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Spring LM, Tolaney SM, Fell G, Bossuyt V, Abelman RO, Wu B, Maheswaran S, Trippa L, Comander A, Mulvey T, McLaughlin S, Ryan P, Ryan L, Abraham E, Rosenstock A, Garrido-Castro AC, Lynce F, Moy B, Isakoff SJ, Tung N, Mittendorf EA, Ellisen LW, Bardia A. Response-guided neoadjuvant sacituzumab govitecan for localized triple-negative breast cancer: results from the NeoSTAR trial. Ann Oncol 2024; 35:293-301. [PMID: 38092228 DOI: 10.1016/j.annonc.2023.11.018] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Sacituzumab govitecan (SG), a novel antibody-drug conjugate (ADC) targeting TROP2, is approved for pre-treated metastatic triple-negative breast cancer (mTNBC). We conducted an investigator-initiated clinical trial evaluating neoadjuvant (NA) SG (NCT04230109), and report primary results. PATIENTS AND METHODS Participants with early-stage TNBC received NA SG for four cycles. The primary objective was to assess pathological complete response (pCR) rate in breast and lymph nodes (ypT0/isN0) to SG. Secondary objectives included overall response rate (ORR), safety, event-free survival (EFS), and predictive biomarkers. A response-guided approach was utilized, and subsequent systemic therapy decisions were at the discretion of the treating physician. RESULTS From July 2020 to August 2021, 50 participants were enrolled (median age = 48.5 years; 13 clinical stage I disease, 26 stage II, 11 stage III). Forty-nine (98%) completed four cycles of SG. Overall, the pCR rate with SG alone was 30% [n = 15, 95% confidence interval (CI) 18% to 45%]. The ORR per RECIST V1.1 after SG alone was 64% (n = 32/50, 95% CI 77% to 98%). Higher Ki-67 and tumor-infiltrating lymphocytes (TILs) were predictive of pCR to SG (P = 0.007 for Ki-67 and 0.002 for TILs), while baseline TROP2 expression was not (P = 0.440). Common adverse events were nausea (82%), fatigue (76%), alopecia (76%), neutropenia (44%), and rash (48%). With a median follow-up time of 18.9 months (95% CI 16.3-21.9 months), the 2-year EFS for all participants was 95%. Among participants with a pCR with SG (n = 15), the 2-year EFS was 100%. CONCLUSIONS In the first NA trial with an ADC in localized TNBC, SG demonstrated single-agent efficacy and feasibility of response-guided escalation/de-escalation. Further research on optimal duration of SG as well as NA combination strategies, including immunotherapy, are needed.
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Affiliation(s)
- L M Spring
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - S M Tolaney
- Dana-Farber Cancer Institute, Harvard Medical School, Boston
| | - G Fell
- Dana-Farber Cancer Institute, Harvard Medical School, Boston
| | - V Bossuyt
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - R O Abelman
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - B Wu
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - S Maheswaran
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - L Trippa
- Dana-Farber Cancer Institute, Harvard Medical School, Boston
| | - A Comander
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - T Mulvey
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - S McLaughlin
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - P Ryan
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - L Ryan
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - E Abraham
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - A Rosenstock
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | | | - F Lynce
- Dana-Farber Cancer Institute, Harvard Medical School, Boston
| | - B Moy
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - S J Isakoff
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - N Tung
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - E A Mittendorf
- Brigham and Women's Hospital, Harvard Medical School, Boston
| | - L W Ellisen
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston; Ludwig Center, Harvard Medical School, Boston, USA
| | - A Bardia
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston.
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Guglielmetti L, Ardizzoni E, Atger M, Baudin E, Berikova E, Bonnet M, Chang E, Cloez S, Coit JM, Cox V, de Jong BC, Delifer C, Do JM, Tozzi DDS, Ducher V, Ferlazzo G, Gouillou M, Khan A, Khan U, Lachenal N, LaHood AN, Lecca L, Mazmanian M, McIlleron H, Moschioni M, O’Brien K, Okunbor O, Oyewusi L, Panda S, Patil SB, Phillips PPJ, Pichon L, Rupasinghe P, Rich ML, Saluhuddin N, Seung KJ, Tamirat M, Trippa L, Cellamare M, Velásquez GE, Wasserman S, Zimetbaum PJ, Varaine F, Mitnick CD. Evaluating newly approved drugs for multidrug-resistant tuberculosis (endTB): study protocol for an adaptive, multi-country randomized controlled trial. Trials 2021; 22:651. [PMID: 34563240 PMCID: PMC8465691 DOI: 10.1186/s13063-021-05491-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment of multidrug- and rifampin-resistant tuberculosis (MDR/RR-TB) is expensive, labour-intensive, and associated with substantial adverse events and poor outcomes. While most MDR/RR-TB patients do not receive treatment, many who do are treated for 18 months or more. A shorter all-oral regimen is currently recommended for only a sub-set of MDR/RR-TB. Its use is only conditionally recommended because of very low-quality evidence underpinning the recommendation. Novel combinations of newer and repurposed drugs bring hope in the fight against MDR/RR-TB, but their use has not been optimized in all-oral, shorter regimens. This has greatly limited their impact on the burden of disease. There is, therefore, dire need for high-quality evidence on the performance of new, shortened, injectable-sparing regimens for MDR-TB which can be adapted to individual patients and different settings. METHODS endTB is a phase III, pragmatic, multi-country, adaptive, randomized, controlled, parallel, open-label clinical trial evaluating the efficacy and safety of shorter treatment regimens containing new drugs for patients with fluoroquinolone-susceptible, rifampin-resistant tuberculosis. Study participants are randomized to either the control arm, based on the current standard of care for MDR/RR-TB, or to one of five 39-week multi-drug regimens containing newly approved and repurposed drugs. Study participation in all arms lasts at least 73 and up to 104 weeks post-randomization. Randomization is response-adapted using interim Bayesian analysis of efficacy endpoints. The primary objective is to assess whether the efficacy of experimental regimens at 73 weeks is non-inferior to that of the control. A sample size of 750 patients across 6 arms affords at least 80% power to detect the non-inferiority of at least 1 (and up to 3) experimental regimens, with a one-sided alpha of 0.025 and a non-inferiority margin of 12%, against the control in both modified intention-to-treat and per protocol populations. DISCUSSION The lack of a safe and effective regimen that can be used in all patients is a major obstacle to delivering appropriate treatment to all patients with active MDR/RR-TB. Identifying multiple shorter, safe, and effective regimens has the potential to greatly reduce the burden of this deadly disease worldwide. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02754765. Registered on 28 April 2016; the record was last updated for study protocol version 3.3, on 27 August 2019.
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Affiliation(s)
- L. Guglielmetti
- Médecins Sans Frontières, Paris, France
- Sorbonne Université, INSERM, U1135, Centre d’Immunologie Et Des Maladies Infectieuses, Paris, France
- Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié-Salpêtrière, Centre National De Référence Des Mycobactéries Et De La Résistance Des Mycobactéries Aux Antituberculeux, Paris, France
| | - E. Ardizzoni
- Institute of Tropical Medicine, Antwerp, Belgium
| | - M. Atger
- Médecins Sans Frontières, Paris, France
| | | | - E. Berikova
- Partners In Health, Astana, Kazakhstan
- National Scientific Center of Phthisiopulmonology, Almaty, Kazakhstan
| | - M. Bonnet
- Médecins Sans Frontières, Paris, France
- Institut de Recherche pour le Développement/INSERM U1175/UMI233/ Université de Montpellier, Montpellier, France
| | - E. Chang
- Médecins Sans Frontières, Toronto, Ontario Canada
| | - S. Cloez
- Médecins Sans Frontières, Paris, France
| | - J. M. Coit
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - V. Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | | | - J. M. Do
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | | | - V. Ducher
- Médecins Sans Frontières, Paris, France
| | - G. Ferlazzo
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | | | - A. Khan
- Interactive Research and Development, Karachi, Pakistan
| | - U. Khan
- Interactive Research and Development, Karachi, Pakistan
| | | | - A. N. LaHood
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - L. Lecca
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Socios En Salud-Sucursal Peru, Lima, Peru
| | - M. Mazmanian
- Médecins Sans Frontières, Paris, France
- Assistance Publique Hôpitaux de Paris, Unité de Recherche Clinique, Hôpital Pitié-Salpêtrière, Paris, France
| | - H. McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - O. Okunbor
- Social & Scientific Systems-DLH, Silver Spring, MD USA
| | | | - S. Panda
- Epidemiology and Communicable Diseases Division, Indian Council of Medical Research, Pune, India
- Indian Council of Medical Research – National AIDS Research Institute, Pune, India
| | - S. B. Patil
- Indian Council of Medical Research – National AIDS Research Institute, Pune, India
| | - P. P. J. Phillips
- University of San Francisco Center for Tuberculosis, San Francisco, CA USA
| | - L. Pichon
- Médecins Sans Frontières, Paris, France
| | | | - M. L. Rich
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Partners In Health, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
| | - N. Saluhuddin
- Department of Infectious Diseases, Indus Hospital, Karachi, Pakistan
| | - K. J. Seung
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Partners In Health, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
| | | | - L. Trippa
- Dana-Farber Cancer Institute, Boston, MA USA
- Harvard T.H. Chan School of Public Health, Boston, MA USA
| | | | - G. E. Velásquez
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, MA USA
| | - S. Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - P. J. Zimetbaum
- Harvard Medical School, Boston, MA USA
- Beth Israel Deaconess Medical Center, Boston, MA USA
| | | | - C. D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Partners In Health, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
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Mayer EL, Abramson V, Jankowitz R, Falkson C, Marcom PK, Traina T, Carey L, Rimawi M, Specht J, Miller K, Stearns V, Tung N, Perou C, Richardson AL, Componeschi K, Trippa L, Tan-Wasielewski Z, Timms K, Krop I, Wolff AC, Winer EP. TBCRC 030: a phase II study of preoperative cisplatin versus paclitaxel in triple-negative breast cancer: evaluating the homologous recombination deficiency (HRD) biomarker. Ann Oncol 2020; 31:1518-1525. [PMID: 32798689 PMCID: PMC8437015 DOI: 10.1016/j.annonc.2020.08.2064] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 04/24/2020] [Revised: 07/21/2020] [Accepted: 08/02/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cisplatin and paclitaxel are active in triple-negative breast cancer (TNBC). Despite different mechanisms of action, effective predictive biomarkers to preferentially inform drug selection have not been identified. The homologous recombination deficiency (HRD) assay (Myriad Genetics, Inc.) detects impaired double-strand DNA break repair and may identify patients with BRCA1/2-proficient tumors that are sensitive to DNA-targeting therapy. The primary objective of TBCRC 030 was to detect an association of HRD with pathologic response [residual cancer burden (RCB)-0/1] to single-agent cisplatin or paclitaxel. PATIENTS AND METHODS This prospective phase II study enrolled patients with germline BRCA1/2 wild-type/unknown stage I-III TNBC in a 12-week randomized study of preoperative cisplatin or paclitaxel. The HRD assay was carried out on baseline tissue; positive HRD was defined as a score ≥33. Crossover to an alternative chemotherapy was offered if there was inadequate response. RESULTS One hundred and thirty-nine patients were evaluable for response, including 88 (63.3%) who had surgery at 12 weeks and 51 (36.7%) who crossed over to an alternative provider-selected preoperative chemotherapy regimen due to inadequate clinical response. HRD results were available for 104 tumors (74.8%) and 74 (71.1%) were HRD positive. The RCB-0/1 rate was 26.4% with cisplatin and 22.3% with paclitaxel. No significant association was observed between HRD score and RCB response to either cisplatin [odds ratio (OR) for RCB-0/1 if HRD positive 2.22 (95% CI: 0.39-23.68)] or paclitaxel [OR for RCB-0/1 if HRD positive 0.90 (95% CI: 0.19-4.95)]. There was no evidence of an interaction between HRD and pathologic response to chemotherapy. CONCLUSIONS In this prospective preoperative trial in TNBC, HRD was not predictive of pathologic response. Tumors were similarly responsive to preoperative paclitaxel or cisplatin chemotherapy.
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Affiliation(s)
- E L Mayer
- Dana-Farber Cancer Institute, Boston, USA.
| | - V Abramson
- Vanderbilt-Ingram Cancer Center, Vanderbilt University, Nashville, USA
| | - R Jankowitz
- University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, USA
| | - C Falkson
- University of Rochester Medical Center, Rochester, USA
| | - P K Marcom
- Duke University Cancer Institute, Durham, USA
| | - T Traina
- Memorial Sloan Kettering Cancer Center, New York, USA
| | - L Carey
- University of North Carolina at Chapel Hill Lineberger Comprehensive Cancer Center, Chapel Hill, USA
| | - M Rimawi
- Baylor College of Medicine, Houston, USA
| | - J Specht
- Seattle Cancer Care Alliance, Seattle, USA
| | - K Miller
- Indiana University Simon Cancer Center, Indianapolis, USA
| | - V Stearns
- Johns Hopkins University Sidney Kimmel Cancer Center, Baltimore, USA
| | - N Tung
- Beth Israel Deaconess Medical Center, Boston, USA
| | - C Perou
- University of North Carolina at Chapel Hill Lineberger Comprehensive Cancer Center, Chapel Hill, USA
| | - A L Richardson
- Johns Hopkins University Sidney Kimmel Cancer Center, Baltimore, USA
| | | | - L Trippa
- Dana-Farber Cancer Institute, Boston, USA
| | | | - K Timms
- Myriad Genetics Inc., Salt Lake City, USA
| | - I Krop
- Dana-Farber Cancer Institute, Boston, USA
| | - A C Wolff
- Johns Hopkins University Sidney Kimmel Cancer Center, Baltimore, USA
| | - E P Winer
- Dana-Farber Cancer Institute, Boston, USA
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Abstract
BACKGROUND Biomarkers that predict treatment response are the foundation of precision medicine in clinical decision-making and have the potential to significantly improve the efficiency of clinical trials. Such biomarkers may be identified before clinical testing but many trials enroll unselected populations. We hypothesized that time-varying treatment effects in unselected trials may result from identifiable responder subpopulations that may have associated biomarkers. MATERIALS AND METHODS We first simulated scenarios of clinical trials with biomarker populations of varying prevalence and prognostic and predictive associations to illustrate the impact of subgroup-specific effects on overall population estimates. To show a real-world example of time-dependent treatment effects resulting from a prognostic and predictive biomarker, we re-analyzed data from a published clinical trial (RTOG, Radiation Therapy Oncology Group, 9402). We then demonstrated a quantitative framework to fit survival data from clinical trials using statistical models incorporating known estimates of biomarker prevalence and prognostic value to prioritize predictive biomarker hypotheses. RESULTS Our simulation studies demonstrate how biomarker subgroups that are both predictive and prognostic can manifest as time-dependent treatment effects in overall populations. RTOG 9402 provides a representative example where 1p/19q co-deletion and IDH mutation biomarker-specific effects led to time-varying treatment effects and a considerable deviation from proportional hazards in the overall trial population. Finally, using biomarker data from The Cancer Genome Atlas, we were able to generate statistical models that correctly identified and prioritized a commonly used biomarker through retrospective analysis of published clinical trial data. CONCLUSIONS Biomarkers that are both predictive and prognostic can result in characteristic changes in survival results. Retrospectively analyzing survival data from clinical trials may highlight potential indications for which an underlying predictive biomarker may be found.
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Affiliation(s)
- R Rahman
- Department of Radiation Oncology, Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston; Department of Radiation Oncology, Harvard Medical School, Boston
| | - S Ventz
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston
| | - G Fell
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston
| | - A M Vanderbeek
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, USA
| | - L Trippa
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston
| | - B M Alexander
- Department of Radiation Oncology, Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston; Department of Radiation Oncology, Harvard Medical School, Boston.
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Cellamare M, Milstein M, Ventz S, Baudin E, Trippa L, Mitnick CD. Bayesian adaptive randomization in a clinical trial to identify new regimens for MDR-TB: the endTB trial. Int J Tuberc Lung Dis 2016; 20:8-12. [DOI: 10.5588/ijtld.16.0066] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- M. Cellamare
- Department of Statistical Sciences, Sapienza University of Rome, Rome, Italy
| | - M. Milstein
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA; Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts, USA
| | - S. Ventz
- Department of Computer Science and Statistics, University of Rhode Island, Kingstown, Rhode Island, USA; Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute and Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - E. Baudin
- Department of Clinical Research, Epicentre Médecins Sans Frontières, Paris, France
| | - L. Trippa
- Department of Biostatistics and Computational Biology, Dana Farber Cancer Institute and Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - C. D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA; Partners In Health, Boston, Massachusetts, USA; Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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