Trastuzumab deruxtecan versus treatment of physician's choice in patients with HER2-positive metastatic breast cancer (DESTINY-Breast02): patient-reported outcomes from a randomised, open-label, multicentre, phase 3 trial

BACKGROUND

In DESTINY-Breast02, patients with HER2-positive unresectable or metastatic breast cancer who received trastuzumab deruxtecan demonstrated superior progression-free and overall survival compared with those receiving treatment of physician's choice. We present the patient-reported outcomes (PROs) and hospitalisation data.

METHODS

In this randomised, open-label, phase 3 trial conducted at 227 clinical sites globally, enrolled patients had to be aged 18 years or older with HER2-positive unresectable or metastatic breast cancer that had progressed on trastuzumab emtansine and had an Eastern Cooperative Oncology Group performance status of 0 or 1. Patients were randomly assigned (2:1) using block randomisation (block size of 3) to receive trastuzumab deruxtecan (5·4 mg/kg intravenously once every 21 days) or treatment of physician's choice by an independent biostatistician using an interactive web-based system. Patients and investigators remained unmasked to treatment. Treatment of physician's choice was either capecitabine (1250 mg/m2 orally twice per day on days 1-14) plus trastuzumab (8 mg/kg intravenously on day 1 then 6 mg/kg once per day) or capecitabine (1000 mg/m2) plus lapatinib (1250 mg orally once per day on days 1-21), with a 21-day schedule. The primary endpoint, which was progression-free survival based on blinded independent central review, has previously been reported. PROs were assessed in the full analysis set (all patients randomly assigned to the study) using the oncology-specific European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), breast cancer-specific EORTC Quality of Life Questionnaire Breast 45 (QLQ-BR45), and the generic HRQoL EQ-5D-5L questionnaire. Analyses included change from baseline and time to definitive deterioration for PRO variables of interest and hospitalisation-related endpoints. This study is registered with ClinicalTrials.gov, NCT03523585, and is closed to recruitment.

FINDINGS

Between Sept 6, 2018, and Dec 31, 2020, 608 patients were randomly assigned to receive either trastuzumab deruxtecan (n=406; two did not receive treatment) or treatment of physician's choice (n=202; seven did not receive treatment). Overall, 603 patients (99%) were female and five (<1%) were male. The median follow-up was 21·5 months (IQR 15·2-28·4) in the trastuzumab deruxtecan group and 18·6 months (IQR 8·8-26·0) in the treatment of physician's choice group. Median treatment duration was 11·3 months (IQR 6·2-20·5) in the trastuzumab deruxtecan group and approximately 4·5 months in the treatment of physician's choice group (4·4 months [IQR 2·5-8·7] with trastuzumab; 4·6 months [2·1-8·9] with capecitabine; and 4·5 months [2·1-10·6] with lapatinib). Baseline EORTC QLQ-C30 global health status (GHS) scores were similar with trastuzumab deruxtecan (n=393) and treatment of physician's choice (n=187), and remained stable with no clinically meaningful change (defined as ≥10-point change from baseline) over time. Median time to definitive deterioration was delayed with trastuzumab deruxtecan compared with treatment of physician's choice for the primary PRO variable EORTC QLQ-C30 GHS (14·1 months [95% CI 10·4-18·7] vs 5·9 months [4·3-7·9]; HR 0·5573 [0·4376-0·7099], p<0·0001) and all other prespecified PROs (EORTC QLQ-C30 subscales, EORTC QLQ-BR45 arm and breast symptoms, and EQ-5D-5L visual analogue scale). Patient hospitalisation rates were similar in the trastuzumab deruxtecan (92 [23%] of 406) and treatment of physician's choice (41 [20%] of 202) groups; however, median time to hospitalisation was 133 days (IQR 56-237) with trastuzumab deruxtecan versus 83 days (30-152) with treatment of physician's choice.

INTERPRETATION

Overall, GHS and quality of life were maintained for both treatment groups, with prespecified PRO variables favouring trastuzumab deruxtecan over treatment of physician's choice, suggesting that despite a longer treatment duration, there was no detrimental impact on patient health-related quality of life with trastuzumab deruxtecan. When considered with efficacy and safety data from DESTINY-Breast02, these results support the overall benefit of trastuzumab deruxtecan for patients with HER2-positive unresectable or metastatic breast cancer previously treated with trastuzumab emtansine.

FUNDING

Daiichi Sankyo and AstraZeneca.

Patient-reported outcomes and hospitalization data in patients with HER2-positive metastatic breast cancer receiving trastuzumab deruxtecan or trastuzumab emtansine in the phase III DESTINY-Breast03 study

BACKGROUND

In the DESTINY-Breast03 clinical trial, trastuzumab deruxtecan (T-DXd) showed superior progression-free survival and overall survival versus trastuzumab emtansine (T-DM1) and manageable safety in patients with human epidermal growth factor receptor 2 (HER2)-positive (HER2+) metastatic breast cancer. Here, patient-reported outcomes (PROs) are reported along with hospitalization data.

PATIENTS AND METHODS

Patients in DESTINY-Breast03 were assessed for prespecified PRO measures, including European Organization for Research and Treatment of Cancer quality of life (EORTC-QoL) questionnaires [the oncology-specific EORTC Quality of Life Questionnaire Core 30 (QLQ-C30) and breast cancer-specific EORTC QLQ-BR45] and the generic EuroQol 5-dimension 5-level questionnaire (EQ-5D-5L) visual analogue scale. Analyses included change from baseline, time to definitive deterioration (TDD), and hospitalization-related endpoints.

RESULTS

EORTC QLQ-C30 baseline global health status (GHS) scores for T-DXd (n = 253) and T-DM1 (n = 260) were similar, with no clinically meaningful change (<10-point change from baseline) while on either treatment (median treatment duration: T-DXd, 14.3 months; T-DM1, 6.9 months). TDD analyses of QLQ-C30 GHS (primary PRO variable) and all other prespecified PROs (QLQ-C30 subscales, the QLQ-BR45 arm symptoms scale, and the EQ-5D-5L visual analogue scale) suggested T-DXd was numerically favored over T-DM1 based on TDD hazard ratios. Of all randomized patients, 18 (6.9%) receiving T-DXd versus 19 (7.2%) receiving T-DM1 were hospitalized, and the median time to first hospitalization was 219.5 versus 60.0 days, respectively.

CONCLUSIONS

In DESTINY-Breast03, EORTC GHS/QoL was maintained on both therapies throughout treatment, indicating that despite the longer treatment duration with T-DXd versus T-DM1, health-related QoL did not worsen on T-DXd. Furthermore, TDD hazard ratios numerically favored T-DXd over T-DM1 in all prespecified variables of interest including pain, suggesting T-DXd may delay time until health-related QoL deterioration compared with T-DM1. Median time to first hospitalization was three times longer with T-DXd versus T-DM1. Together with reported improved efficacy and manageable toxicity, these results support the overall benefit of T-DXd for patients with HER2+ metastatic breast cancer.

Prevalence and Patient Outcomes of Adult Primary Hypercholesterolemia and Dyslipidemia in the UK: Longitudinal Retrospective Study Using a Primary Care Dataset from 2009 to 2019

Background

Guidelines for the management of dyslipidemias recommend intensive low-density lipoprotein (LDL-C) control through lifestyle advice and lipid-lowering drugs to reduce the risk of cardiovascular disease (CVD).

Objective

This retrospective study aimed to characterize the adult primary care population with primary hypercholesterolemia (PH)/mixed dyslipidemia (MD).

Methods

Data on adults with PH/MD between 1 January 2009 and 31 December 2019 in the UK were extracted from linked primary Clinical Practice Research Datalink (CPRD) and secondary care (Hospital Episode Statistics) datasets and analyzed.

Results

A total of 279,221 patients met the inclusion criteria. Mean follow-up was 8.6 years. Crude prevalence of PH/MD increased from 13.5% in 2009 to 23.5% by 2019. The incidence decreased from 176 to 49 per 100,000 population. Mean age of the cohort was 58 years, baseline LDL-C was 4.32 mmol/L, 19.6% had atherosclerotic CVD, 30.1% diabetes, and 8.5% heterozygous familial hypercholesterolemia. Estimated LDL-C reductions of 40% and 50% were achieved in 2.6% and 2.3% of patients, respectively. Most received moderate-intensity statins as monotherapy (62.4%); high-intensity statins were used less frequently (24.3% as initial treatment). Less than 10% of patients received ezetimibe plus statins of different intensities.

Conclusion

The prevalence of dyslipidemia doubled between 2009 and 2019, likely due to more systematic identification of PH/MD. A large proportion of patients with PH/MD are of high and very high CV risk, remain suboptimally treated in terms of lipid lowering, and may experience CV events with associated non-negligible clinical and economic sequelae. Despite intensive LDL-C-lowering recommendations, these do not translate in clinical practice to the wider population.

The prevalence and patient outcomes of adult primary hypercholesterolaemia and dyslipidaemia in the UK: a longitudinal retrospective study using a primary care dataset from 2008 to 2018

Background

Cardiovascular disease (CVD) remains the leading cause of death and morbidity in Europe and United Kingdom (UK). Increased low-density lipoprotein cholesterol (LDL-C), implicated in primary hypercholesterolaemia and mixed dyslipidaemia (PH/MD), is an extensively studied risk factor, with proven direct and linear causality of CVD. Lowering LDL-C remains a primary goal in the treatment and prevention of atherosclerotic CVD.

Objectives

This study aimed to quantify adult prevalence and incidence of PH/MD in the UK.

Methods

We used an anonymised dataset covering primary care practices across the UK, accessed through the Clinical Practice Research Datalink (CPRD GOLD). Ethics approval was sought and provided (Protocol 19_238R). Using a validated set of clinical codes as well as pre-treatment lipid profile levels for total cholesterol (TC) (&gt;8 mmol/L), LDL-C (&gt;4.9 mmol/L), we calculated prevalent and new adult cases starting from 2009 to 2018. Our denominator population was the CPRD GOLD GP-registered adult population each calendar year, adjusted for mortality.

Results

There were 1,514,916 adults in the CPRD GOLD GP register for the period from 2009 to 2018. During that period there were 354,444 patients diagnosed with PH/MD. Males comprised 46.5%, mean age on diagnosis was 58.2 years. Mean follow-up time was 104 months. The annual prevalence of PH/MD increased from 2009 to 2019 (see graph). The overall prevalence across the period was 22.7%. Mean annual incidence across the decade was 1.7%. Mean LDL-C levels were 4.7 mmol/L and mean TC level was 6.8 mmol/L. In this cohort, 15.9% experienced cardiovascular events (see table). Nearly all patients have used lipid lowering therapies. Only 2.2% achieved at least 40% reduction of LDL-C from baseline.

Conclusions

The prevalence of PH/MD has been increasing despite the availability of interventions. Considering guidelines, only a small proportion of patients have achieved LDL-C goals.

Est prevalence of PH/MD in the UK

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Daiichi Sankyo Europe, Health iQ Ltd

Systematic review of cost-effectiveness analyses for combinations of prevention strategies against human papillomavirus (HPV) infection: a general trend

BACKGROUND

Due to the arrival of multi-valent HPV vaccines, it is more and more important to have a better understanding of the relationship between vaccination and screening programmes. This review aimed to: (1) collect published evidence on the cost-effectiveness profile of different HPV prevention strategies and, in particular, those combining vaccination with changes in screening practices; (2) explore the cost-effectiveness of alternative preventive strategies based on screening and vaccination.

METHODS

A systematic literature review was conducted in order to identify the relevant studies regarding the cost-effectiveness of prevention strategies against HPV infection. Analysis comparing the modelling approaches between studies was made along with an assessment of the magnitude of impact of several factors on the cost-effectiveness of different screening strategies.

RESULTS

A total of 18 papers were quantitatively summarised within the narrative. A high degree of heterogeneity was found in terms of how HPV prevention strategies have been assessed in terms of their economic and epidemiological impact, with variation in screening practice and valence of HPV vaccination found to have large implications in terms of cost-effectiveness.

CONCLUSIONS

This review demonstrated synergies between screening and vaccination. New prevention strategies involving multi-valence vaccination, HPV DNA test screening, delayed commencement and frequency of screening could be implemented in the future. Strategies implemented in the future should be chosen with care, and informed knowledge of the potential impact of all possible prevention strategies. Highlighted in this review is the difficulty in assessing multiple strategies. Appropriate modelling techniques will need to be utilised to assess the most cost-effective strategies.

Arctic biogeography: The paradox of the marine benthic fauna and flora

The marine benthic fauna and flora that inhabit the shallow arctic sublittoral zone comprise a relatively young marine assemblage characterized by species of either Pacific or Atlantic affinity and notably few endemics. The young character of nearshore arctic communities, as well as their biogeographical composition, is largely a product of the Pleistocene glaciation. However, analysis of more recent collections and comparison between the origins of the benthic fauna and flora present some interesting paradoxes to biogeographers. One enigma is the low frequency of algal species with Pacific affinities in the Arctic, especially in the Chukchi, Beaufort and East Siberian Seas of the Eastern Arctic, which receive direct inputs of northward-flowing Pacific waters. In contrast, animal species with Pacific affinities are found throughout the nearshore regions of the Arctic, reaching their highest frequency in the marginal seas between the New Siberian Islands and the Canadian Archipelago. Organization of published and unpublished data, additional field collections, and the use of cladistics and molecular DNA techniques by systematists are a high priority for future research in reconstructing the evolution of the arctic biotic assemblage.