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Lindeman GJ, Lok SW, Whittle JR, Siow ZR, Bergin AR, Dawson SJ, Desai J, Gray DH, Liew D, Mann GB, Murugasu A, Roberts AW, Rosenthal MA, Shackleton K, Sherman P, Silva MJ, Teh C, Travers A, Vaillant F, Visvader JE. Abstract PD1-06: A phase 1b dose-escalation and expansion study of the BCL-2 inhibitor venetoclax combined with tamoxifen in ER and BCL-2–positive metastatic breast cancer (MBC). Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-pd1-06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Venetoclax, a potent and selective inhibitor of the survival protein BCL-2 (recently approved in CLL and in development in other hematopoietic malignancies), has yet to be evaluated in pts with solid tumors. BCL-2 is overexpressed in ˜85% of ER+ breast cancer. Pre-clinical findings using patient-derived xenograft breast tumor models suggest that venetoclax synergizes with endocrine therapy by increasing apoptosis. Here we report mBEP, an investigator-initiated phase 1b study of venetoclax with tamoxifen in 33 pts with ER+ (>1%), BCL-2+ (>10%, 2-3+ intensity) and HER2– MBC.
Methods: We conducted a 3+3 dose escalation study comprising cohorts receiving venetoclax 200, 400, 600 or 800 mg/d with tamoxifen 20 mg/d (continued until progression). The primary endpoint was to determine the maximum tolerated dose (MTD), define dose-limiting toxicities (DLTs) and identify the recommended phase 2 dose (RP2D). In a dose expansion phase (at the RP2D), secondary endpoints including safety and tolerability, response at 24 wks (RECIST v1.1), clinical benefit rate (CBR) and progression-free survival (PFS) were studied.
Results: In the escalation phase (n=15 pts), treatment was well tolerated with no DLTs or high-grade (Gd 3/4) adverse events observed, apart from asymptomatic on-target lymphopenia (Gd 3, 2/15 pts). MTD was not reached. The 800 mg/d dose was selected as the RP2D and the cohort expanded to include 24 pts with ≥24 wks follow up (range 24-105 wks). Fifteen pts had received prior regimens for MBC (median 3, range 1-9) that included tamoxifen in 5/15.
For the RP2D cohort (n=24), overall responses (OR) included 1 CR (4%) and 12 PR (50%), with 5 SD (21%), corresponding to a CBR of 75%. The 9 pts treated in the first line setting experienced a 78% OR (7/9 pts) and 11% SD (1/9 pts), equating to an 89% CBR. The data are immature for determining median PFS for the RP2D cohort (currently 40+ wks).
Treatment responses were pre-empted by metabolic responses (FDG-PET) at 4 wks (seen in 13/16 (81%) pts studied), and correlated with serial changes in circulating tumor DNA (ctDNA). Intriguingly, responses and clinical benefit were observed in pts with plasma-detected ESR1 mutations (4/10 and 7/10, respectively).
The most common treatment-related AEs (CTCAE v4.0) for all pts were lymphopenia in 29/33 (88%; 57% Gd 1-2, 30% Gd 3-4), neutropenia in 24/33 (73%; 67% Gd 1-2, 6% Gd 3), nausea in 22/33 (67%; all ≤Gd 2), anemia in 13/33 (39%; 33% Gd 1-2, 6% G3), thrombocytopenia in 11/33 (33%; all ≤Gd 2), vomiting in 11/33 (33%, all ≤Gd 2), diarrhea in 10/33 (30%; 24% Gd 1-2, 6% Gd 3), infection in 9/33 (27%; 18% Gd 2, 9% Gd 3) and fatigue in 7/33 (21%; all ≤Gd 2). There was one possible treatment-related SAE (infection).
Conclusions: In the first clinical study to evaluate venetoclax in a solid tumor, we demonstrate that combining venetoclax with endocrine therapy has a tolerable safety profile and elicits remarkable activity in ER+ and BCL-2+ MBC. These findings support further investigation of combination therapy for patients with BCL-2-positive breast cancer.
Sponsor: The Royal Melbourne Hospital (ACTRN12615000702516)
Citation Format: Lindeman GJ, Lok SW, Whittle JR, Siow ZR, Bergin AR, Dawson S-J, Desai J, Gray DH, Liew D, Mann GB, Murugasu A, Roberts AW, Rosenthal MA, Shackleton K, Sherman P, Silva MJ, Teh C, Travers A, Vaillant F, Visvader JE. A phase 1b dose-escalation and expansion study of the BCL-2 inhibitor venetoclax combined with tamoxifen in ER and BCL-2–positive metastatic breast cancer (MBC) [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 PD1-06.
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Affiliation(s)
- GJ Lindeman
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - SW Lok
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - JR Whittle
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - ZR Siow
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - AR Bergin
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - S-J Dawson
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - J Desai
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - DH Gray
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - D Liew
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - GB Mann
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - A Murugasu
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - AW Roberts
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - MA Rosenthal
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - K Shackleton
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - P Sherman
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - MJ Silva
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - C Teh
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - A Travers
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - F Vaillant
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
| | - JE Visvader
- The Royal Melbourne Hospital, Melbourne, Australia; The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia; The Peter MacCallum Cancer Centre, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; The Royal Women's Hospital, Melbourne, Australia
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Lindeman GJ, Nolan E, Pal B, Vaillant F, Giner G, Whitehead L, Mann GB, Lok SW, Shackleton K, Smyth GK, Visvader JE. Abstract P3-11-05: RANK ligand is a target for breast cancer prevention in BRCA1 mutation carriers. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p3-11-05] [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: BRCA1 mutation carriers often undergo prophylactic mastectomy to minimize their risk of breast cancer. The value of targeting ovarian hormones to prevent breast tumorigenesis remains contentious and the identification of an effective and acceptable chemoprevention strategy remains a 'holy grail' for the field. Recently, luminal progenitor cells have been identified as the likely cell-of-origin for BRCA1-associated breast tumors1. In addition, deregulated progesterone signaling has been implicated as a potential mechanism underlying tumor development in Brca1-deficient mammary glands2, although its role in luminal progenitor activation in BRCA1 mutation carriers is unknown. RANKL (Receptor Activator of Nuclear Factor-kappa B Ligand) has been identified as a key paracrine effector of progesterone-induced mammary epithelial proliferation in both mouse and human tissue3-5. Notably, RANKL and its receptor RANK play a critical role in the development of breast cancer, with inhibition of RANKL resulting in attenuation of tumorigenesis in mouse models of hormone-driven mammary carcinogenesis6,7.
Methods: We explored a role for the RANK/RANKL pathway during the preneoplastic phase in freshly isolated, histologically normal specimens from BRCA1 mutation carriers using a combination of strategies. RANK and RANKL expression in breast cancer was also evaluated in formalin fixed paraffin embedded (FFPE) archival sections by IHC. All samples were obtained with relevant IRB approval. A role for RANKL inhibition in attenuating tumor onset was studied using models that recapitulate human basal-like cancer.
Results: A RANK+ subset of luminal progenitor cells was identified in histologically normal breast tissue from BRCA1-mutation carriers. The RANK+ luminal progenitors exhibited higher proliferative activity compared to RANK- progenitors. RNA profiling revealed a distinctive molecular signature, consistent with the RANK+ subset being a possible target for neoplastic transformation. In established BRCA1-associated breast tumors, a four-fold higher incidence of RANK expression was observed, compared to tumors from non-carriers. In ongoing work, histologically normal pre-neoplastic BRCA1mut/+ tissue is being studied using ex vivo breast organoid assays to determine whether RANKL inhibition can attenuate breast epithelial proliferation.
Conclusions: Our data raise the possibility that RANK signaling is implicated in the initiation of tumorigenesis in BRCA1 mutation carriers (and possibly other high risk women) and that RANKL is a promising chemoprevention target. The findings are of sufficient interest to have led to a clinical trial, BRCA-D (Registered as ACTRN12614000694617). A finalized abstract will be submitted in early September, during the Late-Breaking Abstract submission period.
References:
1. Lim et al Nature Med 2009: 15, 907-13.
2. Poole et al Science 2006: 314, 1467-70.
3. Asselin-Labat et al Nature 2010: 465, 798-802.
4. Joshi et al Nature 2010: 465, 803-7.
5. Tanos et al Sci Transl Med 2013: 5, 182ra55.
6. Schramek et al Nature 2010: 468, 98-102.
7. Gonzales-Suarez et al Nature 2010: 468, 103-7.
Citation Format: Lindeman GJ, Nolan E, Pal B, Vaillant F, Giner G, Whitehead L, Mann GB, Lok SW, Shackleton K, Kathleen Cuningham Foundation Consortium (kConFab), Smyth GK, Visvader JE. RANK ligand is a target for breast cancer prevention in BRCA1 mutation carriers. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-11-05.
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Affiliation(s)
- GJ Lindeman
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia; The Royal Melbourne Hospital, Melbourne, Victoria, Australia; The Royal Women's Hospital, Melbourne, Victoria, Australia; The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - E Nolan
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia; The Royal Melbourne Hospital, Melbourne, Victoria, Australia; The Royal Women's Hospital, Melbourne, Victoria, Australia; The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - B Pal
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia; The Royal Melbourne Hospital, Melbourne, Victoria, Australia; The Royal Women's Hospital, Melbourne, Victoria, Australia; The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - F Vaillant
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia; The Royal Melbourne Hospital, Melbourne, Victoria, Australia; The Royal Women's Hospital, Melbourne, Victoria, Australia; The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - G Giner
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia; The Royal Melbourne Hospital, Melbourne, Victoria, Australia; The Royal Women's Hospital, Melbourne, Victoria, Australia; The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - L Whitehead
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia; The Royal Melbourne Hospital, Melbourne, Victoria, Australia; The Royal Women's Hospital, Melbourne, Victoria, Australia; The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - GB Mann
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia; The Royal Melbourne Hospital, Melbourne, Victoria, Australia; The Royal Women's Hospital, Melbourne, Victoria, Australia; The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - SW Lok
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia; The Royal Melbourne Hospital, Melbourne, Victoria, Australia; The Royal Women's Hospital, Melbourne, Victoria, Australia; The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - K Shackleton
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia; The Royal Melbourne Hospital, Melbourne, Victoria, Australia; The Royal Women's Hospital, Melbourne, Victoria, Australia; The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - GK Smyth
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia; The Royal Melbourne Hospital, Melbourne, Victoria, Australia; The Royal Women's Hospital, Melbourne, Victoria, Australia; The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - JE Visvader
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia; The Royal Melbourne Hospital, Melbourne, Victoria, Australia; The Royal Women's Hospital, Melbourne, Victoria, Australia; The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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