, White C, Marra A, Ahmed M, Acevedo B, Dang CT, Modi S, Solit DB, Norton L, Robson ME, Reis-Filho J, Chandarlapaty S, Razavi P. Abstract P4-02-01: Efficacy of HER2 ADCs against HER2 inhibitor resistance alterations in the PI3K and MAPK pathways in HER2-positive breast cancer. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p4-02-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: HER2 positive (HER2+) breast cancers harboring downstream MAPK or PI3K pathway alterations manifest persistent downstream signaling on anti-HER2 inhibitors with metastatic patients having worse outcomes on first line trastuzumab and pertuzumab (HP) therapy. However, HER2 antibody-drug conjugates (ADCs) are not as dependent upon potent signal transduction inhibition to exert their antitumor effects. To further investigate, we sought to determine whether MAPK and/or PI3K alterations affect the biologic or clinical outcomes of patients and models receiving HER2 ADCs. Methods: We performed prospective genomic sequencing using MSK-IMPACT on patients with advanced HER2+ breast cancer who received trastuzumab emtansine (T-DM1) in the metastatic setting between March 2013 and July 2021. We collected detailed information on clinical outcomes and correlates through our institutional IRB-approved retrieval process. HER2/ER/PR status at the time of metastatic recurrence were defined as per ASCO/CAP guidelines. Cox proportional hazard models were used to determine the association between MAPK and PI3K pathways alterations and progression-free survival (PFS) on T-DM1. Common mutations associated with outcomes were modeled in HER2+ breast cancer cell lines using short hairpin RNAs and CRISPR/Cas9, and the sensitivity to HER2 ADC was evaluated via cell proliferation and xenograft assays. Results: We identified 185 HER2+ breast cancer patients treated with T-DM1 at any line (median: 5) whose primary (N=65) or metastatic (N=120) tumor samples were sequenced. Median age was 55 (range: 20-87). The majority of the patients received T-DM1 in 2nd or 3rd line (52%) and received prior trastuzumab or HER2 TKI in metastatic setting (96%). 74/185 (40%) had de novo metastatic breast cancer and 119/185 (64%) had ER/PR+/HER2+ disease. Pathogenic activating alterations involving the MAPK pathway were observed in 14% of patients with the most frequent alterations being ERBB2 activating mutations (42%) and NF1 loss (34%). PI3K pathway alterations were identified in 42% of the patients, the majority being activating mutations of PIK3CA (87%). MAPK alterations were significantly enriched in the metastatic tumors compared to the treatment-naïve primaries (20% vs 3%, p=0.001), while PI3K alterations were not (44% vs 40%, p=0.6). To reduce the possible confounding resistance mechanisms induced by prior treatment, we restricted the survival analyses to patients who received T-DM1 up to 3rd line of therapy (N=100). On multivariable analysis adjusted for ER/PR status (positive vs negative), stage at the presentation of metastatic disease (de novo metastatic vs recurrence), treatment line and type of sequenced sample (primary vs metastatic), patients with MAPK (N=14) and PI3K (N= 38) alterations had similar PFS compared to wild type (HR 1.20, 95%CI 0.62-2.30, p=0.6 and HR 1.23, 95%CI 0.77-1.95, p=0.4, respectively). Similar results were found in the combined analysis including alterations in either pathway (N=48, HR 1.28, 95%CI 0.81-2.04, p=0.3). To verify the antiproliferative effect of HER2 ADCs on breast cancer cells with MAPK pathway activation, we depleted NF1 in a panel of HER2+ breast cancer cell lines. Consistently, MAPK-altered cell lines were sensitive to FDA-approved HER2 ADCs including trastuzumab deruxtecan (T-DXd). Conclusions: In contrast to H/P therapy, T-DM1 therapy was equally effective in tumors with downstream PI3K or MAPK alterations and wild type tumors. Expanded analysis on a larger cohort, including a subgroup of patients treated with novel HER2 ADCs such as T-DXd will be presented. The characterization of PI3K and MAPK pathways status in metastatic HER2+ breast cancer may inform prioritization of treatment options.
Citation Format: Emanuela Ferraro, Anton Safonov, Yuan Chen, Charlie White, Antonio Marra, Mehnaj Ahmed, Barbara Acevedo, Chau T Dang, Shanu Modi, David B. Solit, Larry Norton, Mark E. Robson, Jorge Reis-Filho, Sarat Chandarlapaty, Pedram Razavi. Efficacy of HER2 ADCs against HER2 inhibitor resistance alterations in the PI3K and MAPK pathways in HER2-positive breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-02-01.
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Affiliation(s)
| | | | - Yuan Chen
- 3Memorial Sloan Kettering Cancer Center
| | | | | | | | | | | | - Shanu Modi
- 9Memorial Sloan Cancer Center, New York, NY
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12
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Tolaney SM, Tarantino P, Graham N, Tayob N, Parè L, Villacampa G, Dang CT, Yardley DA, Moy B, Marcom PK, Albain KS, Rugo HS, Ellis MJ, Shapira I, Wolff AC, Carey LA, Barroso-Sousa R, Villagrasa P, DeMeo M, DiLullo M, Zanudo JGT, Weiss J, Wagle N, Partridge AH, Waks AG, Hudis CA, Krop IE, Burstein HJ, Prat A, Winer EP. Adjuvant paclitaxel and trastuzumab for node-negative, HER2-positive breast cancer: final 10-year analysis of the open-label, single-arm, phase 2 APT trial. Lancet Oncol 2023; 24:273-285. [PMID: 36858723 DOI: 10.1016/s1470-2045(23)00051-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND We aimed to report on long-term outcomes of patients with small, node-negative, HER2-positive breast cancer treated with adjuvant paclitaxel and trastuzumab and to establish potential biomarkers to predict prognosis. METHODS In this open-label, single-arm, phase 2 study, patients aged 18 years or older, with small (≤3 cm), node-negative, HER2-positive breast cancer, and an Eastern Cooperative Oncology Group performance status of 0-1, were recruited from 16 institutions in 13 cities in the USA. Eligible patients were given intravenous paclitaxel (80 mg/m2) with intravenous trastuzumab (loading dose of 4 mg/kg, subsequent doses 2 mg/kg) weekly for 12 weeks, followed by trastuzumab (weekly at 2 mg/kg or once every 3 weeks at 6 mg/kg) for 40 weeks to complete a full year of trastuzumab. The primary endpoint was 3-year invasive disease-free survival. Here, we report 10-year survival outcomes, assessed in all participants who received protocol-defined treatment, with exploratory analyses using the HER2DX genomic tool. This study is registered on ClinicalTrials.gov, NCT00542451, and is closed to accrual. FINDINGS Between Oct 29, 2007, and Sept 3, 2010, 410 patients were enrolled and 406 were given adjuvant paclitaxel and trastuzumab and included in the analysis. Mean age at enrolment was 55 years (SD 10·5), 405 (99·8%) of 406 patients were female and one (0·2%) was male, 350 (86·2%) were White, 28 (6·9%) were Black or African American, and 272 (67·0%) had hormone receptor-positive disease. After a median follow-up of 10·8 years (IQR 7·1-11·4), among 406 patients included in the analysis population, we observed 31 invasive disease-free survival events, of which six (19·4%) were locoregional ipsilateral recurrences, nine (29·0%) were new contralateral breast cancers, six (19·4%) were distant recurrences, and ten (32·3%) were all-cause deaths. 10-year invasive disease-free survival was 91·3% (95% CI 88·3-94·4), 10-year recurrence-free interval was 96·3% (95% CI 94·3-98·3), 10-year overall survival was 94·3% (95% CI 91·8-96·8), and 10-year breast cancer-specific survival was 98·8% (95% CI 97·6-100). HER2DX risk score as a continuous variable was significantly associated with invasive disease-free survival (hazard ratio [HR] per 10-unit increment 1·24 [95% CI 1·00-1·52]; p=0·047) and recurrence-free interval (1·45 [1·09-1·93]; p=0·011). INTERPRETATION Adjuvant paclitaxel and trastuzumab is a reasonable treatment standard for patients with small, node-negative, HER2-positive breast cancer. The HER2DX genomic tool might help to refine the prognosis for this population. FUNDING Genentech.
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Affiliation(s)
- Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Paolo Tarantino
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy; European Institute of Oncology IRCCS, Milan, Italy
| | - Noah Graham
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Nabihah Tayob
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | - Chau T Dang
- Solid Tumor Division, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Denise A Yardley
- Department of Medical Oncology, Sarah Cannon Cancer Center, Nashville, TN, USA
| | - Beverly Moy
- Department of Hematology-Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - P Kelly Marcom
- Department of Medicine, Division of Medical Oncology, Duke Cancer Institute, Durham, NC, USA
| | - Kathy S Albain
- Department of Medicine, Division of Hematology-Oncology, Loyola University Medical Center, Maywood, IL, USA
| | - Hope S Rugo
- Department of Medicine, Division of Oncology, University of California, San Francisco, CA, USA
| | - Matthew J Ellis
- Baylor Clinic Lester and Sue Smith Breast Center, Houston, TX, USA
| | - Iuliana Shapira
- Regional Cancer Care Associates, New Hyde Park, New York, NY, USA
| | - Antonio C Wolff
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Lisa A Carey
- Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | | | - Michelle DeMeo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Molly DiLullo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jorge Gomez Tejeda Zanudo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Broad Institute of MIT and Harvard, Boston, MA, USA
| | - Jakob Weiss
- Broad Institute of MIT and Harvard, Boston, MA, USA
| | - Nikhil Wagle
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Boston, MA, USA
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Adrienne G Waks
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Clifford A Hudis
- Solid Tumor Division, Memorial Sloan Kettering Cancer Center, New York, NY, USA; American Society of Clinical Oncology, Alexandria, VA, USA
| | - Ian E Krop
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Yale Cancer Center, New Haven, CT, USA
| | - Harold J Burstein
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Aleix Prat
- Reveal Genomics, Barcelona, Spain; Translational Genomics and Targeted Therapeutics in Solid Tumors, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Yale Cancer Center, New Haven, CT, USA
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Tolaney S, Tarantino P, Graham N, Tayob N, Dang CT, Yardley D, Moy B, Marcom PK, Albain KS, Rugo H, Ellis M, Shapira I, Wolff AC, Carey L, Barroso-Sousa R, DeMeo MK, DiLullo MK, Partridge A, Waks A, Hudis C, Krop I, Burstein H, Prat A, Winer E. Abstract PD18-02: Adjuvant Paclitaxel and Trastuzumab Trial (APT) for Node-Negative, Human Epidermal Growth Factor Receptor 2–Positive (HER2+) Breast Cancer: final 10-year analysis. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-pd18-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Abstract
Background: The APT trial evaluated the activity of adjuvant paclitaxel and trastuzumab (TH) among patients with small, node negative HER2+ breast cancer. This regimen showed a 7-year invasive disease-free survival (iDFS) of 93%, a recurrence-free interval (RFI) of 97.5% with only four (1.0%) distant recurrences, and a 7-year overall survival (OS) of 95%. In this end-of-study analysis, we report the survival outcomes at 10 years and assess the role of HER2DX testing in predicting long-term outcomes with adjuvant TH.
Methods: APT was a single-arm multicenter investigator-initiated phase II study in which patients with HER2+ breast cancer with tumors ≤3 cm and negative nodes (one single micrometastatic node allowed) received IV weekly paclitaxel (80 mg/m2) with IV weekly trastuzumab for 12 weeks, followed by IV trastuzumab for 9 months. The primary endpoint was 3-year iDFS. Here we report 10-year iDFS, RFI, breast cancer–specific survival (BCSS) and OS. In an exploratory analysis, the risk of recurrence was evaluated with the HER2DX genomic assay.
Results: A total of 410 patients were enrolled from October 2007 to September 2010, of which 406 started the study treatment and were included in the intent to treat analysis. Median age at enrollment was 55 years (range, 24 to 85 years), and most patients (67%) had hormone receptor (HR)-positive disease. Fifty percent of patients had tumors 1.0 cm or smaller and only 9% of patients had tumors between 2 cm to 3 cm. Mean tumor size was 1.1 cm. After a median follow-up of 10.2 years (122 months), 36 iDFS events were observed, consistent with a 10-year iDFS of 89.7% (95% CI, 86.3%-93.1%). Ten-year iDFS was 90.2% (95% CI, 86.3%-94.3%) and 88.5% (95% CI, 82.4%-95.1%) for patients with HR-positive and HR-negative tumors at baseline, respectively. 10-year RFI was 96.8% (95% CI, 95.0%-98.7%), 10-year OS was 94.2% (95% CI, 91.6%-96.8%) and 10-year BCSS was 99.1% (95% CI, 98.1%-100.0%). Of the iDFS events observed in the trial, 6 were non-breast cancer related deaths and 9 were contralateral tumors, all but one locally found to be HER2-negative upon biopsy (Table 1). Among patients experiencing an iDFS event, 7 patients (1.7%) had distant recurrences, including 1 with a T2 tumor, 3 with a T1c tumor and 3 with a T1b tumor. At baseline, 6 of them had HR-positive disease, 1 had HR-negative disease, and 6 had high-grade disease. Upon biopsy of metastatic lesions, 5 of the 7 distant recurrences were locally found to be HER2+, 1 was HER2-negative and 1 had unknown HER2 status. HER2DX testing was conducted on available baseline archival tumor tissue and analyses of patients’ survival outcomes based on the HER2DX score will be presented.
Conclusion: After 10 years of follow-up, adjuvant TH confirmed excellent long-term outcomes for small, node-negative HER2+ breast cancer, with a 10-year RFI of 96.8% and a 10-year BCSS of 99.1%.
Table 1: iDFS events with adjuvant paclitaxel plus trastuzumab after 10.2 years of follow up
Citation Format: Sara Tolaney, Paolo Tarantino, Noah Graham, Nabihah Tayob, Chau T Dang, Denise Yardley, Beverly Moy, Paul K. Marcom, Kathy S. Albain, Hope Rugo, Matthew Ellis, Iuliana Shapira, Antonio C. Wolff, Lisa Carey, Romualdo Barroso-Sousa, Michelle K. DeMeo, Molly K. DiLullo, Ann Partridge, Adrienne Waks, Clifford Hudis, Ian Krop, Harold Burstein, Aleix Prat, Eric Winer. Adjuvant Paclitaxel and Trastuzumab Trial (APT) for Node-Negative, Human Epidermal Growth Factor Receptor 2–Positive (HER2+) Breast Cancer: final 10-year analysis [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD18-02.
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Affiliation(s)
| | - Paolo Tarantino
- 2Breast Oncology Program, Dana-Farber Cancer Institute; Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Denise Yardley
- 6Sarah Cannon Research Institute, Tennessee Oncology, Nashville, TN, USA
| | | | | | - Kathy S. Albain
- 9Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center
| | - Hope Rugo
- 10University of California San Francisco, San Francisco, CA
| | | | | | | | - Lisa Carey
- 14UNC-Lindberger Comprehensive Cancer Center, Chapel Hill, NC
| | | | | | | | | | | | - Clifford Hudis
- 20American Society of Clinical Oncology, Alexandria, Virginia
| | - Ian Krop
- 21Yale School of Medicine, New Haven, Connecticut
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14
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Williams AD, Dang CT, Sevilimedu V, Morrow M, Barrio AV. Neoadjuvant Chemotherapy for Breast Cancer In the Elderly: Are We Accomplishing Our Treatment Goals? Ann Surg Oncol 2022; 29:8002-8011. [PMID: 35871672 PMCID: PMC10162805 DOI: 10.1245/s10434-022-12206-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 06/25/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Rates of downstaging and tolerability to NAC in women age ≥ 70 years with operable breast cancer have not been well studied. We sought to compare downstaging rates and NAC completion between women age 50-69 years and age ≥ 70 years. METHODS Consecutively treated women age ≥ 50 years with cT1-3N0-1 breast cancer receiving NAC followed by surgery from November 2013 to April 2020 were studied. Rates of downstaging from breast-conserving surgery (BCS)-ineligible to BCS-eligible and avoidance of axillary dissection (ALND) in cN1 patients were compared between patients age 50-69 and ≥ 70 years. NAC regimens and rates of completion also were assessed. RESULTS Overall, 651 women, age ≥ 50 years, with 668 cT1-3N0-1 breast cancers that were treated with NAC, were identified; 75 (11.1%) were age ≥ 70 years. Patients age ≥ 70 years were less likely to have lobular cancers (5% vs. 10%, p = 0.03), receive an anthracycline-based regimen (69% vs. 93%, p < 0.001), and complete their entire prescribed regimen (57% vs. 78%, p < 0.001). Of 312 BCS-ineligible patients eligible for downstaging, conversion rates to BCS-eligibility were similar between age groups (72% [≥ 70] vs. 74% [50-69], p > 0.9). Women age ≥ 70 years who converted to BCS-eligible post-NAC were more likely to undergo BCS than younger patients (93% vs. 74%, p = 0.04). Of 390 cN1 patients, 162 (42%) achieved a nodal pCR; ALND avoidance was similar between age groups (43% [≥ 70] vs. 42% [50-69], p > 0.9). CONCLUSIONS While patients age ≥ 70 years received less anthracycline-based NAC and were less likely to complete their prescribed regimen, they experienced high rates of breast and axillary downstaging, similar to younger patients, suggesting that well-selected elderly patients can safely receive NAC with substantial clinical benefit.
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Affiliation(s)
- Austin D Williams
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chau T Dang
- Breast Cancer Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Williams AD, Dang CT, Sevilimedu V, Morrow M, Barrio AV. ASO Visual Abstract: Neoadjuvant Chemotherapy for Breast Cancer in the Elderly-Are We Accomplishing Our Treatment Goals? Ann Surg Oncol 2022; 29:8014-8015. [PMID: 35902502 DOI: 10.1245/s10434-022-12282-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Austin D Williams
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chau T Dang
- Breast Cancer Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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16
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Dang CT, Tolaney SM, Riaz F, Tan AR, Tkaczuk KHR, Yu AF, Liu J, Fung AM, Yang A, Day BM, Rugo HS. Preliminary analysis of an expanded access study of the fixed-dose combination of pertuzumab (P) and trastuzumab (H) for subcutaneous injection (PH FDC SC) for at-home administration (admin) in patients (pts) with HER2-positive (HER2+) breast cancer (BC) during the COVID-19 pandemic. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.1515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1515 Background: Standard of care for HER2+ early/first-line metastatic BC (EBC/MBC) is P + H and concurrent chemotherapy (CT); PH FDC SC offers faster, more convenient admin vs intravenous (IV) P + H. COVID-19 has caused unprecedented strain on healthcare systems and disruption to cancer care; treatment (Tx) at home may: enable pts to continue cancer Tx; reduce exposure to COVID-19; free up hospital resources. This study’s main objectives: to enable continuity of care during COVID-19; to assess safety of PH FDC SC given at home. Methods: This is an ongoing single-arm, hybrid, decentralized clinical trial (NCT04395508). Pts with HER2+ EBC/MBC who completed concurrent CT with P + H IV and are receiving/about to receive maintenance P + H IV, PH FDC SC, or H SC are switched to PH FDC SC given at home by a home health nursing provider (HHNP) until disease progression, unacceptable toxicity, pt withdrawal, or physician recommendation (pts with EBC will complete ≤18 cycles). The study endpoint is safety. A subset of pts took part in HARRIET, a substudy of at-home cardiac surveillance with artificial intelligence-guided cardiac ultrasound and optional 6L ECG acquired by an HHNP. Results: Data for 114 pts (1 male) were available at cutoff (Jan 19, 2022): 18 (16%) completed Tx; 20 (18%) discontinued; 76 (67%) remain on study; 79 (69%) had a COVID-19 vaccine while on study. Median age was 49 years; pts were balanced between EBC (n = 55, 48%) and MBC (n = 59, 52%); received a median of 6 (EBC) and 8 (MBC) cycles; and were from metropolitan (n = 109), urban (n = 4), and rural (n = 1) areas. 11 pts tested COVID-19-positive during the Tx phase: 8 continued Tx after appropriate COVID-19 Tx and/or quarantine. Safety is summarized in the table. No new adverse events (AEs) emerged due to home admin. AEs of special interest were grade (gr) 1–2: admin-related reactions (n = 76, 67%), hypersensitivity (n = 5, 4%), cardiac dysfunction (n = 4, 4%), except 1 case of gr ≥3 diarrhea. AEs leading to study Tx discontinuation or interruption/dose reduction occurred in 3 (3%) and 15 (13%) pts. A subset of 7 pts completed at-home cardiac surveillance testing; quantitative assessment of left ventricular ejection fraction was feasible in 3 (43%); 5 (71%) preferred at-home surveillance to clinic. Conclusions: In this preliminary analysis, safety of PH FDC SC at home was consistent with the established P + H safety profile, indicating that PH FDC SC at home is a viable option for continuing BC care during and beyond COVID-19. Clinical trial information: NCT04395508. [Table: see text]
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Affiliation(s)
- Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Fauzia Riaz
- Stanford University, Division of Oncology, Stanford, CA
| | | | | | | | - Jennifer Liu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Anna Yang
- Genentech, Inc., South San Francisco, CA
| | | | - Hope S. Rugo
- University of California-San Francisco, San Francisco, CA
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Lacouture ME, Pan A, Dranitsaris G, Harris U, Chandarlapaty S, Dang CT, Gajria D, Gordon A, Iyengar NM, Robson ME, Razavi P, Rosen E, Wong STL, Jain M, Moy A, Markova A. Interim analysis of a single-center, single-arm, prospective phase 2 study to evaluate the efficacy and safety of benralizumab for alpelisib rash in metastatic PIK3CA-mutant, hormone receptor–positive breast cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.12100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12100 Background: Rash associated with increased peripheral eosinophils develops in approximately 50% of metastatic breast cancer patients receiving alpelisib. Antihistamines and corticosteroids have limited benefit. Refractory rash may lead to decreased dose intensity and affect clinical outcome. Benralizumab is an anti-IL-5Rα chimeric monoclonal antibody that depletes peripheral eosinophils and has demonstrated benefit in eosinophilic asthma and hypereosinophilic syndrome. We investigate the efficacy and safety of benralizumab for the treatment of alpelisib rash. Methods: We performed a single-center, single-arm, prospective phase 2 study to evaluate the efficacy and safety of benralizumab in cancer patients who developed CTCAE grade 2/3 skin events resulting from immunotherapy or targeted therapies with absolute blood eosinophil counts of ≥300/mcl. While remaining on culprit drugs, patients were treated with benralizumab 30mg once every 4 weeks for the first 3 doses followed by once every 8 weeks for 3 additional doses (approved dosing for eosinophilic asthma). Primary endpoint was clinical response measured as reduction in CTCAE grade 2/3 skin event to grade ≤1 by week 4. Secondary endpoints were patient quality of life (QoL) measured by skindex16, safety data, need for supportive oral corticosteroids, and changes in cytokines and eosinophil biomarkers. This interim analysis focuses on patients with PIK3CA-mutant metastatic breast cancer receiving alpelisib. Results: Between September 16th 2020 and January 1st 2022, we enrolled 10 metastatic breast cancer patients with grade 2/3 rash attributed to alpelisib (5 pts with G3). All patients had a reduction of rash to grade ≤1 (n = 10, p < 0.0001), and a decrease in peripheral absolute eosinophils (mean 500/mcl to 0, p < 0.0001). Of these, 6 patients had been on prophylactic oral antihistamines and 2 had oral steroid coadministration. QoL significantly improved (Skindex16 mean score 58 to 16, p = 0.0001) and eosinophils in skin histology decreased per HPF (mean 6.25 to 0.25, n = 8, p = 0.2) by week 4. An increase in IL-5 > 600% and reduction IL-6 and TNF-α > 50% were reported by week 4 and 8. Grade 1/2 mucositis in 4 patients were reported as adverse events. Conclusions: Our findings suggest that benralizumab is safe and effective for the treatment of grade 2/3 rash with eosinophilia related to alpelisib in patients with breast cancer. A reduction in rash severity was evidenced in all patients, along with improved QoL. Larger controlled studies are in development to evaluate the efficacy of benralizumab for the prevention of alpelisib rash. Clinical trial information: NCT04552288.
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Affiliation(s)
| | - Alexander Pan
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Devika Gajria
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Allison Gordon
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Neil M. Iyengar
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Pedram Razavi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ezra Rosen
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Manu Jain
- Memorial Sloan Kettering Cancer Center, Manhattan, NY
| | - Andrea Moy
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alina Markova
- Memorial Sloan Kettering Cancer Center, New York, NY
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Moore ZR, Yu AF, Liu J, Dang CT, Oeffinger KC, Steingart R, Schmitt A. Quantification of methylation-specific cardiomyocyte cell-free DNA as an early marker of cardiotoxicity in patients with breast cancer receiving anthracyclines and trastuzumab. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.12090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12090 Background: There is currently no way to reliably predict which patients undergoing therapy for breast cancer will develop cardiotoxicity. An early biomarker of cardiotoxicity could provide opportunity for intervention prior to the appearance of gross abnormalities on echocardiogram (ECHO). A droplet digital PCR (ddPCR) assay for circulating cell-free DNA (cfDNA) can detect cfDNA released from dying cardiomyocytes with high sensitivity by differentiating cfDNA of cardiomyocyte origin based on the pattern of methylation specific to the cell type. Circulating cfDNA of cardiac origin was tested as an early biomarker of toxicity in patients who underwent breast cancer treatment while closely monitoring cardiac function in a prospective clinical trial. Methods: A cardiomyocyte methylation-specific quantitative ddPCR assay was tested in plasma samples from 29 patients who were part of a larger prospectively enrolled cohort of women who received anthracyclines and trastuzumab for HER2-positive breast cancer. Blood samples were tested from prior to doxorubicin and cyclophosphamide (AC) chemotherapy, two months later after completing AC and prior to trastuzumab, and every 3 months to 12 months post-treatment. Patients were assessed for clinical cardiotoxicity, defined as heart failure (NYHA class III/IV) or significant EF decline (> = 10% to below 53% or > = 16%) until completion of cancer therapy. The maximum detected level of cardiac cfDNA (copies per 500 µL plasma) was compared between those who experienced cardiotoxicity and those who did not by two-sided T-tests. Results are reported as mean +/- standard deviation. Results: At baseline, cardiac cfDNA levels were low (mean 1.1 +/- 2.4 copies). Of 29 patients, five developed clinical cardiotoxicity. The maximum number of cfDNA copies at any time point was elevated in patients who experienced cardiotoxicity compared to those who did not (mean of 20.6 +/- 7.3 copies versus 9.3 +/- 9.8 copies, p = 0.0216). Of the patients with cardiotoxicity, elevated cfDNA of greater than 10 copies was detected an average of 3.6 +/- 2.5 months prior to the onset of clinical cardiotoxicity. Conclusions: Methylation specific cardiac cfDNA shows promise as an early indicator of cardiotoxicity in patients treated with anthracyclines in this pilot study. A previously reported analysis in the levels of seven other biomarkers including high-sensitivity troponin I and NT-proBNP pre- versus post-treatment in the full cohort of 80 patients did not show any statistically significant associations with the development of cardiotoxicity, suggesting that cardiac cfDNA may be uniquely informative. Clinical trial information: NCT02177175.
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Affiliation(s)
| | | | - Jennifer Liu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Adam Schmitt
- Memorial Sloan Kettering Cancer Center, New York, NY
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Bellon JR, Tayob N, Yang DD, Tralins J, Dang CT, Isakoff SJ, DeMeo M, Burstein HJ, Partridge AH, Winer EP, Krop IE, Tolaney SM. Local Therapy Outcomes and Toxicity From the ATEMPT Trial (TBCRC 033): A Phase II Randomized Trial of Adjuvant Trastuzumab Emtansine Versus Paclitaxel in Combination With Trastuzumab in Women With Stage I HER2-Positive Breast Cancer. Int J Radiat Oncol Biol Phys 2022; 113:117-124. [PMID: 34990776 DOI: 10.1016/j.ijrobp.2021.12.173] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/21/2021] [Accepted: 12/28/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE Human epidermal growth factor receptor 2 (HER2)-directed therapy improves local control among women with HER2-positive breast cancer. This retrospective analysis evaluates the safety and efficacy of radiation therapy (RT) among patients receiving adjuvant trastuzumab emtansine (T-DM1) or paclitaxel (T) plus trastuzumab (H) in the ATEMPT (Adjuvant Trastuzumab Emtansine Versus Paclitaxel in Combination With Trastuzumab) trial; Translational Breast Cancer Research Consortium (TBCRC) 033. METHODS AND MATERIALS Patients with stage I HER2-positive breast cancer were randomized 3:1 to receive adjuvant T-DM1 or TH after mastectomy or breast-conserving surgery (BCS). Breast RT was required after BCS and permitted after mastectomy. Patients receiving T-DM1 began RT after 12 weeks of therapy and received RT concurrently with T-DM1. Patients receiving TH began RT after paclitaxel, but concurrent with trastuzumab. RT records were retrospectively reviewed to determine details of radiation delivery and acute RT-related toxicity. RESULTS Protocol therapy was initiated by 497 patients. Among the 299 BCS patients, 289 received whole breast RT (WBRT) and 10 partial breast. Among WBRT patients, 40.2% in the T-DM1 arm and 41.5% of TH patients received hypofractionated (≥2.5 Gy/fraction) RT. Eight mastectomy patients received RT, all conventional fractionation. Skin toxicity (grade ≥2) was seen in 33.9% of patients in the T-DM1 arm and 23.2% in the TH arm (P = .11). In conventionally fractionated WBRT patients, 44.7% had a grade ≥2 skin toxicity compared with 17.9% of patients receiving hypofractionation (P < .001). Five patients experienced pneumonitis after RT (T-DM1: n = 4, 1.0%; TH: n = 1, 0.9%). Three-year invasive disease-free survival was 97.8% for T-DM1 (95% confidence interval, 96.3-99.3) and 93.4% for TH (95% confidence interval, 88.7-98.2). Among the 18 invasive disease-free survival events, 7 were isolated locoregional recurrences (2, T-DM1; 5, TH). CONCLUSIONS RT was well-tolerated when given concurrently with either T-DM1 or TH. Among BCS patients, hypofractionation resulted in lower grade ≥2 acute skin toxicity even with concurrent anti-HER2 therapy. Although follow-up was short, local recurrences were uncommon, attesting to the efficacy of HER2-directed therapy combined with RT.
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Affiliation(s)
- Jennifer R Bellon
- Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Nabihah Tayob
- Harvard Medical School, Boston, Massachusetts; Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - David D Yang
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts
| | | | - Chau T Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Steven J Isakoff
- Harvard Medical School, Boston, Massachusetts; Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michelle DeMeo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Harold J Burstein
- Harvard Medical School, Boston, Massachusetts; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ann H Partridge
- Harvard Medical School, Boston, Massachusetts; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Eric P Winer
- Harvard Medical School, Boston, Massachusetts; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ian E Krop
- Harvard Medical School, Boston, Massachusetts; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sara M Tolaney
- Harvard Medical School, Boston, Massachusetts; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Ferraro E, Singh J, Patil S, Razavi P, Modi S, Chandarlapaty S, Barrio AV, Malani R, Mellinghoff IK, Boire A, Wen HY, Brogi E, Seidman AD, Norton L, Robson ME, Dang CT. Incidence of brain metastases in patients with early HER2-positive breast cancer receiving neoadjuvant chemotherapy with trastuzumab and pertuzumab. NPJ Breast Cancer 2022; 8:37. [PMID: 35319017 PMCID: PMC8940915 DOI: 10.1038/s41523-022-00380-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 11/01/2021] [Indexed: 11/12/2022] Open
Abstract
The addition of pertuzumab (P) to trastuzumab (H) and neoadjuvant chemotherapy (NAC) has decreased the risk of distant recurrence in early stage HER2-positive breast cancer. The incidence of brain metastases (BM) in patients who achieved pathological complete response (pCR) versus those who do not is unknown. In this study, we sought the incidence of BM in patients receiving HP-containing NAC as well as survival outcome. We reviewed the medical records of 526 early stage HER2-positive patients treated with an HP-based regimen at Memorial Sloan Kettering Cancer Center (MSKCC), between September 1, 2013 to November 1, 2019. The primary endpoint was to estimate the cumulative incidence of BM in pCR versus non-pCR patients; secondary endpoints included disease free-survival (DFS) and overall survival (OS). After a median follow-up of 3.2 years, 7 out of 286 patients with pCR had a BM while 5 out of 240 non-pCR patients had a BM. The 3-year DFS was significantly higher in the pCR group compared to non-pCR group (95% vs 91 %, p = 0.03) and the same trend was observed for overall survival. In our cohort, despite the better survival outcomes of patients who achieved pCR, we did not observe appreciable differences in the incidence of BM by pCR/non-pCR status. This finding suggests that the BM incidence could not be associated with pCR. Future trials with new small molecules able to cross the blood brain barrier should use more specific biomarkers rather than pCR for patients' selection.
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Affiliation(s)
- Emanuela Ferraro
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jasmeet Singh
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Pedram Razavi
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine College, New York, NY, USA
| | - Shanu Modi
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine College, New York, NY, USA
| | - Sarat Chandarlapaty
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine College, New York, NY, USA
| | - Andrea V Barrio
- Breast Cancer Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rachna Malani
- Brain Tumor Center, Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ingo K Mellinghoff
- Brain Tumor Center, Human Oncology and Pathogenesis Program, Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Adrienne Boire
- Brain Tumor Center, Human Oncology and Pathogenesis Program, Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hannah Y Wen
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edi Brogi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew D Seidman
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine College, New York, NY, USA
| | - Larry Norton
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine College, New York, NY, USA
| | - Mark E Robson
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine College, New York, NY, USA
| | - Chau T Dang
- Breast Cancer Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medicine College, New York, NY, USA.
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21
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Ferraro E, Safonov A, Wen HY, Brogi E, Gonan M, Barrio AV, Razavi P, Chandarlapaty S, Modi S, Seidman AD, Norton L, Robson ME, Dang CT. Abstract P2-13-06: Clinical implication of HER2 status change after neoadjuvant chemotherapy with Trastuzumab and Pertuzumab (HP) in patients with HER2-positive breast cancer. Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-p2-13-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Patients with early HER2-positive breast cancer (BC) and residual disease after HER2-targeted neoadjuvant chemotherapy (NAC) are at high risk of recurrence. It is estimated that 10-30% of HER2-positive breast cancers change HER2 status after trastuzumab alone, but the effects of adding pertuzumab on this phenomenon and clinical outcomes remain unclear. We previously reported a high rate (~50%) of HER2 status change after HP in a small subset of patients. Herein, we present an updated analysis incorporating pathological review of additional cases.Methods: We identified patients with HER2-positive BC who received NAC with pertuzumab and trastuzumab (NAC-HP) followed by surgery at our institution between September 1, 2013 to November 1, 2019. Patients with HER2 status performed either at MSKCC or outside institutions were included. Change in HER2 status on residual disease from baseline was evaluated. We defined HER2 positivity as immunohistochemistry (IHC) IHC3+ or IHC0-2+ FISH amplified (ratio ≥ 2 or ratio < 2 and HER2 copy number ≥ 6 signals/cell). HER2-low was defined as IHC 1+ or 2+, FISH non-amplified. Disease free survival (DFS) and overall survival (OS) were analyzed using the Kaplan-Meier method. Differences between patients with concordant and discordance HER2 status were assessed using the log-rank test.Results: Of 525 patients receiving NAC with HP, 229 (44%) patients had residual disease post NAC-HP. Among these 229 patients, 141 had both pre and post NAC-HP HER2 status available and were included in this analysis. HER2 status on biopsy specimens was determined at MSKCC in 35/141 (25%) and at external institution in 106/141 (75%). The majority of patients (84%) received dose-dense AC-THP; the remainder received TCHP or other HP-based regimens. Most (96%) of patients continued HP after surgery, and 2 patients received T-DM1. Of the 141 patients, 84/141(60%) were found to be HER2 concordant, while 57 (40%) were found to be HER2 discordant. In 13/57 (23%) patients, HER2 expression was lost (IHC 0), while in 44/57 (77%) patients, HER2-low profile was detected (IHC 1+ in 31, and IHC 2+, FISH non-amplified in 13). Further details are reported in the table. Patients with HER2 discordance after NAC-HP had similar survival outcome compared with patients who remained HER2 concordant (5-years DFS: 92.3% versus 88.7%, p=0.49 and 5-yr OS 93.6% versus 88.4%, p=0.70).Conclusions: In a single center cohort, discordant HER2 status after NAC-HP appeared frequently without statistically significant impact on survival outcome, although this finding may be due to the small size and hence low statistical power. Of these, HER2-low profile is the most frequent post treatment HER2 status change. This raises the possibility that patients with change in HER2 status may have heterogenous expression of HER2 at baseline, and HER2-loss or low sub-clones survive as residual disease due to the selection pressure of HP. Alternatively, anti-HER2 therapy may suppress HER2 expression in surviving cells. These findings could inform studies of tailored approaches in the post-neoadjuvant setting based on the biological profile of residual disease.
Pre NAC-HP HER2 statusNPost NAC-HP HER2 statusNDiscordantN=57IHC 3+: 19IHC0: 4IHC1+: 9IHC2+ FISH not ampl: 6IHC 0-2+ FISH ampl: 38IHC0: 9IHC1+: 22IHC2+ FISH not ampl: 7Concordant N= 84IHC 3+: 59IHC 3+: 47IHC 0- 2+ FISH ampl: 12IHC 0-2+ FISH ampl: 25IHC 3+: 4IHC 0- 2+ FISH ampl: 21
Citation Format: Emanuela Ferraro, Anton Safonov, Hanna Y Wen, Edi Brogi, Mithat Gonan, Andrea V. Barrio, Pedram Razavi, Sarat Chandarlapaty, Shanu Modi, Andrew D. Seidman, Larry Norton, Mark E. Robson, Chau T. Dang. Clinical implication of HER2 status change after neoadjuvant chemotherapy with Trastuzumab and Pertuzumab (HP) in patients with HER2-positive breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-13-06.
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Affiliation(s)
| | - Anton Safonov
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hanna Y Wen
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Edi Brogi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gonan
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Pedram Razavi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Shanu Modi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Larry Norton
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
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22
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Ferraro E, Smith A, Safonov A, De Lara PT, Bernado' C, Lahuerta EJA, Arribas J, Solit D, Reis-Filho JS, Rosen N, Norton L, Modi S, Robson ME, Dang CT, Curigliano G, Chandarlapaty S, Razavi P. Abstract GS3-03: Genomic analysis of 733 HER2+ breast cancers identifies recurrent pathways alterations associated with anti-HER2 resistance and new therapeutic vulnerabilities. Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-gs3-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background:The introduction of anti-HER2 therapies, trastuzumab and pertuzumab (HP) to the treatment of metastatic HER2-positive breast cancer has had a transformational impact on the outcomes for this disease. Nevertheless, disease progression is ultimately observed in most patients within 3 years carrying the potential for morbidity and potentially more toxic therapies. To identify selective strategies to prevent disease progression, we sought to elucidate mechanisms of resistance to anti-HER2 therapies by analyzing a large cohort of genomically and clinically annotated HER2+ breast cancers. Methods: Patients with advanced HER2+ breast cancer who underwent prospective clinical tumor sequencing utilizing MSK-IMPACT assay between April 2014 and February 2021 were included in the analysis. Clinical HER2 positivity was defined as per ASCO/CAP guidelines. Cox proportional hazard models were used to determine the association between genomic alterations and progression-free survival (PFS) on 1st line HP and taxane-based therapy (THP). Only patients with a sequenced pre-treatment tumor sample were included in the survival analysis. Recurrent mutations identified were modeled in HER2+ breast cancer cell lines using short hairpin RNAs and CRISPR/Cas9, and the sensitivity of these isogenic pairs to HER2-targeted therapies was evaluated via metabolic and colony formation assays of cell proliferation. Results: We identified 733 ERBB2-amplified primary (n=385) and metastatic (n=348) that underwent sequencing. Concurrent PIK3CA mutations were identified in 30% of the tumors. Pathogenic activating alterations involving the MAPK pathway were observed in 12.8% of tumors with the most frequent alterations being NF1 loss, ERBB2 and RAS activating mutations. MAPK alterations were significantly enriched in the metastatic tumors (16.6%) compared to the treatment-naïve primaries (9.8%, p=0.020). The outcome analysis included 145 patients with advanced clinically HER2+ breast cancer whose tumors were sequenced prior to starting 1st line THP. Twenty percent (29/145) of tumors did not show genomic ERBB2 amplification as detected by NGS and had a significantly worse outcome (median PFS of 9.4 months [95% CI 5.5-19] and 23 months [95% CI 17-30], respectively; p=0.015). PIK3CA mutations were also associated with a shorter PFS (mutant: 13 months [95%CI: 7.7-18] vs wild type: 23 months [95%CI 17-16], p=0.0013). We further found reduced PFS in MAPK altered tumors (median PFS 9.9 months; 95% CI: 5.5-17) compared to the rest of the population (median PFS 21 months; 95% CI: 17-30; p=0.01). On multivariable analysis adjusted for estrogen receptor status, and presence of PIK3CA/AKT1/PTEN mutations and genomic ERBB2 amplification, MAPK pathway alterations were independently associated with worse outcome (HR: 2.25; 95% CI: 1.29, 3.93; multivariate p = 0.0043). To establish a causal role for MAPK alterations in reducing efficacy of anti-HER2 therapy, we depleted NF1 expression or expressed mutant KRAS or BRAF in a panel of HER2+ breast cancer cell lines. Consistently, MAPK-altered cell lines exhibited resistance to FDA approved HER2 inhibitors in vitro and in vivo. Conclusions: This clinicogenomic analysis of mechanisms of resistance to anti-HER2 therapy demonstrated that PIK3CA activating mutations and lack of genomic ERBB2 amplification as detected by tumor sequencing are associated with shortened PFS on HP-based therapy. Our analysis uniquely identified MAPK pathway alterations as additional potential drivers of resistance to anti-HER2 therapy. Inhibition of the PI3K or MAPK pathway in such tumors may represent a new therapeutic strategy to extend H/P benefit.
Citation Format: Emanuela Ferraro, Alison Smith, Anton Safonov, Paulino Tallon De Lara, Cristina Bernado', Enrique J. Arenas Lahuerta, Joaquín Arribas, David Solit, Jorge S. Reis-Filho, Neal Rosen, Larry Norton, Shanu Modi, Mark E. Robson, Chau T. Dang, Giuseppe Curigliano, Sarat Chandarlapaty, Pedram Razavi. Genomic analysis of 733 HER2+ breast cancers identifies recurrent pathways alterations associated with anti-HER2 resistance and new therapeutic vulnerabilities [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr GS3-03.
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Affiliation(s)
| | - Alison Smith
- Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Anton Safonov
- Memorial Sloan Kettering Cancer Center, New York City, NY
| | | | | | | | | | - David Solit
- Memorial Sloan Kettering Cancer Center, New York City, NY
| | | | - Neal Rosen
- Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Larry Norton
- Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Shanu Modi
- Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Mark E. Robson
- Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York City, NY
| | | | | | - Pedram Razavi
- Memorial Sloan Kettering Cancer Center, New York City, NY
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Sparano JA, O’Neill A, Graham N, Northfelt DW, Dang CT, Wolff AC, Sledge GW, Miller KD. Inflammatory cytokines and distant recurrence in HER2-negative early breast cancer. NPJ Breast Cancer 2022; 8:16. [PMID: 35136076 PMCID: PMC8825796 DOI: 10.1038/s41523-021-00376-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 12/07/2021] [Indexed: 01/14/2023] Open
Abstract
Systemic inflammation is believed to contribute to the distant recurrence of breast cancer. We evaluated serum samples obtained at diagnosis from 249 case:control pairs with stage II-III Her2-negative breast cancer with or without subsequent distant recurrence. Conditional logistic regression analysis, with models fit via maximum likelihood, were used to estimate hazard ratios (HRs) and test for associations of cytokines with distant recurrence risk. The only biomarker associated with a significantly increased distant recurrence risk when adjusted for multiple testing was the proinflammatory cytokine IL-6 (HR 1.37, 95% confidence intervals [CI] 1.15, 1.65, p = 0.0006). This prospective-retrospective study provides evidence indicating that higher levels of the cytokine IL-6 at diagnosis are associated with a significantly higher distant recurrence risk.
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Affiliation(s)
- Joseph A. Sparano
- grid.59734.3c0000 0001 0670 2351Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY USA
| | - Anne O’Neill
- grid.65499.370000 0001 2106 9910Dana Farber Cancer Institute ECOG-ACRIN Biostatistics Center, Boston, MA USA
| | - Noah Graham
- grid.65499.370000 0001 2106 9910Dana Farber Cancer Institute ECOG-ACRIN Biostatistics Center, Boston, MA USA
| | | | - Chau T. Dang
- grid.51462.340000 0001 2171 9952Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Antonio C. Wolff
- grid.280502.d0000 0000 8741 3625Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD USA
| | - George W. Sledge
- grid.168010.e0000000419368956Stanford Cancer Center, Palo Alto, CA USA
| | - Kathy D. Miller
- grid.257413.60000 0001 2287 3919Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN USA
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24
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Rosenberg SM, O’Neill A, Sepucha K, Miller KD, Dang CT, Northfelt DW, Sledge GW, Schneider BP, Partridge AH. Quality of Life Following Receipt of Adjuvant Chemotherapy With and Without Bevacizumab in Patients With Lymph Node-Positive and High-Risk Lymph Node-Negative Breast Cancer. JAMA Netw Open 2022; 5:e220254. [PMID: 35226083 PMCID: PMC8886546 DOI: 10.1001/jamanetworkopen.2022.0254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
IMPORTANCE Breast cancer treatment can impact not only short-term health but may also affect longer-term quality of life (QOL). OBJECTIVE To describe and evaluate factors associated with diminished QOL following completion of active treatment. DESIGN, SETTING, AND PARTICIPANTS This was a secondary analysis of a randomized clinical trial included patients with lymph node-positive or high-risk lymph node-negative breast cancer who had undergone definitive surgery and were enrolled in ECOG-ACRIN E5103, a multisite phase 3 trial. A survey was administered 18 months after enrollment to patients enrolled between January and June 2010. Final analysis of the data took place from March to December 2021. INTERVENTIONS Patients received adjuvant doxorubicin, cyclophosphamide, and paclitaxel with either bevacizumab or placebo. MAIN OUTCOMES AND MEASURES QOL and health status assessed with the EuroQol 5-Dimension 3-Levels (EQ-5D-3L), EQ-visual analog scale (EQ-VAS), and the Functional Assessment of Cancer Therapy-Breast Cancer, with arm subscale (FACT-B+4). Groups were compared by Fisher exact test, Wilcoxon rank sum, or Kruskal-Wallis test. Multivariable linear regression was used to assess factors independently associated with FACT-B scores. RESULTS Data at 18 months were available from 455 of 519 patients (87.7%) enrolled in the trial. Median (range) age at enrollment was 52 (25-76) years. No differences in QOL (median [range] FACT-B scores: group A, 123 [67-146]; group B, 114 [54-148]; group C, 117 [42-148]; P = .23) or health status (median [range] EQ-5D-3L index scores: group A, 0.83 [0.28-1.00]; group B, 0.83 [0.20-1.00]; group C, 0.83 [0.17-1.00], P = .80; median EQ-VAS: group A, 85 [20-100]; group B, 85 [0-100]; group C, 85 [0-100]; P = .79) were observed across treatment groups; results for subsequent analyses were therefore reported irrespective of primary treatment. Overall, half of patients (258 of 444 [58%]) reported at least some pain or discomfort; 170 (38%) reported symptoms of anxiety or depression. In multivariable analyses, mastectomy with radiation (vs breast conserving surgery) and Asian, Black, or American Indian or Alaska Native race (vs White race) were associated with lower QOL (mastectomy with radiation: coefficient: -5.5; 95% CI, -10.1 to -0.9; Asian, Black, or American Indian or Alaska Native race: coefficient: -7.3; 95% CI, -13.2, -1.4). CONCLUSIONS AND RELEVANCE In this study, the addition of bevacizumab to chemotherapy was not negatively associated with QOL at 18 months. A substantial proportion of participants reported problems related to pain or discomfort and anxiety or depression, demonstrating persistent consequences for physical and psychosocial well-being in this heavily treated population. Many problems reported are amenable to intervention, underscoring the need for timely referral to supportive resources, especially for women of color and those who have more extensive local therapy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00433511.
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Affiliation(s)
| | - Anne O’Neill
- Dana-Farber Cancer Institute, Boston, Massachusetts
- ECOG-ACRIN Biostatistics Center, Boston, Massachusetts
| | | | | | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - George W. Sledge
- Indiana University, Indianapolis
- Stanford University, Stanford, California
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25
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Ruddy KJ, Zheng Y, Tayob N, Hu J, Dang CT, Yardley DA, Isakoff SJ, Valero VV, Faggen MG, Mulvey TM, Bose R, Sella T, Weckstein DJ, Wolff AC, Reeder-Hayes KE, Rugo HS, Ramaswamy B, Zuckerman DS, Hart LL, Gadi VK, Constantine M, Cheng KL, Briccetti FM, Schneider BP, Merrill Garrett A, Kelly Marcom P, Albain KS, DeFusco PA, Tung NM, Ardman BM, Nanda R, Jankowitz RC, Rimawi M, Abramson V, Pohlmann PR, Van Poznak C, Forero-Torres A, Liu MC, Rosenberg S, DeMeo MK, Burstein HJ, Winer EP, Krop IE, Partridge AH, Tolaney SM. Chemotherapy-related amenorrhea (CRA) after adjuvant ado-trastuzumab emtansine (T-DM1) compared to paclitaxel in combination with trastuzumab (TH) (TBCRC033: ATEMPT Trial). Breast Cancer Res Treat 2021; 189:103-110. [PMID: 34120223 DOI: 10.1007/s10549-021-06267-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Chemotherapy-related amenorrhea (CRA) is a surrogate for ovarian toxicity and associated risk of infertility and premature menopause. Here, we compare CRA rate with paclitaxel (T)-trastuzumab (H) to that with ado-trastuzumab emtansine (T-DM1). METHODS Patients with T1N0 HER2 + early-stage breast cancer (eBC) enrolled on the ATEMPT trial and were randomized 3:1 to T-DM1 3.6 mg/kg IV every (q) 3 weeks (w) × 17 vs. T 80 mg/m2 with H IV qw × 12 (4 mg/kg load → 2 mg/kg), followed by H (6 mg/kg IV q3w × 13). Enrollees who self-reported as premenopausal were asked to complete menstrual surveys at baseline and every 6-12 months for 60 months. 18-month CRA (no periods reported during prior 6 months on 18-month survey) was the primary endpoint of this analysis. RESULTS Of 512 ATEMPT enrollees, 123 who began protocol therapy and answered baseline and at least one follow-up menstrual survey were premenopausal at enrollment. 76 had menstrual data available at 18 months without having received a gonadotropin-releasing hormone agonist or undergone hysterectomy and/or oophorectomy. Median age was 45 (range 23-53) among 18 who had received TH and 46 (range 34-54) among 58 who had received T-DM1. The 18-month rate of CRA was 50% after TH and 24% after T-DM1 (p = 0.045). CONCLUSION Amenorrhea at 18 months was less likely in recipients of adjuvant T-DM1 than TH. Future studies are needed to understand how T-DM1 impacts risk of infertility and permanent menopause, and to assess amenorrhea rates when T-DM1 is administered after standard HER2-directed chemotherapy regimens.
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Affiliation(s)
- Kathryn J Ruddy
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Yue Zheng
- Dana-Farber Cancer Institute, Boston, USA
| | | | - Jiani Hu
- Dana-Farber Cancer Institute, Boston, USA
| | - Chau T Dang
- Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | | | | | | | - Ron Bose
- Siteman Cancer Center, St. Louis, USA
| | - Tal Sella
- Dana-Farber Cancer Institute, Boston, USA
| | | | | | | | - Hope S Rugo
- Diller Family Comprehensive Cancer Center, University of California San Francisco Helen, San Francisco, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Rachel C Jankowitz
- Penn Medicine Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mothaffar Rimawi
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | | | - Paula R Pohlmann
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | | | | | - Minetta C Liu
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | | | | | | | - Ian E Krop
- Dana-Farber Cancer Institute, Boston, USA
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26
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Ferraro E, Razavi P, Chandarlapaty S, Modi S, Wen HY, Brogi E, Norton L, Robson ME, Dang CT. Change in HER2 status after neoadjuvant chemotherapy (NAC) with trastuzumab and pertuzumab (HP) in patients with HER2-positive early-stage breast cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e12614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e12614 Background: Combination of HP with NAC in the neoadjuvant setting leads to an high rate of pathological complete response (pCR) in patients with stage II-III HER2+ breast cancer (BC). The rate of change in HER2-status after NAC reported in literature is between 10-30%, although NAC comprises a various regimens, and the clinical significance of this phenomenon is unclear. Methods: We extracted data on patients with HER2+ BC treated with NAC and HP between September 1, 2013 to November 1, 2019. Only patients with internally verified HER2 status at our center were enrolled. The rate of pCR (ypT0/is ypN0) and the change in HER2 status on residual disease from baseline were evaluated. We used standard definition of HER2 status based on ASCO/CAP guidelines 2018. HER2-low was defined as immunohistochemistry (IHC) 1+ or 2+, FISH non-amplified. Results: Overall, 130 pts were identified. All patients received dose-dense AC-THP, except for 13 patients who received TCHP or other HP-based regimens. The pCR was achieved in 77/130 (59%) of patients and 53/130 (41%) had residual disease. Among 53 patients with residual disease, HER2 status was analyzed in 25 patients and was pending on the remaining patients. In the 25 analyzed patients, 13 had HER2-loss in residual disease. In 4/13 patients, HER2 expression was lost (IHC 0); in 9/13 patients, HER2-low profile was found (IHC 1+ in 6 patients, and IHC 2+, FISH non-amplified in 3). Details on HER2 status change are described in the table below. Conversely, 12/25 had concordant HER2 status after NAC. Conclusions: At single center, the change in HER2 status after NAC with HP appeared frequent. Pathological review of additional cases is ongoing. The clinical significance is still unclear but may open the possibility to investigate tailored approach in post-neoadjuvant setting based on the biological profile of residual disease. [Table: see text]
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Affiliation(s)
| | - Pedram Razavi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Shanu Modi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hannah Yong Wen
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Edi Brogi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Larry Norton
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
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27
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Sparano JA, O'Neill AM, Graham N, Northfelt DW, Dang CT, Wolff AC, Sledge GW, Miller K. Inflammatory cytokines and distant recurrence in HER2-negative early breast cancer in the ECOG-ACRIN 5103 trial. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
520 Background: Systemic inflammation may contribute to cancer progression (PMC2803035), including recurrence of early breast cancer (PMC4828958). We hypothesized that inflammatory cytokines and/or chemokines may be associated with distant recurrence (DR). Methods: We performed a case:control study in women with stage II-III Her2-negative breast cancer, all of whom had surgery and adjuvant chemotherapy (doxorubicin/cyclophosphamide, then weekly paclitaxel) with/without bevacizumab, plus endocrine therapy if ER-positive (PMC6118403). Propensity score matching was used to identify approximately 250 case:control pairs (with/without DR). Serum samples obtained before adjuvant chemotherapy were analyzed using the MSD V-Plex Human Cytokine 36-Plex Kit for detection of human cytokines and chemokines involved in the Th1/Th2 pathway, chemotaxis, the Th17 pathway, angiogenesis, and immune system regulation. Conditional logistic regression analysis, with models fit via maximum likelihood, were used to estimate hazard ratios (HRs) and test for associations. Due to skewed nature of cytokines, HRs are reported on log base 2 scale. If adjusted for multiple testing including 36 markers, a p value of < 0.0014 would be required for statistical significance. Results: A total 249 matched pairs (498 patients) were identified. Covariates used for propensity score matching included age, menopausal status (post 54% vs. pre/peri 46%), ER/PR status (one/both pos 64% vs. both neg 36%) tumor size ( < = 2cm 17%, > 2-5cm 67%, > 5cm 16%) nodal status (neg 15%,1-3+ 32%, 4+ 53%), and grade (low 3%, int. 31%, high 66%). The only biomarker associated with a significantly increased DR risk when adjusted for multiple testing was the proinflammatory cytokine IL-6 (HR 1.37, 95% confidence intervals [CI] 1.15, 1.65, p = 0.0006). Others associated with a 2-sided p value < 0.05 included the chemokine MDC(macrophage-derived chemokine/CCL22) (1.90, 95% CI 1.17, 3.1, p = 0.0098), the T helper cell inflammatory cytokine IL-17A (HR 1.36, 95% CI 1.10, 1.67, p = 0.0052), and the cytokine VEGF-A (HR 1.13 for, 95% CI 1.01, 1.27, p = 0.037). There was no statistical interaction between VEGF-A and bevacizumab benefit. The median and mean value for IL-6 was 0.95 and 7.5 pg/ml (range 0.04-2761.24 pg/ml). Conclusions: This analysis provides level 1B evidence indicating that higher levels of the cytokine IL-6 at diagnosis are associated with a significantly higher DR risk in high-risk stage II-III breast cancer despite optimal adjuvant systemic therapy. This provides a foundation for confirmatory validation of IL-6 as a prognostic biomarker, and potentially as a predictive biomarker for testing therapeutic interventions targeting the IL-6/JAK/STAT3 pathway. Supported by NCI U10CA180820,180794,180821; UG1CA189859,232760,233290, 233196; Komen Foundation; Breast Cancer Research Foundation. Clinical trial information: NCT00433511.
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Affiliation(s)
- Joseph A. Sparano
- Montefiore Medical Center/Albert Einstein College of Medicine/Albert Einstein Cancer Center, Bronx, NY
| | | | | | | | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Antonio C. Wolff
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD
| | | | - Kathy Miller
- Indiana University Simon Cancer Center Indianapolis, Indianapolis, IN
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Wang R, Singh JC, Wong STL, Lake D, Iyengar NM, D'Andrea G, Brockway-Marchello JP, Kaba A, Traina TA, Robson ME, Dang CT. Phase Ib/II study of capecitabine 7/7 schedule with neratinib in patients with HER2-positive metastatic breast cancer (MBC). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e15016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e15016 Background: Neratinib (N) is a potent irreversible inhibitor of HER1, HER2, and HER4. Capecitabine (X) at optimal dose of 7 days on and 7 days off schedule (7/7) is well-tolerated with low rates of ≥ grade (G3) diarrhea. Methods: We conducted phase Ib/II study of N with X (7/7) with loperamide and colestipol prophylaxis in patients (pts) with pretreated HER2+ MBC (NCT03377387). Eligible pts had normal left ventricular ejection fraction (≥ 50%), any and < 4 prior chemotherapy-based treatments in phase Ib and II, respectively. Primary endpoint of phase Ib is maximum tolerated dose (MTD) and phase II is response rate. Secondary endpoints are safety, tolerability, and progression-free survival. Exploratory endpoint is to quantify cell-free DNA (cfDNA), correlating with response. Phase Ib follows traditional 3+3 design with 4 dose levels. In phase II, if > 3/9 respond, study is expanded to 24. If > 10/24 respond, study is deemed successful. Results: As of 2-4-2021, 10 pts were enrolled in phase Ib. 4 pts were treated at dose level 1 (X at 1500 mg BID at 7/7 and N at 240 mg daily); 2/4 pts experienced with G3 diarrhea during cycle 1. Six pts were treated at dose level -1 (X at 1000 mg BID 7/7 and N at 240 mg daily); 1 (17%) developed G3 diarrhea. The MTD is X at 1000 mg BID 7/7 and N at 240 mg daily. Twenty-two of 24 pts have been enrolled in phase II. Of 22 pts, data show 6 with partial response, 8 with stable disease, 3 with progressive disease, and 5 have not been assessed radiographically. Overall, 6/22 (27.3%) and 1/22 (4.5%) had all G and G3 diarrhea, respectively. Other significant toxicities at MTD included G2 hand foot syndrome (n = 1, 4.5%), G1 fatigue (n = 1, 4.5%) and G1 nausea (n = 4, 18%). Conclusions: The MTD is X at 1000 mg BID at 7/7 and N at 240 mg daily. This combination is safe and well tolerated with G3 diarrhea rate of 4.5%, which is significantly lower than the X 14/7 schedule in NALA study. The phase II portion of the study is near completion and updated result will be presented. Analysis of cfDNA, to correlate with response for phase II portion, is ongoing. Clinical trial information: NCT03377387.
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Affiliation(s)
- Rui Wang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Diana Lake
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Neil M. Iyengar
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Asta Kaba
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
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Al-Sadawi M, Hussain Y, Copeland-Halperin RS, Tobin JN, Moskowitz CS, Dang CT, Liu JE, Steingart RM, Johnson MN, Yu AF. Racial and Socioeconomic Disparities in Cardiotoxicity Among Women With HER2-Positive Breast Cancer. Am J Cardiol 2021; 147:116-121. [PMID: 33617819 DOI: 10.1016/j.amjcard.2021.02.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/27/2021] [Accepted: 02/02/2021] [Indexed: 01/23/2023]
Abstract
Breast cancer and cardiovascular-specific mortality are higher among blacks compared with whites, but disparities in cancer therapy-related adverse cardiovascular outcomes have not been well studied. We assessed for the contribution of race and socioeconomic status on cardiotoxicity among women with HER2-positive breast cancer. This retrospective cohort analysis studied women diagnosed with stage I-III HER2-positive breast cancer from 2004-2013. All underwent left ventricular ejection fraction assessment at baseline and at least one follow-up after beginning trastuzumab. Multivariable logistic regression was used to assess the association between race and socioeconomic status (SES) on cardiotoxicity, defined by clinical heart failure (New York Heart Association class III or IV) or asymptomatic left ventricular ejection fraction decline (absolute decrease ≥ 10% to < 53%, or ≥ 16%). Blacks had the highest prevalence of hypertension, diabetes, and increased BMI. Neighborhood-level SES measures including household income and educational attainment were lower for blacks compared with whites and others. The unadjusted cardiotoxicity risk was significantly higher in black compared with white women (OR, 2.10; 95% CI, 1.42 to 3.10). In a multivariable analysis, this disparity persisted after controlling for relevant cardiovascular risk factors (adjusted OR, 1.88; 95% CI, 1.25 to 2.84). Additional models adjusting for SES factors of income, educational attainment, and insurance status did not significantly alter the association between race and cardiotoxicity. In conclusion, black women are at increased risk of cardiotoxicity during HER2-targeted breast cancer therapy. Future etiologic analyses, particularly studies exploring biologic or genetic mechanisms, are needed to further elucidate and reduce racial disparities in cardiotoxicity.
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Yu AF, Flynn JR, Moskowitz CS, Scott JM, Oeffinger KC, Dang CT, Liu JE, Jones LW, Steingart RM. Long-term Cardiopulmonary Consequences of Treatment-Induced Cardiotoxicity in Survivors of ERBB2-Positive Breast Cancer. JAMA Cardiol 2021; 5:309-317. [PMID: 31939997 DOI: 10.1001/jamacardio.2019.5586] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Trastuzumab improves outcomes in patients with ERBB2-positive (formerly HER2) breast cancer but is associated with treatment-induced cardiotoxicity, most commonly manifest by an asymptomatic decline in left ventricular ejection fraction (LVEF). Little is known to date regarding the long-term effects of treatment-induced cardiotoxicity on cardiopulmonary function in patients who survive trastuzumab-treated breast cancer. Objective To determine whether treatment-induced cardiotoxicity recovers or is associated with long-term cardiopulmonary dysfunction in survivors of ERBB2-positive breast cancer. Design, Setting, and Participants This cross-sectional case-control study enrolled patients with nonmetastatic ERBB2-positive breast cancer after completion of trastuzumab-based therapy (median, 7.0 [interquartile range (IQR), 6.2-8.7] years after therapy) who met 1 of 2 criteria: (1) cardiotoxicity (TOX group) developed during trastuzumab treatment (ie, asymptomatic decrease of LVEF≥10% from baseline to <55% [n = 22]) or (2) no evidence of cardiotoxicity during trastuzumab treatment (NOTOX group [n = 20]). Patients were treated at the Memorial Sloan Kettering Cancer Center. Fifteen healthy control participants (HC group) were also enrolled for comparison purposes. All groups were frequency matched by age strata (<55, 55-64, and ≥65 years). Data were collected from September 9, 2016, to August 10, 2018, and analyzed from November 20, 2018, to August 12, 2019. Main Outcomes and Measures Speckle-tracking echocardiography and maximal cardiopulmonary exercise testing were performed to measure indices of left ventricular function (including LVEF and global longitudinal strain [GLS]) and peak oxygen consumption (peak VO2). Results A total of 57 participants (median age, 60.8 [IQR, 52.7-65.7] years) were included in the analysis. Overall, 38 of 42 patients with breast cancer (90%) were treated with anthracyclines before trastuzumab. Resting mean (SD) LVEF was significantly lower in the TOX group (56.9% [5.2%]) compared with the NOTOX (62.4% [4.0%]) and HC (65.3% [2.9%]) groups; similar results were found for GLS (TOX group, -17.8% [2.2%]; NOTOX group, -19.8% [2.2%]; HC group, -21.3% [1.8%]) (P < .001). Mean peak VO2 in the TOX group (22.9 [4.4] mL/kg/min) was 15% lower compared with the NOTOX group (27.0 [5.3] mL/kg/min; P = .03) and 25% lower compared with the HC group (30.5 [3.4] mL/ kg/min; P < .001). In patients with breast cancer, GLS was significantly associated with peak VO2 (β coefficient, -0.75; 95% CI, -1.32 to -0.18). Conclusions and Relevance Treatment-induced cardiotoxicity appears to be associated with long-term marked impairment of cardiopulmonary function and may contribute to increased risk of late-occurring cardiovascular disease in survivors of ERBB2-positive breast cancer.
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Affiliation(s)
- Anthony F Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Cornell Medical College, New York, New York
| | - Jessica R Flynn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chaya S Moskowitz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jessica M Scott
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Cornell Medical College, New York, New York
| | | | - Chau T Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Cornell Medical College, New York, New York
| | - Jennifer E Liu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Cornell Medical College, New York, New York
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Cornell Medical College, New York, New York
| | - Richard M Steingart
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Cornell Medical College, New York, New York
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Copeland-Halperin RS, Al-Sadawi M, Patil S, Liu JE, Steingart RM, Dang CT, Yu AF. Early Trastuzumab Interruption and Recurrence-Free Survival in ERBB2-Positive Breast Cancer. JAMA Oncol 2020; 6:1971-1972. [PMID: 33057570 PMCID: PMC7563661 DOI: 10.1001/jamaoncol.2020.4749] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/28/2020] [Indexed: 01/27/2023]
Affiliation(s)
| | | | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Jennifer E. Liu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Richard M. Steingart
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Chau T. Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Anthony F. Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
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Yu AF, Moskowitz CS, Lee Chuy K, Yang J, Dang CT, Liu JE, Oeffinger KC, Steingart RM. Cardiotoxicity Surveillance and Risk of Heart Failure During HER2 Targeted Therapy. JACC CardioOncol 2020; 2:166-175. [PMID: 33103123 PMCID: PMC7584138 DOI: 10.1016/j.jaccao.2020.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/05/2020] [Accepted: 03/14/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Guidelines recommend left ventricular ejection fraction (LVEF) assessments every 3 months for cardiotoxicity monitoring during human epidermal growth factor receptor 2 (HER2) targeted therapy. Evidence in support of this practice is lacking. OBJECTIVES This study examines the association between adherence to cardiotoxicity surveillance guidelines and heart failure (HF) in HER2-positive breast cancer patients. METHODS A case-control study was performed in 53 patients who developed cardiotoxicity during HER2 targeted therapy, and 159 controls matched by age, anthracycline exposure, and year of treatment. Cardiotoxicity was defined as HF (New York Heart Association functional class III or IV) or cardiac death. Adherence to cardiotoxicity surveillance guidelines was ascertained from the beginning of HER2 targeted therapy to the diagnosis date of HF for cases or the corresponding timepoint for matched controls. Conditional logistic regression was used for case-control comparisons. RESULTS Eighty-one percent of cases and controls were previously treated with an anthracycline. Adherence to cardiotoxicity surveillance guidelines during the entire observation period or during the first 6 months of treatment was not associated with lower risk of HF. An LVEF <55% at any surveillance timepoint was identified in 49% of cases and 3% of controls, and an LVEF <55% during the final surveillance timepoint before developing HF was identified in 54% of cases and 4% of controls. In multivariable-adjusted analyses, LVEF <55% at any timepoint or during the final surveillance timepoint (odds ratio: 27.0; 95% confidence interval: 9.3 to 78.8 and odds ratio: 25.6; 95% confidence interval: 7.3 to 90.3, respectively) was associated with HF. CONCLUSIONS Patients with LVEF <55% on routine surveillance during HER2 targeted therapy are at increased risk for HF. Additional studies to define their optimal management are warranted.
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Affiliation(s)
- Anthony F. Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Chaya S. Moskowitz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Ji Yang
- New York Presbyterian Brooklyn Methodist Hospital, New York, New York, USA
| | - Chau T. Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Jennifer E. Liu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Kevin C. Oeffinger
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Richard M. Steingart
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
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Daly B, Kuperman G, Zervoudakis A, Baldwin Medsker A, Roy A, Ro AS, Arenas J, Yanamandala HV, Kottamasu R, Salvaggio R, Holland J, Hirsch S, Walters CB, Lauria T, Chow K, Begue A, Rozenshteyn M, Zablocki M, Dhami AK, Silva N, Brown E, Katzen LL, Chiu YO, Perry C, Sokolowski S, Wagner I, Veach SR, Grisham RN, Dang CT, Reidy-Lagunes DL, Simon BA, Perchick W. InSight Care Pilot Program: Redefining Seeing a Patient. JCO Oncol Pract 2020; 16:e1050-e1059. [PMID: 32468925 DOI: 10.1200/op.20.00214] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Early detection and management of symptoms in patients with cancer improves outcomes. However, the optimal approach to symptom monitoring and management is unknown. InSight Care is a mobile health intervention that captures symptom data and facilitates patient-provider communication to mitigate symptom escalation. PATIENTS AND METHODS Patients initiating antineoplastic treatment at a Memorial Sloan Kettering regional location were eligible. Technology supporting the program included the following: a predictive model that identified patient risk for a potentially preventable acute care visit; a secure patient portal enabling communication, televisits, and daily delivery of patient symptom assessments; alerts for concerning symptoms; and a symptom-trending application. The main outcomes of the pilot were feasibility and acceptability evaluated through enrollment and response rates and symptom alerts, and perceived value evaluated on the basis of qualitative patient and provider interviews. RESULTS The pilot program enrolled 100 high-risk patients with solid tumors and lymphoma (29% of new treatment starts v goal of 25%). Over 6 months of follow-up, the daily symptom assessment response rate was 56% (the goal was 50%), and 93% of patients generated a severe symptom alert. Patients and providers perceived value in the program, and archetypes were developed for program improvement. Enrolled patients were less likely to use acute care than were other high-risk patients. CONCLUSION InSight Care was feasible and holds the potential to improve patient care and decrease facility-based care. Future work should focus on optimizing the cadence of patient assessments, the workforce supporting remote symptom management, and the return of symptom data to patients and clinical teams.
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Affiliation(s)
- Bobby Daly
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Ankita Roy
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alice S Ro
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Raj Kottamasu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | - Tara Lauria
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kim Chow
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Aaron Begue
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | - Emily Brown
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Yeneat O Chiu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Claire Perry
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Isaac Wagner
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Chau T Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Brett A Simon
- Memorial Sloan Kettering Cancer Center, New York, NY
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Khoury K, Barac A, Lynce F, Geng X, Dang CT, Yu AF, Smith KL, Gallagher C, Pohlmann PR, Nunes R, Herbolsheimer PM, Warren RD, Srichai MB, Hofmeyer M, Asch FM, Tan MT, Isaacs C, Swain SM. Long-term follow-up assessment of cardiac safety in SAFE-HEaRt, a clinical trial evaluating the use of HER2-targeted therapies in patients with HER2-positive breast cancer and compromised heart function. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.12069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12069 Background: HER2-targeted therapies are associated with cardiotoxicity, mostly asymptomatic and reversible. The impact of withholding these therapies on breast cancer outcomes is unknown. SAFE-HEaRt trial was the first study to evaluate the safety of HER2-targeted agents in patients with reduced left ventricular ejection fraction (LVEF) receiving concomitant cardioprotective medications and close cardiac monitoring. We report the 3-year follow-up (f/u) results. Methods: Thirty patients with stage I-IV HER2-positive breast cancer receiving trastuzumab, pertuzumab or ado-trastuzumab emtansine (TDM-1), with asymptomatic LVEF 40-49%, were started on beta blockers (ß-blockers) and/or ACE inhibitors/ARBs, with the primary endpoint being completion of HER2-targeted therapy without cardiac events (CE) or protocol-defined asymptomatic worsening of LVEF. Results: Patients were accrued from 10/2013 to 12/2017 and median f/u as of 2/7/20 is 37 months. The study met its primary endpoint with 27 patients (90%) completing their HER2-targeted therapies without cardiac issues. 24 patients were reconsented for long-term f/u. There were 23 evaluable patients (1 lost for f/u). Off study, 2 patients continued treatment with trastuzumab, 3 with trastuzumab and pertuzumab, and 3 with TDM-1 for metastatic disease. 1 of the 2 patients who had developed a CE with symptomatic heart failure (HF) died of progressive oncological disease, and the second had LVEF recovery on cardiac medications after completion of adjuvant HER2-targeted therapy. Almost 5 years later, she had an asymptomatic decline in her LVEF to 35% after deciding to stop her ß-blocker and ARB. Of the remaining 21 patients, 15 had recovery of their LVEF to ≥50%, 9 of whom remain on cardiac medications. 5 patients had stable LVEF 40-49% and remain asymptomatic on cardiac medications. Only 1 patient had symptoms suggestive of HF, with last documented LVEF stable at 45-50%, but she has not sought medical care for the last 15 months since relocating to another country. There were no new CE and no cardiac deaths. Mean LVEF was 45% at baseline, 46% at end of treatment, and 51.5% at long term f/u. Conclusions: Long-term f/u of the SAFE-HEaRt study continues to provide safety data of HER2-targeted therapy use in patients with compromised heart function. The late development of cardiac dysfunction is uncommon and continued multi-disciplinary oncologic and cardiac care of patients is essential for improved patient outcomes. Clinical trial information: NCT04143594 .
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Affiliation(s)
- Katia Khoury
- Georgetown Lombardi Cancer Center, Washington, DC
| | - Ana Barac
- MedStar Heart and Vascular Institute, Washington, DC
| | - Filipa Lynce
- Division of Hematology/Oncology, Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC
| | - Xue Geng
- Georgetown University, Washington, DC
| | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Karen L. Smith
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | | | - Raquel Nunes
- Sidney Kimmel Cancer Center, Johns Hopkins University, Baltimore, MD
| | | | | | | | - Mark Hofmeyer
- MedStar Heart and Vascular Institute, Washington, DC
| | | | - Ming Tony Tan
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Claudine Isaacs
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Sandra M. Swain
- NSABP/NRG Oncology, and The Washington Cancer Institute, MedStar Washington Hospital Center, Washington, DC
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Ferraro E, Barrio AV, Patil S, Robson ME, Dang CT. Incidence of brain metastases in patients receiving neoadjuvant chemotherapy (NAC) with trastuzumab and pertuzumab (HP) in HER2-positive early breast cancer (BC). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e12653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e12653 Background: The addition of pertuzumab in the neoadjuvant setting has become a standard of care in stage II-III HER2-positive BC. In the Katherine study the incidence of brain metastases (BM) at the follow-up of 3-years was 5.9 % in patients (pts) with residual disease who received TDM1. The aim of this study was to assess the incidence of BM in pts who received NAC with HP at a single center who were found to have pathological complete response (pCR) (ypT0/is ypN0) versus non-pCR at the time of surgery. Methods: Chart review on HER2-positive pts treated with NAC and HP between September 1, 2013 to May 1, 2018 was conducted. Only surgical specimens of pts whose pre-NAC specimens were internally reviewed for HER2 status by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) were included in this analysis. Data on BM as component of distant recurrence along with invasive disease-free (IDFS) and overall survival (OS) were collected. Results: 540 pts were identified. Cases with no internally verified-HER2 status (387), equivocal status (10) and discordant internal assessment (13) were excluded. 130 pts with preoperative HER2 status confirmed by dedicated breast pathologists were included. Clinicopathological features are described in Table. pCR was achieved in 77/130 (60%) of cases, residual disease in 53/130 (40%). The median follow-up was 2.83 (0.35-5.3) years. The rate of BM as first presentation of distant disease was 3.8 % (3/77) and 3.7 % (2/53) in pts with pCR and non-pCR, respectively. Median time to development BM was 35 (13-58) months and 11.7 (9-14) months in the pCR group and non-pCR, respectively. Conclusions: In our cohort, the combination of HP was associated with a high pCR rate. At a median follow-up of 2.8 years, the incidence of BM appeared to be similar in pts who achieved pCR versus non-pCR. The data of IDFS and OS will be reported. Further data are needed to validate our findings before designing clinical trials to test prophylactic strategies to prevent BM. [Table: see text]
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Affiliation(s)
| | | | - Sujata Patil
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
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Scott JM, Thomas SM, Peppercorn JM, Herndon JE, Douglas PS, Khouri MG, Dang CT, Yu AF, Catalina D, Ciolino C, Capaci C, Michalski MG, Eves ND, Jones LW. Effects of Exercise Therapy Dosing Schedule on Impaired Cardiorespiratory Fitness in Patients With Primary Breast Cancer: A Randomized Controlled Trial. Circulation 2020; 141:560-570. [PMID: 32065769 DOI: 10.1161/circulationaha.119.043483] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Current exercise guidelines for clinical populations recommend an exercise therapy (ET) prescription of fixed intensity (moderate), duration (40-50 minutes per session), and volume (120-160 min/wk). A critical overarching element of exercise programming that has received minimal attention is dose scheduling. We investigated the tolerability and efficacy of 2 exercise training dose regimens on cardiorespiratory fitness and patient-reported outcomes in patients with posttreatment primary breast cancer. METHODS Using a parallel-group randomized trial, we randomly allocated 174 postmenopausal patients (2.8 years after adjuvant therapy) with impaired peak oxygen consumption (VO2peak) to 1 of 2 supervised exercise training interventions delivered with a standard linear (LET) (fixed dose intensity per session for 160 min/wk) or nonlinear (NLET) (variable dose intensity per session for ≈120 min/wk) schedule compared with a stretching attention control group for 16 consecutive weeks. Stretching was matched to exercise dosing arms on the basis of location, frequency, duration, and treatment length. The primary end point was change in VO2peak (mL O2·kg-1·min-1) from baseline to after intervention. Secondary end points were patient-reported outcomes, tolerability, and safety. RESULTS No serious adverse events were observed. Mean attendance was 64%, 75%, and 80% for attention control, LET, and NLET, respectively. In intention-to-treat analysis, VO2peak increased 0.6±1.7 mL O2·kg-1·min-1 (P=0.05) and 0.8±1.8 mL O2·kg-1·min-1 (P=0.07) in LET and NLET, respectively, compared with attention control. Change in VO2peak ranged from -2.7 to 4.1 mL O2·kg-1·min-1 and from -3.6 to 5.1 mL O2·kg-1·min-1 in LET and NLET, respectively. Approximately 40% of patients in both exercise dosing regimens were classified as VO2peak responders (ie, Δ ≥1.32 mL O2·kg-1·min-1). NLET improved all patient-reported outcomes compared with attention control. CONCLUSIONS Short-term exercise training, independently of dosing schedule, is associated with modest improvements in cardiorespiratory fitness in patients previously treated for early-stage breast cancer. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01186367.
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Affiliation(s)
- Jessica M Scott
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.)
| | - Samantha M Thomas
- Duke University Medical Center, Durham, NC (S.M.T., J.E.H., P.S.D., M.G.K.)
| | - Jeffrey M Peppercorn
- Weill Cornell Medical College, New York, NY (J.M.S., C.T.D., L.W.J.).,Massachusetts General Hospital Cancer Center, Boston (J.M.P.)
| | - James E Herndon
- Duke University Medical Center, Durham, NC (S.M.T., J.E.H., P.S.D., M.G.K.)
| | - Pamela S Douglas
- Duke University Medical Center, Durham, NC (S.M.T., J.E.H., P.S.D., M.G.K.)
| | - Michel G Khouri
- Duke University Medical Center, Durham, NC (S.M.T., J.E.H., P.S.D., M.G.K.)
| | - Chau T Dang
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.).,Weill Cornell Medical College, New York, NY (J.M.S., C.T.D., L.W.J.)
| | - Anthony F Yu
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.)
| | - Diane Catalina
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.)
| | - Cristi Ciolino
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.)
| | - Catherine Capaci
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.)
| | - Meghan G Michalski
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.)
| | - Neil D Eves
- University of British Columbia, Kelowna, British Columbia, Canada (N.D.E.)
| | - Lee W Jones
- Memorial Sloan Kettering Cancer Center, New York, NY (J.M.S., C.T.D., A.F.Y., D.C., C.C., C.C., M.G.M., L.W.J.).,Weill Cornell Medical College, New York, NY (J.M.S., C.T.D., L.W.J.)
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Iyengar NM, Smyth LM, Lake D, Gucalp A, Singh JC, Traina TA, DeFusco P, Fornier MN, Goldfarb S, Jhaveri K, Modi S, Troso-Sandoval T, Patil S, Ulaner GA, Jochelson M, Norton L, Hudis CA, Dang CT. Efficacy and Safety of Gemcitabine With Trastuzumab and Pertuzumab After Prior Pertuzumab-Based Therapy Among Patients With Human Epidermal Growth Factor Receptor 2-Positive Metastatic Breast Cancer: A Phase 2 Clinical Trial. JAMA Netw Open 2019; 2:e1916211. [PMID: 31774522 PMCID: PMC6902832 DOI: 10.1001/jamanetworkopen.2019.16211] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Taxanes with trastuzumab and pertuzumab for initial treatment of human epidermal growth factor receptor 2 (ERBB2, formerly HER2)-positive metastatic breast cancer is associated with improved progression-free survival (PFS) and overall survival. While continued use of trastuzumab in therapeutic combinations after disease progression is standard, the efficacy of continuing pertuzumab is unknown. OBJECTIVE To evaluate the efficacy and safety of pertuzumab in combination with gemcitabine and trastuzumab after prior treatment with pertuzumab for ERBB2-positive metastatic breast cancer. DESIGN, SETTING, AND PARTICIPANTS This is a phase 2 single-arm clinical trial of dual anti-ERBB2 therapy after prior treatment with pertuzumab. The study took place at a single academic center from March 2015 to April 2017 among women with ERBB2-positive metastatic breast cancer, prior pertuzumab-based treatment, and 3 or fewer prior chemotherapy regimens. Data were analyzed between January 2019 and March 2019. INTERVENTION Treatment consisted of gemcitabine, 1200 mg/m2 (later amended to 1000 mg/m2) on days 1 and 8 every 3 weeks, plus trastuzumab (8-mg/kg loading dose, then 6 mg/kg) and pertuzumab (840-mg loading dose, then 420 mg) once every 3 weeks. MAIN OUTCOMES AND MEASURES The primary end point was 3-month PFS. Based on prior trials, a target rate of 70% or higher was selected as the promising progression-free rate at 3 months. Secondary outcomes included safety, tolerability, and overall survival. RESULTS A total of 45 patients (median [range] age, 57.1 [31.7-77.2] years) were enrolled; 22 (49%) were treated in the second-line setting, and 23 (51%) were treated in the third-line setting or beyond. Of these, 22 (49%) received prior trastuzumab emtansine (T-DM1). At a median (range) follow-up of 27.6 (8.3-36.0) months, 3-month PFS was 73.3% (95% CI, 61.5%-87.5%). Overall, median PFS was 5.5 months (95% CI, 5.4-8.2 months). Treatment was well tolerated, with no occurrences of febrile neutropenia or symptomatic left ventricular systolic dysfunction. CONCLUSIONS AND RELEVANCE In this phase 2 trial, treatment with gemcitabine, trastuzumab, and pertuzumab after prior pertuzumab-based therapy for ERBB2-positive metastatic breast cancer was associated with a 3-month PFS rate of 73.3% and was well tolerated. Continuation of pertuzumab beyond progression was associated with apparent clinical benefit. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02252887.
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Affiliation(s)
- Neil M. Iyengar
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Lillian M. Smyth
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Diana Lake
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Ayca Gucalp
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Jasmeet C. Singh
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Tiffany A. Traina
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Patricia DeFusco
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Monica N. Fornier
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Shari Goldfarb
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Komal Jhaveri
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Shanu Modi
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Tiffany Troso-Sandoval
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Sujata Patil
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Gary A. Ulaner
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Maxine Jochelson
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | - Larry Norton
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
| | | | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medicine, New York, New York
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Sparano J, O'Neill A, Alpaugh K, Wolff AC, Northfelt DW, Dang CT, Sledge GW, Miller KD. Association of Circulating Tumor Cells With Late Recurrence of Estrogen Receptor-Positive Breast Cancer: A Secondary Analysis of a Randomized Clinical Trial. JAMA Oncol 2019; 4:1700-1706. [PMID: 30054636 DOI: 10.1001/jamaoncol.2018.2574] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Late recurrence 5 or more years after diagnosis accounts for at least one-half of all cases of recurrent hormone receptor-positive breast cancer. Objective To determine whether the presence of circulating tumor cells (CTCs) in a peripheral blood sample obtained approximately 5 years after diagnosis was associated with late clinical recurrence of operable human epidermal growth factor receptor 2-negative breast cancer. Design, Setting, and Participants This per-protocol secondary analysis of the Double-Blind Phase III Trial of Doxorubicin and Cyclophosphamide Followed by Paclitaxel With Bevacizumab or Placebo in Patients With Lymph Node Positive and High Risk Lymph Node Negative Breast Cancer enrolled patients from 2007 to 2011 who were without clinical evidence of recurrence between 4.5 and 7.5 years after primary surgical treatment of human epidermal growth factor receptor 2-negative stage II-III breast cancer followed by adjuvant systemic therapy. Patients were enrolled in a subprotocol for secondary analysis from February 25, 2013, to July 29, 2016, after signing consent for the subprotocol. The analysis was performed in April 2018. Interventions A blood sample was obtained for identification and enumeration of CTCs. Main Outcome and Measures The association between a positive CTC assay result (at least 1 CTC per 7.5 mL of blood) and clinical recurrence. Results Among 547 women included in this analysis, the results of the CTC assay were positive for 18 of 353 with hormone receptor-positive disease (5.1% [95% CI, 3.0%-7.9%]); 23 of 353 patients (6.5% [95% CI, 4.2%-9.6%]) had a clinical recurrence. The recurrence rates per person-year of follow-up in the CTC-positive and CTC-negative groups were 21.4% (7 recurrences per 32.7 person-years) and 2.0% (16 recurrences per 796.3 person-years), respectively. In multivariate models including clinical covariates, a positive CTC assay result was associated with a 13.1-fold higher risk of recurrence (hazard ratio point estimate, 13.1; 95% CI, 4.7-36.3). Seven of 23 patients (30.4% [95% CI, 13.2%-52.9%]) with recurrence had a positive CTC assay result at a median of 2.8 years (range, 0.1-2.8 years) before clinical recurrence. The CTC assay result was also positive for 8 of 193 patients (4.1% [95% CI, 1.8%-8.0%]) with hormone receptor-negative disease, although only 1 patient (0.5% [95% CI, 0%-2.9%]) experienced disease recurrence (this patient was CTC negative). Conclusions and Relevance A single positive CTC assay result 5 years after diagnosis of hormone receptor-positive breast cancer provided independent prognostic information for late clinical recurrence, which provides proof of concept that liquid-based biomarkers may be used to risk stratify for late recurrence and guide therapy. Trial Registration ClinicalTrials.gov identifier: NCT00433511.
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Affiliation(s)
- Joseph Sparano
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Anne O'Neill
- Department of Biostatistics & Computational Biology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Katherine Alpaugh
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Antonio C Wolff
- Department of Oncology, Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Donald W Northfelt
- Department of Internal Medicine, Division of Hematology/Oncology, Mayo Clinic, Scottsdale, Arizona
| | - Chau T Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - George W Sledge
- Department of Medicine, Division of Oncology, Stanford Cancer Center, Palo Alto, California
| | - Kathy D Miller
- Department of Medicine, Division of Hematology/Oncology, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis
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Dang CT, Blaes A, Lynce F, Swain SM, Dent S. Left Ventricular Ejection Fraction Monitoring Adherence Rates: Why So Low? JACC Cardiovasc Imaging 2019; 11:1094-1097. [PMID: 30092968 DOI: 10.1016/j.jcmg.2018.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 02/15/2018] [Indexed: 01/27/2023]
Affiliation(s)
- Chau T Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Anne Blaes
- Department of Medicine, University of Minnesota Masonic Cancer Center, Minneapolis, Minnesota
| | - Filipa Lynce
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Sandra M Swain
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Susan Dent
- Division of Medical Oncology, Department of Medicine, Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, Ontario, Canada
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40
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Affiliation(s)
- Richard M. Steingart
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Medical College of Cornell University, New York, New York, USA
| | - Anthony F. Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Medical College of Cornell University, New York, New York, USA
| | - Chau T. Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center and Weill Medical College of Cornell University, New York, New York, USA
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dos Anjos CH, Razavi P, Herbert J, Colon J, Gill K, Modi S, Bromberg J, Dang CT, Liu D, Norton L, Chandarlapaty S, Robson ME, Jhaveri KL. A large retrospective analysis of CDK 4/6 inhibitor retreatment in ER+ metastatic breast cancer (MBC). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.1053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1053 Background: Sequential retreatment with endocrine therapy (ET) has been the clinical paradigm for ER+ MBC due to persistent dependence on hormone signaling. Recently CDK4/6i + ET have improved PFS and are routinely utilized in the first/second- line setting. Whether this paradigm of sequential retreatment holds for CDK 4/6i is unknown. To evaluate the potential benefit of CDK4/6i re-treatment we conducted this retrospective analysis. Methods: We identified ER+/HER2- MBC pts treated with ≥ 2 lines of CDK4/6i at our institution between 2015-2018. We categorized pts based on reason for discontinuation of their first CDK4/6i: cohort 1 – switch to alternate CDK4/6i due to toxicity; cohort 2 – retreatment with same CDK4/6i beyond progression with change of ET and cohort 3- switch to alternate CDK4/6i as monotherapy or with same or another ET. We analyzed pt demographics, imaging reports and time to subsequent therapy (TTST) for every CDK4/6i line for each cohort. If a pt received > 2 lines of CDK4/6i, then that pt was evaluated for every CDK4/6i exposure. Results: 135 pts received ≥ 2 lines of CDK4/6i treatment (Tx). Cohorts 1, 2 and 3 had 23, 43 pts and 84 pts respectively. In Cohort 2, 95% of pts received 2 subsequent CDK 4/6i + ET Tx; 56% had the second CDK4/6i in second-line met setting. TTST1 (1st CDK4/6i Tx) was 9.6m (95% CI 4.9 - 11 m), TTST2 (second CDK4/6i Tx) was 4.5m (95% CI 3.3 – 7.6 m) and 35% had TTST2 ≥ 24 weeks. For Cohort 3, 48% were retreated with a different CDK 4/6i in ≥ fifth-line. 51% received 2 subsequent CDK 4/6i Tx with 18% in second-line met setting. TTST1 was 9.6 m (95% CI 5.9 – 12 m), TTST2 was 4.4 m (95% CI 3.8 – 5.9 m) and 29% had TTST2 ≥ 24 weeks. In cohort 3, 29% (n=24) pts had PD as best response at the time of first CDK4/6i exposure but 29% (7/24) achieved a radiologic response to their second CDK4/6i Tx. Pts had tumor sequencing using MSK-IMPACT which will be correlated with TTST. Conclusions: This large single institution retrospective analysis suggests that retreatment with a CDK4/6i regimen should be evaluated in prospective trials. Additionally, despite PD as best response with the first CDK4/6i (palbociclib/ribociclib) regimen, a subset of pts had radiologic response to a subsequent abemaciclib-containing regimen, which is an hypothesis generating observation.
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Affiliation(s)
| | - Pedram Razavi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Jodecy Colon
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kaitlyn Gill
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Shanu Modi
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Dazhi Liu
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Larry Norton
- Memorial Sloan Kettering Cancer Center, New York, NY
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Daly RM, Perry C, Chiu YO, Katzen LL, Rozenshteyn M, Kuperman G, Dhami AK, Salvaggio R, Baldwin A, Holland JC, Chow K, Dang CT, Grisham RN, Veach SR, Zervoudakis A, Wagner I, Simon BA, Reidy DL, Perchick W. Risk stratification and daily symptom monitoring for oncology patients. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.6535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6535 Background: Monitoring and managing patient reported outcomes (PROs) has been recommended for oncology patients on active treatment but can be time and resource intensive. Identifying patients likely to benefit and the optimal frequency of PRO capture is still under investigation. We tested the feasibility of monitoring patients who are high-risk risk for acute care with daily PROs. Methods: Using data from our institution, we developed a model that employs over 400 clinical variables to calculate a patient’s risk of an emergency room visit within 6 months following the onset of treatment. From October 15, 2018 to January 23, 2019, we enrolled patients identified as high risk through a technology-enabled program to monitor and manage those patients’ symptoms. Enrolled patients entered PRO assessments daily via an online portal. Symptoms were monitored and managed by a centralized clinical team. Tiered notifications informed the team of concerning or escalating symptoms. We assessed how frequently patients completed symptom assessments and the frequency of symptom notifications. Results: During the pilot, 28 patients were identified as high risk and enrolled in the program (median age 65; 64% percent female). Disease types were: 15 (54%) thoracic, 7 (25%) gynecologic, 6 (21%) gastrointestinal. Median time in the program was 50 (6-98) days. Patients completed 840 of 1,350 assessments (62%). There were 328 assessments that triggered moderate alerts (39%) and 220 that triggered severe alerts (26%). The table describes the prevalence of symptoms at the patient-level. Conclusions: A model can be employed to identify high-risk patients in collaboration with clinicians. Our adherence rate with a daily symptom assessment was similar to those found in studies of less frequent PRO capture. Future work will expand to a larger patient population with other cancer types, evaluate impact on outcomes, and assess optimal frequency for PRO collection and alert thresholds. [Table: see text]
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Affiliation(s)
| | - Claire Perry
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | | | | | | | - Kimberly Chow
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rachel N. Grisham
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | | | | | - Isaac Wagner
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brett A Simon
- Memorial Sloan Kettering Cancer Center, New York, NY
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Scott J, Thomas SM, Herndon JE, Peppercorn JM, Douglas PS, Khouri M, Dang CT, Yu AF, Catalina D, Ciolino C, Capaci C, Michalski M, Eves ND, Jones L. Effects of Non-Linear or Linear Aerobic Training (AT) Dosing Regimens on Impaired Cardiovascular (CV) Function in Patients with Operable Breast Cancer: A Randomized Controlled Trial (RCT). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
541 Background: Breast cancer therapy causes marked impairments in CV function predisposing to elevated risk of CV morbidity. We investigated the effects of two AT dosing regimens on CV function in post-treatment patients with operable breast cancer. Methods: In a three-arm, parallel-group RCT, 174 post-menopausal patients (2.8 years post primary adjuvant therapy) with impaired age/sex-matched peak oxygen consumption (VO2peak) were randomized to: (1) conventional linear AT (uniform dose-intensity / session), (2) nonlinear AT (variable dose-intensity / session), or (3) stretching (attention control). AT consisted of 64 supervised treadmill walking sessions delivered four times weekly at either ~70% VO2peak for 40 mins/session (linear) or 55% to 100% VO2peak for 20-45 mins/session (nonlinear) for 16 consecutive weeks. Stretching was matched to AT on the basis of location, frequency, duration, and treatment length. The primary end point was change in VO2peak. Secondary end points were other markers of CV risk profile (biochemical CV risk profile, cardiac function, body composition), patient-reported outcomes (PROs), tolerability (e.g., relative dose intensity), and safety. All analyses followed the intention-to-treat principle. Results: Rates of lost-to-follow were < 10% in all arms. Relative dose intensity of AT was 73% ± 27% and 80% ± 21% in linear and nonlinear arms, respectively. No serious adverse events were observed. In adjusted analysis, compared to control, VO2peak (ml O2.kg-1.min-1) increased 0.7 (± 0.3) ml O2.kg-1.min-1 (p = 0.06) and 0.8 (± 0.4) ml O2.kg-1.min-1 (p = 0.02) in linear and nonlinear AT, respectively. Rates of VO2peak improvement greater than the technical error of measurement (i.e., ≥1.32ml O2.kg-1.min-1) were 33% and 39% in linear and nonlinear AT (p = 0.03), respectively. Both AT regimens were associated with improvements in several secondary CV end points but only nonlinear AT improved PROs compared with control (all p’s < 0.05). There were no differences between the two AT regimens. Conclusion: AT significantly improves CV function and PROs in post-treatment breast cancer patients. The efficacy-tolerability ratio favors the non-linear regimen over the conventional linear prescription approach. Clinical trial information: NCT01186367.
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Affiliation(s)
- Jessica Scott
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | - Chau T. Dang
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | | | - Lee Jones
- Memorial Sloan Kettering Cancer Center, New York, NY
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Bellon JR, Guo H, Barry WT, Dang CT, Yardley DA, Moy B, Marcom PK, Albain KS, Rugo HS, Ellis M, Wolff AC, Carey LA, Overmoyer BA, Partridge AH, Hudis CA, Krop I, Burstein HJ, Winer EP, Tolaney SM. Local-regional recurrence in women with small node-negative, HER2-positive breast cancer: results from a prospective multi-institutional study (the APT trial). Breast Cancer Res Treat 2019; 176:303-310. [PMID: 31004299 DOI: 10.1007/s10549-019-05238-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 04/12/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Women with HER2-positive breast cancer treated prior to effective anti-HER2 therapy have higher rates of local-regional recurrence (LRR) than those with HER2-negative disease. Effective systemic therapy, however, has been shown to decrease LRR. This study examines LRR in women with HER2-positive breast cancer treated on a single-arm prospective multicenter trial of adjuvant trastuzumab (H) and paclitaxel (T). METHODS Patients with HER2-positive tumors ≤ 3.0 cm with negative axillary nodes or micrometastatic disease were eligible. Systemic therapy included weekly T and H for 12 weeks followed by continuation of H to complete 1 year. Radiation therapy (RT) was required following breast-conserving surgery (BCS), but dose and fields were not specified. Disease-free survival (DFS) and LRR-free survival were calculated using the Kaplan-Meier method. RESULTS Of the 410 patients enrolled from September 2007 to September 2010, 406 initiated protocol therapy and formed the basis of this analysis. A total of 272 (67%) had hormone receptor-positive tumors. Of 162 patients undergoing mastectomy, local therapy records were unavailable for two. None of the 160 for whom records were available received RT. Among 244 BCS patients, detailed RT records were available for 217 (89%). With a median follow-up of 6.5 years, 7-year DFS was 93.3% (95% CI 90.4-96.2), and LRR-free survival was 98.6% (95% CI 97.4-99.8). CONCLUSION LRR in this select group of early-stage patients with HER2-positive disease receiving effective anti-HER2 therapy is extremely low. If confirmed in additional studies, future investigational efforts should focus on de-escalating local therapy.
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Affiliation(s)
- Jennifer R Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, 450 Brookline Avenue, Boston, MA, USA.
| | - Hao Guo
- Department of Statistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - William T Barry
- Department of Statistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Chau T Dang
- Breast Cancer Medicine Service, Solid Tumor Division, Department of Medicine, Memorial Sloan Kettering Cancer Center and Department of Medicine, Weill Cornell Medical Center, New York, NY, USA
| | - Denise A Yardley
- Department of Medical Oncology, Sarah Cannon Cancer Center, Nashville, TN, USA
| | - Beverly Moy
- Department of Hematology-Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - P Kelly Marcom
- Division of Medical Oncology, Department of Medicine, Duke Cancer Institute, Durham, NC, USA
| | - Kathy S Albain
- Division of Hematology/Oncology, Department of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Hope S Rugo
- Department of Medicine, Division of Oncology, Helen Diller Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Matthew Ellis
- Department of Medical Oncology, Baylor Clinic-Lester and Sue Smith Breast Center, Houston, TX, USA
| | - Antonio C Wolff
- Department of Oncology, Johns Hopkins Kimmel Cancer Center, Baltimore, MD, USA
| | - Lisa A Carey
- Department of Medical Oncology, UNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Beth A Overmoyer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Clifford A Hudis
- Breast Cancer Medicine Service, Solid Tumor Division, Department of Medicine, Memorial Sloan Kettering Cancer Center and Department of Medicine, Weill Cornell Medical Center, New York, NY, USA.,American Society of Clinical Oncology, Alexandria, VA, USA
| | - Ian Krop
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Harold J Burstein
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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Tolaney SM, Guo H, Pernas S, Barry WT, Dillon DA, Ritterhouse L, Schneider BP, Shen F, Fuhrman K, Baltay M, Dang CT, Yardley DA, Moy B, Marcom PK, Albain KS, Rugo HS, Ellis MJ, Shapira I, Wolff AC, Carey LA, Overmoyer B, Partridge AH, Hudis CA, Krop IE, Burstein HJ, Winer EP. Seven-Year Follow-Up Analysis of Adjuvant Paclitaxel and Trastuzumab Trial for Node-Negative, Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer. J Clin Oncol 2019; 37:1868-1875. [PMID: 30939096 DOI: 10.1200/jco.19.00066] [Citation(s) in RCA: 177] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE The Adjuvant Paclitaxel and Trastuzumab trial was designed to address treatment of patients with small human epidermal growth factor receptor 2 (HER2)-positive breast cancer. The primary analysis of the Adjuvant Paclitaxel and Trastuzumab trial demonstrated a 3-year disease-free survival (DFS) of 98.7%. In this planned secondary analysis, we report longer-term outcomes and exploratory results to characterize the biology of small HER2-positive tumors and genetic factors that may predispose to paclitaxel-induced peripheral neuropathy (TIPN). PATIENTS AND METHODS In this phase II study, patients with HER2-positive breast cancer with tumors 3 cm or smaller and negative nodes received paclitaxel (80 mg/m2) with trastuzumab for 12 weeks, followed by trastuzumab for 9 months. The primary end point was DFS. Recurrence-free interval (RFI), breast cancer-specific survival, and overall survival (OS) were also analyzed. In an exploratory analysis, intrinsic subtyping by PAM50 (Prosigna) and calculation of the risk of recurrence score were performed on the nCounter analysis system on archival tissue. Genotyping was performed to investigate TIPN. RESULTS A total of 410 patients were enrolled from October 2007 to September 2010. After a median follow-up of 6.5 years, there were 23 DFS events. The 7-year DFS was 93% (95% CI, 90.4 to 96.2) with four (1.0%) distant recurrences, 7-year OS was 95% (95% CI, 92.4 to 97.7), and 7-year RFI was 97.5% (95% CI, 95.9 to 99.1). PAM50 analyses (n = 278) showed that most tumors were HER2-enriched (66%), followed by luminal B (14%), luminal A (13%), and basal-like (8%). Genotyping (n = 230) identified one single-nucleotide polymorphism, rs3012437, associated with an increased risk of TIPN in patients with grade 2 or greater TIPN (10.4%). CONCLUSION With longer follow-up, adjuvant paclitaxel and trastuzumab is associated with excellent long-term outcomes. Distribution of PAM50 intrinsic subtypes in small HER2-positive tumors is similar to that previously reported for larger tumors.
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Affiliation(s)
| | - Hao Guo
- 1Dana-Farber Cancer Institute, Boston, MA
| | - Sonia Pernas
- 1Dana-Farber Cancer Institute, Boston, MA.,2Institut Català d'Oncologia-H.U.Bellvitge-IDIBELL, Barcelona, Spain
| | | | | | - Lauren Ritterhouse
- Brigham and Women's Hospital, Boston, MA.,4University of Chicago, Chicago, IL
| | | | - Fei Shen
- 5Indiana University School of Medicine, Indianapolis, IN
| | | | | | - Chau T Dang
- Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Medical College of Cornell University, New York, NY
| | | | | | | | - Kathy S Albain
- Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Hope S Rugo
- University of California, San Francisco, San Francisco, CA
| | - Mathew J Ellis
- Baylor Clinic Lester and Sue Smith Breast Center, Houston, TX
| | - Iuliana Shapira
- Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY.,SUNY Downstate Medical Center, Brooklyn, NY
| | | | | | | | | | - Clifford A Hudis
- Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Medical College of Cornell University, New York, NY.,American Society of Clinical Oncology, Alexandria, VA
| | - Ian E Krop
- 1Dana-Farber Cancer Institute, Boston, MA
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Yu AF, Ho AY, Braunstein LZ, Thor ME, Lee Chuy K, Eaton A, Mara E, Cahlon O, Dang CT, Oeffinger KC, Steingart RM, Liu JE. Assessment of Early Radiation-Induced Changes in Left Ventricular Function by Myocardial Strain Imaging After Breast Radiation Therapy. J Am Soc Echocardiogr 2019; 32:521-528. [PMID: 30826225 DOI: 10.1016/j.echo.2018.12.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Radiation therapy (RT)-induced cardiotoxicity is among the concerning sequelae of breast cancer (BCA) treatment, particularly in HER2-positive BCA patients who receive anthracyclines and trastuzumab-based therapy. The aim of this study was to assess for early RT-induced changes in echocardiographic and circulating biomarkers of left ventricular (LV) function and evaluate their association with radiation dose to the heart among patients with HER2-positive BCA treated with contemporary RT. METHODS A total of 47 women with HER2-positive BCA who were treated with an anthracycline, trastuzumab, and RT to the breast and/or chest wall ± regional lymph nodes were included in this study. Two-dimensional echocardiography with speckle-tracking imaging was performed at baseline (prechemotherapy), prior to and after RT (pre-RT and post-RT), and 6 months post-RT. High-sensitivity troponin I (hsTnI) was measured pre-RT and post-RT. Associations between mean heart dose (MHD) and changes in LV function after RT were examined in multivariable linear regression models. RESULTS The MHD was 1.8 ± 1.5 Gy for patients receiving left-sided RT (n = 26) and 1.1 ± 1.3 Gy for patients receiving right-sided RT (n = 21). Pre-RT, post-RT, and 6-month post-RT echocardiograms were performed at median (interquartile range) of 49 days (27, 77) before and 54 days (25, 78) and 195 days (175, 226) after RT, respectively. Compared with pre-RT, a minimal decrease in LV ejection fraction was observed post-RT (61% ± 7% vs 59% ± 8%; P = .003) without any significant change in global longitudinal, circumferential, or radial strain or diastolic indices at the post-RT timepoint. Median (interquartile range) concentrations of hsTnI decreased from 5.7 pg/mL (3.0, 8.7) pre-RT to 3.7 pg/mL (2.0, 5.9) post-RT. There was no significant change in systolic or diastolic indices of LV function at 6 months post-RT compared with pre-RT. MHD was not associated with changes in echocardiographic parameters of LV function after RT. CONCLUSIONS Breast RT using contemporary techniques can be delivered without evidence of early subclinical LV dysfunction or injury as measured by echocardiography and hsTnI in patients treated with anthracyclines and trastuzumab. Future studies should focus on identifying alternative biomarkers to elucidate early RT-induced cardiovascular effects and further characterizing long-term cardiovascular outcomes associated with contemporary breast RT.
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Affiliation(s)
- Anthony F Yu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York.
| | - Alice Y Ho
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria E Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine Lee Chuy
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne Eaton
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - Elton Mara
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chau T Dang
- Weill Cornell Medical College, New York, New York; Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Richard M Steingart
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Jennifer E Liu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
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Rosenberg SM, O'Neill A, Sepucha K, Miller KD, Dang CT, Northfelt DW, Sledge GW, Schneider BP, Partridge AH. Abstract GS6-05: The impact of breast cancer surgery on quality of life: Long term results from E5103. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-gs6-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Breast cancer (BC) treatment, including surgery, can impact not only short-term health outcomes but may also affect longer term health-related and psychosocial quality of life (QOL). We sought to describe the impact of BC surgery on QOL among breast cancer survivors followed in a large randomized trial.
Methods: The ECOG-ACRIN protocol E5103 was a phase III trial that randomized BC patients (pts) who had undergone definitive BC surgery to receive adjuvant doxorubicin, cyclophosphamide, and paclitaxel with either bevacizumab (bev) or placebo. Telephone based surveys were administered to all pts enrolled between 01/Jan/10 and 08/Jun/10 as part of a Decision-Making/QOL component until 18 mos post enrollment. Functional/psychosocial QOL domains were assessed by the EQ-5D-3L and the FACT B+G. Fisher's exact test compared categorical and Wilcoxon rank sum test compared continuous variables between subgroups. Multivariable regression was used to evaluate factors in addition to primary surgery at enrollment (age, race, ER/PgR status, tumor size, nodal status) associated with overall FACT score at 18 mos.
Results: Patient reported outcomes at 18 mos were available from 89.6% (465/519) pts. At enrollment, 57% (266/465) had a mastectomy; 43% (199/465) breast conserving surgery (BCS). Median age at enrollment was 52 (range: 25-76) years. There were no differences in QOL between bev vs placebo treatment arms (EQ-5D-3L Index Score p=0.65; FACT B+G Score p=0.23) at 18 mos so groups were combined. Using EQ-5D-3L, over half of the pts (58%) reported at least some pain/discomfort; 38% symptoms of anxiety/depression. A higher proportion of mastectomy pts reported problems with usual activities compared to BCS pts (Table). Compared to BCS pts, mastectomy pts had lower average EQ5D-3L scores 0.80 vs. 0.84, p=0.04 and FACT B+G scores 109 vs. 114, p=0.01, indicating worse QOL. In univariate analyses, non-white race (p=0.03), ER/PgR+ status (p=0.04) and mastectomy as primary surgery (p=0.01) were significantly associated with worse QOL (lower FACT B+G scores). In multivariable analyses, non-white race (p=0.02) and ER/PgR+ status (p=0.05) remained associated with worse QOL; mastectomy was borderline significant (p=0.06).
Conclusions: Among women participating in a contemporary adjuvant BC chemotherapy trial, a substantial proportion of survivors experience symptoms that may be amenable to intervention, including referral to physical rehabilitation, especially among pts undergoing more extensive surgery. Attention to psychosocial health is also essential both during and after completion of active treatment to optimize QOL outcomes.
N(%) reporting problems* 5 DimensionsBCSMastectomyOverallp**Mobility44(23)59(23)103(23)1.00Self-care11(6)23(9)34(7)0.21Usual activities49(25)90(34)139(30)0.04Pain/discomfort104(53)161(61)265(58)0.08Anxiety/depression70(36)105(40)175(38)0.44*3L: 3 possible answers: 1) no problems 2) some/moderate problems 3) problems; responses then collapsed into no problems vs. any problems' (=some/moderate problems and problems). ** Fisher's exact test p-value.
Citation Format: Rosenberg SM, O'Neill A, Sepucha K, Miller KD, Dang CT, Northfelt DW, Sledge GW, Schneider BP, Partridge AH. The impact of breast cancer surgery on quality of life: Long term results from E5103 [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS6-05.
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Affiliation(s)
- SM Rosenberg
- Dana-Farber Cancer Institute, Boston, MA; ECOG-ACRIN Biostatistics Center, Boston, MA; Massachusetts General Hospital, Boston, MA; Indiana University, Indianapolis, IN; Memorial Sloan-Kettering Cancer Center, New York, NY; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA
| | - A O'Neill
- Dana-Farber Cancer Institute, Boston, MA; ECOG-ACRIN Biostatistics Center, Boston, MA; Massachusetts General Hospital, Boston, MA; Indiana University, Indianapolis, IN; Memorial Sloan-Kettering Cancer Center, New York, NY; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA
| | - K Sepucha
- Dana-Farber Cancer Institute, Boston, MA; ECOG-ACRIN Biostatistics Center, Boston, MA; Massachusetts General Hospital, Boston, MA; Indiana University, Indianapolis, IN; Memorial Sloan-Kettering Cancer Center, New York, NY; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA
| | - KD Miller
- Dana-Farber Cancer Institute, Boston, MA; ECOG-ACRIN Biostatistics Center, Boston, MA; Massachusetts General Hospital, Boston, MA; Indiana University, Indianapolis, IN; Memorial Sloan-Kettering Cancer Center, New York, NY; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA
| | - CT Dang
- Dana-Farber Cancer Institute, Boston, MA; ECOG-ACRIN Biostatistics Center, Boston, MA; Massachusetts General Hospital, Boston, MA; Indiana University, Indianapolis, IN; Memorial Sloan-Kettering Cancer Center, New York, NY; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA
| | - DW Northfelt
- Dana-Farber Cancer Institute, Boston, MA; ECOG-ACRIN Biostatistics Center, Boston, MA; Massachusetts General Hospital, Boston, MA; Indiana University, Indianapolis, IN; Memorial Sloan-Kettering Cancer Center, New York, NY; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA
| | - GW Sledge
- Dana-Farber Cancer Institute, Boston, MA; ECOG-ACRIN Biostatistics Center, Boston, MA; Massachusetts General Hospital, Boston, MA; Indiana University, Indianapolis, IN; Memorial Sloan-Kettering Cancer Center, New York, NY; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA
| | - BP Schneider
- Dana-Farber Cancer Institute, Boston, MA; ECOG-ACRIN Biostatistics Center, Boston, MA; Massachusetts General Hospital, Boston, MA; Indiana University, Indianapolis, IN; Memorial Sloan-Kettering Cancer Center, New York, NY; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA
| | - AH Partridge
- Dana-Farber Cancer Institute, Boston, MA; ECOG-ACRIN Biostatistics Center, Boston, MA; Massachusetts General Hospital, Boston, MA; Indiana University, Indianapolis, IN; Memorial Sloan-Kettering Cancer Center, New York, NY; Mayo Clinic, Rochester, MN; Stanford University, Stanford, CA
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Wang R, Smyth LM, Iyengar N, Chandarlapaty S, Modi S, Jochelson M, Patil S, Norton L, Hudis CA, Dang CT. Phase II Study of Weekly Paclitaxel with Trastuzumab and Pertuzumab in Patients with Human Epidermal Growth Receptor 2 Overexpressing Metastatic Breast Cancer: 5-Year Follow-up. Oncologist 2019; 24:e646-e652. [PMID: 30602614 DOI: 10.1634/theoncologist.2018-0512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/07/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Favorable progression-free survival (PFS) and overall survival (OS) results were previously reported on a phase II trial of patients with human epidermal growth receptor 2 (HER2)-positive metastatic breast cancer (MBC), treated with weekly paclitaxel in combination with trastuzumab and pertuzumab in the first- and second-line setting, with a median follow-up of 33 months. Here, we report updated PFS and OS results with more than 2 years of additional follow-up. MATERIALS AND METHODS In this phase II study, adult patients with HER2-positive MBC who received no or one prior therapy received intravenous paclitaxel (80 mg/m2 weekly) with trastuzumab (8 mg/kg loading dose followed by 6 mg/kg every 3 weeks) and pertuzumab (840 mg loading dose followed by 420 mg every 3 weeks), administered in 21-day cycles. Primary endpoint was 6-month PFS, and secondary endpoints included median PFS and OS. RESULTS From January 2011 to December 2013, 69 patients were enrolled: 51 (74%) and 18 (26%) were treated in first- and second-line metastatic settings, respectively. As of August 21, 2017, the median follow-up was 59 months (range, 20-75 months; 67 [97%] patients were evaluable for efficacy). The 6-month PFS was 86% (95% confidence interval [CI] 0.76-0.93). The median PFS was 24.2 months (95% CI 17-35) for the overall population; it was 25.7 months (95% CI 17.0 to not reached) and 20.1 months (95% CI 8.5-33.0) for patients with no and one prior treatment, respectively. The median OS was not reached for the overall group; it was not reached and 39.7 months (95% CI 32.9-66.7) for patients with no and one prior treatment, respectively. Treatment was well tolerated with no additional safety concerns. CONCLUSION With a longer follow-up of almost 5 years, combination of weekly paclitaxel, trastuzumab, and pertuzumab remains effective with a favorable median PFS and a median OS not reached. IMPLICATIONS FOR PRACTICE The combination of weekly paclitaxel, trastuzumab, and pertuzumab has been endorsed by the National Comprehensive Cancer Network as one of the first-line treatment options in patients with human epidermal growth receptor 2 (HER2)-positive metastatic breast cancer (MBC). However, the long-term safety and efficacy are still unknown. Findings from this phase II study provide favorable preliminary data on the safety and efficacy of trastuzumab and pertuzumab in combination with weekly paclitaxel at 5-year follow-up, and it remains an effective first-line treatment option for patients with HER2-positive MBC.
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Affiliation(s)
- Rui Wang
- Memorial Sloan-Kettering Cancer Center, New York New York, USA
| | - Lillian M Smyth
- Memorial Sloan-Kettering Cancer Center, New York New York, USA
| | - Neil Iyengar
- Memorial Sloan-Kettering Cancer Center, New York New York, USA
| | | | - Shanu Modi
- Memorial Sloan-Kettering Cancer Center, New York New York, USA
| | | | - Sujata Patil
- Memorial Sloan-Kettering Cancer Center, New York New York, USA
| | - Larry Norton
- Memorial Sloan-Kettering Cancer Center, New York New York, USA
| | | | - Chau T Dang
- Memorial Sloan-Kettering Cancer Center, New York New York, USA
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Dang CT, Singh JC, Steingart RM, Yu AF. In Reply. Oncologist 2018; 23:e165-e166. [PMID: 30120162 PMCID: PMC6292538 DOI: 10.1634/theoncologist.2018-0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/19/2018] [Indexed: 11/17/2022] Open
Affiliation(s)
- Chau T Dang
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jasmeet C Singh
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Richard M Steingart
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anthony F Yu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Affiliation(s)
- Chau T Dang
- Chau T. Dang, Anthony F. Yu, Jennifer Liu, and Richard Steingart, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anthony F Yu
- Chau T. Dang, Anthony F. Yu, Jennifer Liu, and Richard Steingart, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jennifer Liu
- Chau T. Dang, Anthony F. Yu, Jennifer Liu, and Richard Steingart, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard Steingart
- Chau T. Dang, Anthony F. Yu, Jennifer Liu, and Richard Steingart, Memorial Sloan Kettering Cancer Center, New York, New York
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