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Gómez Tejeda Zañudo J, Barroso-Sousa R, Jain E, Jin Q, Li T, Buendia-Buendia JE, Pereslete A, Abravanel DL, Ferreira AR, Wrabel E, Helvie K, Hughes ME, Partridge AH, Overmoyer B, Lin NU, Tayob N, Tolaney SM, Wagle N. Exemestane plus everolimus and palbociclib in metastatic breast cancer: clinical response and genomic/transcriptomic determinants of resistance in a phase I/II trial. Nat Commun 2024; 15:2446. [PMID: 38503755 PMCID: PMC10951222 DOI: 10.1038/s41467-024-45835-6] [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] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 02/02/2024] [Indexed: 03/21/2024] Open
Abstract
The landscape of cyclin-dependent kinase 4/6 inhibitor (CDK4/6i) resistance is still being elucidated and the optimal subsequent therapy to overcome resistance remains uncertain. Here we present the final results of a phase Ib/IIa, open-label trial (NCT02871791) of exemestane plus everolimus and palbociclib for CDK4/6i-resistant metastatic breast cancer. The primary objective of phase Ib was to evaluate safety and tolerability and determine the maximum tolerated dose/recommended phase II dose (100 mg palbociclib, 5 mg everolimus, 25 mg exemestane). The primary objective of phase IIa was to determine the clinical benefit rate (18.8%, n = 6/32), which did not meet the predefined endpoint (65%). Secondary objectives included pharmacokinetic profiling (phase Ib), objective response rate, disease control rate, duration of response, and progression free survival (phase IIa), and correlative multi-omics analysis to investigate biomarkers of resistance to CDK4/6i. All participants were female. Multi-omics data from the phase IIa patients (n = 24 tumor/17 blood biopsy exomes; n = 27 tumor transcriptomes) showed potential mechanisms of resistance (convergent evolution of HER2 activation, BRAFV600E), identified joint genomic/transcriptomic resistance features (ESR1 mutations, high estrogen receptor pathway activity, and a Luminal A/B subtype; ERBB2/BRAF mutations, high RTK/MAPK pathway activity, and a HER2-E subtype), and provided hypothesis-generating results suggesting that mTOR pathway activation correlates with response to the trial's therapy. Our results illustrate how genome and transcriptome sequencing may help better identify patients likely to respond to CDK4/6i therapies.
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Affiliation(s)
- Jorge Gómez Tejeda Zañudo
- Cancer Program, Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Romualdo Barroso-Sousa
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Oncology Center, Hospital Sírio-Libanês, Brasília, Brazil
| | - Esha Jain
- Cancer Program, Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Repare Therapeutics, Cambridge, MA, USA
| | - Qingchun Jin
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, MA, USA
| | - Tianyu Li
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, MA, USA
| | - Jorge E Buendia-Buendia
- Cancer Program, Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Cellarity, Somerville, MA, USA
| | | | - Daniel L Abravanel
- Cancer Program, Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Arlindo R Ferreira
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
| | - Eileen Wrabel
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Karla Helvie
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Ann H Partridge
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Beth Overmoyer
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Nancy U Lin
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Nabihah Tayob
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, MA, USA
| | - Sara M Tolaney
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Nikhil Wagle
- Cancer Program, Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
- Genentech, South San Francisco, CA, USA.
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Tarantino P, Gupta H, Hughes ME, Files J, Strauss S, Kirkner G, Feeney AM, Li Y, Garrido-Castro AC, Barroso-Sousa R, Bychkovsky BL, DiLascio S, Sholl L, MacConaill L, Lindeman N, Johnson BE, Meyerson M, Jeselsohn R, Qiu X, Li R, Long H, Winer EP, Dillon D, Curigliano G, Cherniack AD, Tolaney SM, Lin NU. Author Correction: Comprehensive genomic characterization of HER2-low and HER2-0 breast cancer. Nat Commun 2023; 14:8321. [PMID: 38097580 PMCID: PMC10721787 DOI: 10.1038/s41467-023-44124-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Affiliation(s)
- Paolo Tarantino
- 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 Hematology-Oncology, University of Milano, Milano, Italy.
| | - Hersh Gupta
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | | | - Janet Files
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sarah Strauss
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Gregory Kirkner
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Yvonne Li
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ana C Garrido-Castro
- 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
| | - Romualdo Barroso-Sousa
- Dasa Institute for Education and Research (IEPD), Brasilia, Brazil
- Dasa Oncology/Hospital Brasilia, Brasilia, Brazil
| | - Brittany L Bychkovsky
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Simona DiLascio
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Lynette Sholl
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Neal Lindeman
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Pathology, Weill Cornell Medicine, New York, NY, USA
| | - Bruce E Johnson
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Matthew Meyerson
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Rinath Jeselsohn
- 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
| | - Xintao Qiu
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rong Li
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Henry Long
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Eric P Winer
- Yale Cancer Center, Yale School of Medicine, Smilow Cancer Hospital, New Haven, CT, USA
| | - Deborah Dillon
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Giuseppe Curigliano
- Division of Early Drug Development, European Institute of Oncology IRCCS, Milano, Italy
| | - Andrew D Cherniack
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Sara M Tolaney
- 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
| | - Nancy U Lin
- 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
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3
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Tarantino P, Gupta H, Hughes ME, Files J, Strauss S, Kirkner G, Feeney AM, Li Y, Garrido-Castro AC, Barroso-Sousa R, Bychkovsky BL, DiLascio S, Sholl L, MacConaill L, Lindeman N, Johnson BE, Meyerson M, Jeselsohn R, Qiu X, Li R, Long H, Winer EP, Dillon D, Curigliano G, Cherniack AD, Tolaney SM, Lin NU. Comprehensive genomic characterization of HER2-low and HER2-0 breast cancer. Nat Commun 2023; 14:7496. [PMID: 37980405 PMCID: PMC10657399 DOI: 10.1038/s41467-023-43324-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 11/07/2023] [Indexed: 11/20/2023] Open
Abstract
The molecular underpinnings of HER2-low and HER2-0 (IHC 0) breast tumors remain poorly defined. Using genomic findings from 1039 patients with HER2-negative metastatic breast cancer undergoing next-generation sequencing from 7/2013-12/2020, we compare results between HER2-low (n = 487, 47%) and HER2-0 tumors (n = 552, 53%). A significantly higher number of ERBB2 alleles (median copy count: 2.05) are observed among HER2-low tumors compared to HER2-0 (median copy count: 1.79; P = 2.36e-6), with HER2-0 tumors harboring a higher rate of ERBB2 hemideletions (31.1% vs. 14.5%). No other genomic alteration reaches significance after accounting for multiple hypothesis testing, and no significant differences in tumor mutational burden are observed between HER2-low and HER2-0 tumors (median: 7.26 mutations/megabase vs. 7.60 mutations/megabase, p = 0.24). Here, we show that the genomic landscape of HER2-low and HER2-0 tumors does not differ significantly, apart from a higher ERBB2 copy count among HER2-low tumors, and a higher rate of ERBB2 hemideletions in HER2-0 tumors.
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Affiliation(s)
- Paolo Tarantino
- 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 Hematology-Oncology, University of Milano, Milano, Italy.
| | - Hersh Gupta
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | | | - Janet Files
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sarah Strauss
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Gregory Kirkner
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Yvonne Li
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ana C Garrido-Castro
- 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
| | - Romualdo Barroso-Sousa
- Dasa Institute for Education and Research (IEPD), Brasilia, Brazil
- Dasa Oncology/Hospital Brasilia, Brasilia, Brazil
| | - Brittany L Bychkovsky
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Simona DiLascio
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Lynette Sholl
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Neal Lindeman
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Pathology, Weill Cornell Medicine, New York, NY, USA
| | - Bruce E Johnson
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Matthew Meyerson
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Rinath Jeselsohn
- 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
| | - Xintao Qiu
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rong Li
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Henry Long
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Eric P Winer
- Yale Cancer Center, Yale School of Medicine, Smilow Cancer Hospital, New Haven, CT, USA
| | - Deborah Dillon
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Giuseppe Curigliano
- Division of Early Drug Development, European Institute of Oncology IRCCS, Milano, Italy
| | - Andrew D Cherniack
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Sara M Tolaney
- 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
| | - Nancy U Lin
- 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
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Sammons S, Elliott A, Barroso-Sousa R, Chumsri S, Tan AR, Sledge GW, Tolaney SM, Torres ETR. Concurrent predictors of an immune responsive tumor microenvironment within tumor mutational burden-high breast cancer. Front Oncol 2023; 13:1235902. [PMID: 37637072 PMCID: PMC10457522 DOI: 10.3389/fonc.2023.1235902] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/17/2023] [Indexed: 08/29/2023] Open
Abstract
Background Data supporting high tumor mutational burden (TMB-H) as a lone biomarker for an immune-responsive tumor microenvironment (TME) in metastatic breast cancer (MBC) are weak, yet tumor agnostic approval in TMB-H advanced tumors provides immune checkpoint inhibition (ICI) as a clinical option. We evaluated concurrent predictors of immune-responsive and non-responsive TME within MBC. Methods Tumor samples from patients with MBC (N=5621) were analyzed by next-generation sequencing of DNA (592-gene panel or whole exome) and RNA (whole transcriptome) at Caris Life Sciences (Phoenix, AZ). TMB-H threshold was set to ≥ 10 muts/Mb. PDL-1 was evaluated using SP142 antibody. Gene expression profiling and RNA deconvolution were used to estimate immune and stromal cell population abundance in the TME, and transcriptomic signature of immunotherapy response (T cell-inflamed score). Results 461 (8.2%) TMB-H MBC samples were identified. Consistent with prior studies, TMB-H tumors exhibited significant dMMR/MSI-H enrichment (7 vs. 0%, p<0.0001) and PD-L1+ expression (36 vs. 28%, p<0.05) compared to TMB-L. Across all samples, T cell-inflamed scores were weakly correlated with TMB. TMB-H was not associated with significantly increased immune responsive cell types (CD8+ T-cells, NK cells, or B cells) or immune response gene signatures (e.g. antigen presentation), yet positive trends were observed, while immunosuppressive fibroblasts were significantly decreased in TMB-H tumors (0.84-fold change compared to TMB-L, P<0.05). HR+/HER2- breast cancer was the only subtype in which TMB-H tumors exhibited increased T cell-inflamed scores vs. TMB-L. Concurrent PD-L1+ or dMMR/MSI-H with TMB-H was associated with high T cell-inflamed scores in both HR+/HER2- and TNBC. Among several associated biomarkers, B2M mutations and CD274 amplifications were positively associated with T-cell inflamed scores in TMB-H tumors; CDH1 and ERBB2 mutations were negatively associated. Conclusion High TMB alone does not strongly correlate with immune infiltrate or immune-related gene signatures in MBC. TMB-H predicts T-cell inflamed signature compared to TMB-L in HR+/HER2- tumors only. Along with MSI-H and PD-L1+, several biomarkers, including B2M mutation and CD274 amplification, may help predict ICI benefit amongst TMB-H tumors. Co-occurring biomarkers within TMB-H breast cancer warrant evaluation in larger cohorts for response or resistance to ICI to develop composite predictive biomarkers in MBC.
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Affiliation(s)
- Sarah Sammons
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Andrew Elliott
- Clinical and Translational Research, Caris Life Sciences, Phoenix, AZ, United States
| | - Romualdo Barroso-Sousa
- Department of Oncology, Dasa Institute for Education and Research (IEPD), Brasilia, Brazil
- Dasa Oncology/Hospital Brasilia, Brasilia, Brazil
| | - Saranya Chumsri
- Department of Hematology Oncology and Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, United States
| | - Antoinette R. Tan
- Levine Cancer Institute, Atrium Health, Charlotte, NC, United States
| | - George W. Sledge
- Clinical and Translational Research, Caris Life Sciences, Phoenix, AZ, United States
| | - Sara M. Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Evanthia T. Roussos Torres
- Division of Oncology, Department of Medicine, Keck School of Medicine, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, United States
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Barroso-Sousa R, Pacífico JP, Sammons S, Tolaney SM. Tumor Mutational Burden in Breast Cancer: Current Evidence, Challenges, and Opportunities. Cancers (Basel) 2023; 15:3997. [PMID: 37568813 PMCID: PMC10417019 DOI: 10.3390/cancers15153997] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
Tumor mutational burden (TMB) correlates with tumor neoantigen burden, T cell infiltration, and response to immune checkpoint inhibitors in many solid tumor types. Based on data from the phase II KEYNOTE-158 study, the anti-PD-1 antibody pembrolizumab was granted approval for treating patients with advanced solid tumors and TMB ≥ 10 mutations per megabase. However, this trial did not include any patients with metastatic breast cancer; thus, several questions remain unanswered about the true role of TMB as a predictive biomarker of benefit to immune checkpoint inhibitor therapy in breast cancer. In this review, we will discuss the challenges and opportunities in establishing TMB as a predictive biomarker of benefit to immunotherapy in metastatic breast cancer.
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Affiliation(s)
- Romualdo Barroso-Sousa
- Dasa Institute for Education and Research (IEPD), Brasilia 71635-580, DF, Brazil
- Dasa Oncology, Hospital Brasilia, Brasilia 71635-580, DF, Brazil
| | - Jana Priscila Pacífico
- Dasa Institute for Education and Research (IEPD), Brasilia 71635-580, DF, Brazil
- Dasa Oncology, Hospital Brasilia, Brasilia 71635-580, DF, Brazil
| | - Sarah Sammons
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Sara M. Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02115, USA
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Kabraji S, Li YY, Hughes ME, Gupta HV, Buckley L, Files JL, Mohammed-Abreu A, Feeney AM, Kirkner G, Patel A, Garrido-Castro AC, Barroso-Sousa R, Bychkovsky B, Meyerson M, Tolaney S, Dillon DA, Johnson B, Winer E, Cherniack A, Lin NU. Abstract PD7-07: Somatic alterations in primary tumors of patients (pts) with metastatic breast cancer (MBC) may predict likelihood of brain metastasis. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-pd7-07] [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: Despite advances in treatment options, outcomes remain poor for many pts with breast cancer brain metastases (BCBMs). Identifying genomic predictors of brain metastasis from primary tumors could lead to better stratification of pts at risk and drive the development of preventative strategies. The objective of this study was to describe the landscape of genomic alterations in primary tumors from pts with MBC who subsequently did or did not develop BCBMs.
Methods: We performed a case control study to identify somatic alterations in primary tumors associated with a higher incidence of brain metastases. We reviewed outcomes for 2562 unique MBC patients from a single institution who underwent targeted next-generation DNA sequencing of > 280 cancer-related genes (OncoPanel) from their tumor between July 1, 2013 and December 31, 2020. Pts were included in this analysis if they had at least 2 years of follow-up from date of metastatic diagnosis and OncoPanel testing on a primary breast tumor. We compared single nucleotide variants (oncogenic or likely oncogenic), copy number variation (amplification and deep deletions) and tumor mutation burden in the primary tumors of pts in this cohort. Copy number variation was corrected for Panel version and tumor purity. Wilcoxon rank sum test and Fisher exact test was used to compare genomic differences between groups. False discovery rate was used to correct for multiple hypothesis testing and q < 0.1 was considered significant
Results: A total of 369 pts were included in the final analytic cohort. Of these, 115 were diagnosed with brain mets (cases, BM group) and 224 were not (controls, nBM group). The BM group was enriched for patients with HER2-positive breast cancer (33 vs 12.5%), consistent with previous work. In the whole cohort, the most common and clinically significant somatic alterations (oncogenic single nucleotide variants or copy number high amplification or two copy deletion) are shown in Table 1. When adjusting for subtype there were no significantly enriched SNVs in BM vs nBM group. When adjusting for subtype, FGFR1 amplification was significantly enriched in hormone receptor positive HER2 negative (HR+ HER2-) patients with BM (log2 odds ratio 1.22, q < 0.1). Tumor mutation burden was not significantly different in primary tumors between the BM and nBM groups (median TMB 7.3 vs 6.1, Wilcoxon p = 0.08).
Pathway analysis combining all subtypes revealed that RTK_RAS pathway (log2 odds ratio 1.64, q value < 0.1) and TP53 pathway (log2 odds ratio 1.15, q value < 0.1) gene sets were significantly enriched in the BM group. When controlling for subtype, pathway analysis revealed that RTK_RAS pathway gene set was significantly enriched in HR+ HER2- BM group (log2 odds ratio 1.36 q < 0.1).
Conclusions: In this case control series of patients with metastatic breast cancer with or without brain metastases, we found that primary tumors that are enriched for somatic alterations in the RTK_RAS and TP53 pathway may be associated with higher risk of developing brain metastases. Further validation in larger cohorts is warranted.
Table 1. Frequency of somatic alterations in primary tumor by brain metastasis outcome.
Citation Format: Sheheryar Kabraji, Yvonne Y. Li, Melissa E. Hughes, Hersh V. Gupta, Lauren Buckley, Janet L. Files, Ayesha Mohammed-Abreu, Anne-Marie Feeney, Greg Kirkner, Ashka Patel, Ana C. Garrido-Castro, Romualdo Barroso-Sousa, Brittany Bychkovsky, Matthew Meyerson, Sara Tolaney, Deborah A. Dillon, Bruce Johnson, Eric Winer, Andrew Cherniack, Nancy U. Lin. Somatic alterations in primary tumors of patients (pts) with metastatic breast cancer (MBC) may predict likelihood of brain metastasis [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 PD7-07.
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Affiliation(s)
| | | | | | - Hersh V. Gupta
- 4Albert Einstein College of Medicine MSTP (previously: Medical Oncology, Dana-Farber Cancer Institute)
| | | | - Janet L. Files
- 6Medical Oncology, Dana-Farber Cancer Institute, Hull, Massachusetts
| | | | | | | | - Ashka Patel
- 10Department of Pathology, Brigham and Women’s Hospital
| | | | | | - Brittany Bychkovsky
- 13Comprehensive Breast Health Center, Brigham and Women’s Hospital; Breast Oncology Program, Dana-Farber Brigham Cancer Center Division of Cancer Genetics and Prevention; Dana-Farber Cancer Institute; Harvard Medical School
| | - Matthew Meyerson
- 14Medical Oncology, Dana-Farber Cancer Institute; Center for Cancer Genomics, Dana-Farber Cancer Institute; Harvard Medical School; Broad Institute
| | | | - Deborah A. Dillon
- 16Brigham and Women’s Hospital, Breast Oncology Program, Susan F. Smith Center for Women’s Cancers, Dana-Farber Brigham Cancer Center; Harvard Medical School
| | - Bruce Johnson
- 17Medical Oncology, Dana-Farber Cancer Institute; Harvard Medical School
| | | | - Andrew Cherniack
- 19Medical Oncology, Dana-Farber Cancer Institute; Broad Institute
| | - Nancy U. Lin
- 20Dana-Farber Cancer Institute, Boston, Massachusetts
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Correa TS, Sandoval RL, Oliveira ES, Leite ACR, Weis LN, Achatz MI, Oliveira CP, Asprino PF, Barroso-Sousa R. Abstract P5-03-19: Frequency of germline TP53 p.R337H variant among women at risk of hereditary breast cancer in a public health system of Central-West of Brazil. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p5-03-19] [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: Breast Cancer (BC) is one of the most common cancers diagnosed in Li-Fraumeni Syndrome (LFS). Most studies about the frequency of germline pathogenic variant (PV) TP53 p.R337H have been conducted in the South and Southeastern regions of Brazil reaching rates as high as 8% of detection. There is a lack of data on the frequency of this germline PV in other Brazilian regions, especially among patients without access to genetic tests. Objective: This study aims to evaluate the detection rate of TP53 p.R337H in patients (pts) at risk of hereditary breast cancer (HBC) and describe the clinical and demographic profile of the study cohort. Methodology: Hereditary cancer risk assessment based on the National Comprehensive Cancer Network Criteria (NCCN), version 1.2020, was performed in women with BC who were being followed in a public hospital (DF, Brazil) between January 2021 and January 2022. All pts eligible for germline genetic testing according to HBC NCCN criteria were referred for genetic counseling and genetic testing. For those patients who could not afford a comprehensive genetic test, a real time PCR test specifically searching for TP53 p.R337H variant was performed. In case of TP53 p.R337H detection in the proband, genetic counseling and familial variant testing were offered to family members. Results: Among 221 pts eligible for this study, 180 pts performed germline testing, including 100 pts tested only for the TP53 p.R337H variant (real-time PCR) and 80 pts performed out of pocket BC multigene panel testing (including TP53 sequencing). This cohort was mostly represented by pts from Central-West (47%) and Northeast (35%) regions of Brazil. The median age of BC diagnosis was 44 y.o. (18 - 78). Invasive ductal carcinoma represented 92% (n=203) of the tumors, 50% were ER/PR+ HER2-, 25% HER2 +, 25% ER/PR- HER2- (triple negative). Regarding stage at diagnosis, 59% (n=130) were stages IIB-IIIC and 13% IV. The detection rate of TP53 p.R337H was 1.1% (2/180). Among the pts who met the revised Chompret criteria for LFS, this frequency was 5% (2/40). One of them was diagnosed with a stage IIIB IDC ER/PR+HER2- at 28 y.o. and had no relevant family history of cancer. The other pt was diagnosed with a stage IV IDC ER/PR+HER2- at 44 y.o. and the family history revealed four sisters and one niece with BC, and one nephew with brain tumor at 4 y.o. The family members from these two families received genetic counseling and genetic testing. Cascade testing was able to identify 12 additional carriers. All carriers were referred for post-testing follow-up. Conclusion: According to these results, we expect to identify at least one p.R337H carrier in each 90 BC pts treated in the Federal’s District Public Health setting who fulfill HBC NCCN criteria. In a limited resources setting, in Brazil, testing the TP53 p.R337H variant with PCR is a low-cost test that should be considered at least for pts that meet the revised Chompret criteria. The overall detection rate of TP53 p.R337H carriers was lower in comparison to other Brazilian studies from the South/Southeast of the country. Both cases identified in this cohort had advanced local disease or metastatic disease at BC diagnosis, raising the concern about the importance of LFS diagnosis, and high-risk surveillance and risk reduction strategies in this subgroup of pts. Despite the low detection rate of TP53 p.R337H in this cohort, there was a high familial impact through cascade testing.
Citation Format: Tatiana S. Correa, Renata L. Sandoval, Eduarda S. Oliveira, Ana Carolina R. Leite, Luiza Nardin Weis, Maria Isabel Achatz, Claudiner P. Oliveira, Paula Fontes Asprino, Romualdo Barroso-Sousa. Frequency of germline TP53 p.R337H variant among women at risk of hereditary breast cancer in a public health system of Central-West of Brazil [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 P5-03-19.
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Affiliation(s)
| | | | | | | | - Luiza Nardin Weis
- 5Hospital de Base do Distrito Federal, Brasilia, Distrito Federal, Brazil
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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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Tarantino P, Gupta HV, Hughes ME, Files JL, Strauss S, Kirkner G, Feeney AM, Li YY, Garrido-Castro AC, Barroso-Sousa R, Bychkovsky B, MacConaill L, Lindeman N, Johnson B, Meyerson M, Kabraji S, Jeselsohn R, Qiu X, Li R, Long HW, Winer E, Dillon DA, Curigliano G, Cherniack A, Tolaney S, Lin NU. Abstract HER2-05: HER2-05 Comprehensive genomic characterization of HER2-low breast cancer. Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-her2-05] [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: 03/06/2023]
Abstract
Abstract
Background: About half of all breast cancers exhibit low HER2 expression. Despite lack of ERBB2 amplification, HER2-low tumors respond to trastuzumab deruxtecan (T-DXd), leading to the NCCN recommendation of T-DXd both for patients with HER2+ and HER2-low metastatic breast cancer (MBC). It remains however unclear if HER2-low represents a distinct molecular entity, as compared to HER2-0 MBC. Here, we compare the genomic landscape of HER2-low versus HER2-0 breast cancers in a large, single institution cohort. Methods: We identified consecutive patients with MBC seen at Dana-Farber Cancer Institute between 07/2013 and 12/2020. Patients were included if they had HER2-negative MBC per ASCO/CAP Guidelines and had undergone next generation sequencing (NGS) testing with a targeted, tumor-only platform (OncoPanel). Based on the HER2 status of the specimen tested by NGS, patients were divided into 2 groups: (i) HER2-low if immunohistochemistry (IHC) 1+ or 2+ non-amplified, or (ii) HER2-0 if IHC 0. Mutations of interest detected on NGS were classified as oncogenic using the OncoKB tool and additional annotation. Genomic profiles of HER2-low and HER2-0 tumors were compared using Chi-Square and Kruskal-Wallis tests. To determine genomic event enrichment between the two HER2 groups, logistic regression models were used, accounting for background rate and estrogen receptor (ER) expression. ERBB2 copy counts were calculated for tumors with recorded histology-estimated purities and copy-number segmentation using a simple model of allelic gain/loss. Results: Among 1847 patients with HER2-negative MBC, 1043 underwent NGS testing on a HER2-low (n=489, 47%) or HER2-0 sample (n=554, 53%). Most samples were metastatic (71%, n=743) while 29% (n=300) were from primary tumors. 73% had ductal histology, 13% were lobular and 14% had mixed or other histology. ER expression was enriched among HER2-low vs. HER2-0 tumors (76% vs. 60%; p< 0.001). Focusing on the most commonly occurring genetic mutations, no major differences were observed in HER2-low vs. HER2-0 tumors, after correcting for ER status (Table 1). Among all mutational events, any mutation in MPL, CYLD, and MAP3K and oncogenic mutations in TP53 and NF1 were more common in HER2-0, while any mutation in MTOR, RAD21, DNMT3A, and PDGFRA were enriched in HER2-low patients, when controlling for ER status and background mutational rate (p< 0.05). However, no mutation reached significance after accounting for multiple hypothesis testing. Similarly, no deep deletion or high amplification CNV events reached significance for either group. Analysis of tumor mutational burden in HER2-low vs. HER-0 tumors revealed no significant differences (median: 7.26 muts/Mb vs. 7.60 muts/Mb, p=1.00), including when accounting for ER status. Finally, among tumors with sufficient tumor purity for ERBB2 copy count analysis (n=374 and 419 for HER2-low and HER2-0, respectively), HER2-low tumors had a significantly higher number of ERBB2 alleles as compared to HER2-0 (< 2 copies, 15.0% vs. 30.9%, 2 copies 67.4% vs. 60.5%, and >2 copies, 17.6% vs. 8.6%; p< 0.001 by Kruskal-Wallis). Conclusions: To our knowledge, this is the largest comprehensive genomic analysis of HER2-low MBC to date. In our cohort of patients with HER2-negative MBC, the genomic landscape of HER2-low and HER2-0 tumors did not differ significantly, apart from a higher number of ERBB2 alleles. These data further support the notion that HER2-low, as currently defined, is not a distinct molecular subtype of breast cancer.
Citation Format: Paolo Tarantino, Hersh V. Gupta, Melissa E. Hughes, Janet L. Files, Sarah Strauss, Gregory Kirkner, Anne-Marie Feeney, Yvonne Y. Li, Ana C. Garrido-Castro, Romualdo Barroso-Sousa, Brittany Bychkovsky, Laura MacConaill, Neal Lindeman, Bruce Johnson, Matthew Meyerson, Sheheryar Kabraji, Rinath Jeselsohn, Xintao Qiu, Rong Li, Henry W. Long, Eric Winer, Deborah A. Dillon, Giuseppe Curigliano, Andrew Cherniack, Sara Tolaney, Nancy U. Lin. HER2-05 Comprehensive genomic characterization of HER2-low 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 HER2-05.
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Affiliation(s)
- Paolo Tarantino
- 1Breast Oncology Program, Dana-Farber Cancer Institute; Harvard Medical School, Boston, Massachusetts
| | - Hersh V. Gupta
- 2Albert Einstein College of Medicine MSTP (previously: Medical Oncology, Dana-Farber Cancer Institute)
| | | | - Janet L. Files
- 4Medical Oncology, Dana-Farber Cancer Institute, Hull, Massachusetts
| | | | | | | | | | | | | | - Brittany Bychkovsky
- 11Comprehensive Breast Health Center, Brigham and Women’s Hospital; Breast Oncology Program, Dana-Farber Brigham Cancer Center Division of Cancer Genetics and Prevention; Dana-Farber Cancer Institute; Harvard Medical School
| | - Laura MacConaill
- 12Dana-Farber Cancer Institute; Harvard Medical School; Broad Institute of Harvard and MIT
| | - Neal Lindeman
- 13Brigham and Women’s Hospital; Harvard Medical School
| | - Bruce Johnson
- 14Medical Oncology, Dana-Farber Cancer Institute; Harvard Medical School
| | - Matthew Meyerson
- 15Medical Oncology, Dana-Farber Cancer Institute; Center for Cancer Genomics, Dana-Farber Cancer Institute; Harvard Medical School; Broad Institute
| | | | | | | | - Rong Li
- 19Dana-Farber Cancer Institute
| | | | | | - Deborah A. Dillon
- 22Brigham and Women’s Hospital, Breast Oncology Program, Susan F. Smith Center for Women’s Cancers, Dana-Farber Brigham Cancer Center; Harvard Medical School
| | | | - Andrew Cherniack
- 24Medical Oncology, Dana-Farber Cancer Institute; Broad Institute
| | | | - Nancy U. Lin
- 26Dana-Farber Cancer Institute, Boston, Massachusetts
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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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Werutsky G, Reinert T, Rosa DD, Barroso-Sousa R, Resende H, Signorini PA, Fagundes JGM, Figueiredo JMB, Cronemberger E, Vieira AC, Leal JHS, Weis LN, Thommen L, Jesus RG, Gössling G, Bines J. Abstract OT3-07-01: Real-World Data on First-line Treatment of HR-positive, HER2-negative, Metastatic Breast Cancer in Brazil (BRAVE Study/LACOG 0221). Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-ot3-07-01] [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: It is estimated that 50 thousand patients live with metastatic breast cancer (MBC) in Brazil. A recent Brazilian registry (LACOG 0312) on MBC demonstrated a median overall survival (OS) by breast subtype of 15 months for triple negative, 23 months for HER2 positive, and 42 months for Luminal tumors, which are very similar to developed countries except the HER2 positive group which have limited access to targeted agents in the public health system. Recently, CDK 4/6 inhibitors were approved for the treatment of HR+ HER2-negative MBC with an improvement in progression-free survival (PFS) and ribociclib and abemaciclib demonstrating benefit in OS over endocrine therapy alone, establishing the standard of care in first-line setting for this BC subtype. In Brazil, disparities exist in the incorporation of novel anticancer agents between public and private health systems limiting treatment options for patients with HR+ HER2- negative MBC in the public system, which covers most of the population. The BRAVE study aims to describe the patient journey and current patterns of care for HR+ HER2-negative MBC to identify possible gaps and how health insurance type influences treatment patterns in Brazil. Trial Design: This is an observational, retrospective cohort study. All patients diagnosed with mBC (either de novo or recurrent) in the period of January 2018 to December 2020 at participating centers will be included. Data will be collected from medical records. No interventions are proposed. Enrollment of a total of 300 patients (150 patients from public health care system and 150 patients from private health care system) is planned. ClinicalTrials.gov identifier: NCT05034393. Eligibility: Inclusion criteria: women ≥18 years old; histologically confirmed HR-positive HER2-negative invasive breast cancer; HR-positive, defined as 1% to 100% of tumor nuclei positive for ER and/or PgR as per ASCO/CAP Guideline 2020 or Allred score of ≥3; HER2-negative, defined as IHC result is 0/1+ or 2+ with ISH negative as per ASCO/CAP Guideline 2018; diagnosed with de novo or recurrent metastatic breast cancer between January 2018 and December 2020. Exclusion criteria: male BC; first-line treatment for mBC received through clinical trial. Specific Aims: Primary objective is to describe the first-line (1L) treatment of HR-positive, HER2-negative mBC in Brazil. Secondary objectives are to describe progression-free survival (PFS) in the 1L setting until month 24; describe and compare the 1L treatment of HR-positive, HER2-negative mBC and PFS until month 24 according to the health care coverage (public vs. private); describe timelines from symptoms, histopathological diagnosis, molecular test, and treatment; describe the mBC pathological characterization; describe frequency of diagnostic tests to define breast cancer molecular subtypes; describe the subsequent line of treatment and corresponding PFS; describe overall survival (OS); evaluate PFS and OS according to visceral vs. non-visceral metastatic disease, primary endocrine resistance vs. acquired endocrine resistance, de novo versus recurrent disease, public vs. private health system and pre vs postmenopausal status. Statistical Methods: No a priori sample size calculation was performed. The expected sample size of 150 patients in each group allows description of the proportion of patients using CDK 4/6 inhibitors with two-sided 90% confidence interval ranging from 53.4% to 66.6% when the expected proportion is 60% in the private health system. Present Accrual and Target Accrual: A total of 12 sites of 14 planned were activated. The first patient was enrolled on February 8, 2022. As of June 24, 2022, a total of 122 patients were enrolled, 86 from public and 36 from private health system. The target accrual of 300 patients is expected to be completed by November 2022. Results are expected to be presented by April 2023. Funding: Novartis. Acknowledgements: SAS.
Citation Format: Gustavo Werutsky, Tomás Reinert, Daniela D. Rosa, Romualdo Barroso-Sousa, Heloísa Resende, Poliana A. Signorini, Juliana G. Martins Fagundes, Jose Marcio B. Figueiredo, Eduardo Cronemberger, Aline C. Vieira, Jorge Henrique Santos Leal, Luiza Nardin Weis, Ludmila Thommen, Rafaela G. Jesus, Gustavo Gössling, José Bines. Real-World Data on First-line Treatment of HR-positive, HER2-negative, Metastatic Breast Cancer in Brazil (BRAVE Study/LACOG 0221) [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 OT3-07-01.
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Affiliation(s)
- Gustavo Werutsky
- 1Hospital São Lucas, PUCRS University, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Daniela D. Rosa
- 3Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | | | | | | | | | | | | | - Luiza Nardin Weis
- 12Hospital de Base do Distrito Federal, Brasilia, Distrito Federal, Brazil
| | | | - Rafaela G. Jesus
- 14Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Rio Grande do Sul, Brazil
| | | | - José Bines
- 16Instituto Nacional de Câncer (INCA), Brazil
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12
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Gupta HV, Freedman R, Hughes ME, Li YY, Kirkner G, Files JL, Strauss S, Garrido-Castro AC, Buckley L, Barroso-Sousa R, Bychkovsky B, Tolaney S, MacConaill L, Lindeman N, Johnson B, Meyerson M, Winer E, Dillon DA, Cherniack A, Lin NU. Abstract P5-14-06: Tumor Genomic Landscape in Older Women with Metastatic Breast Cancer (MBC). Cancer Res 2023. [DOI: 10.1158/1538-7445.sabcs22-p5-14-06] [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: 03/06/2023]
Abstract
Abstract
Background. Patients (pts) who develop MBC at older ages are underrepresented in clinical trials, are less likely to be included in comprehensive biomarker characterization studies, and experience worse breast cancer-specific survival than their younger counterparts. Elucidating genomic underpinnings of MBC and possible therapeutic targets for older breast cancer patients are critical priorities. Methods. We identified pts age >70 years at MBC diagnosis and a younger cohort (ages 50-69; age < 50), who were treated for MBC at a single center and who had their metastatic (or if not available, the primary) tumor, assessed by a targeted, tumor-only next generation sequencing (NGS) platform (OncoPanel) between 2013-2020. The NGS panel included mutations, copy number variation, tumor mutational burden (TMB), and hypermutation (HM) status, with mutations classified as oncogenic using the OncoKB tool and additional annotation. Copy number events were selected as being “oncogenic” if a high amplification was called for an oncogene or a deep deletion for a tumor suppressor. We compared findings for older (age >70) vs. younger (age < 50 and ages 50-69) MBC pts using Chi-Square and Kruskal-Wallis tests. To determine genomic event enrichment, logistic regression (LR) models were used, controlling for age (continuous), background rate, and tumor subtype (those with unknown subtype [n=27] were excluded from models). False discovery rate (FDR) was used to correct for multiple hypothesis testing. Results. The final analytic cohort included 2,380 pts. The median age at MBC diagnosis was 54.1 years overall (range 18.5- 91.9) and 73.6 years for those age >70. A total of 137 metastatic and 76 primary tumors were sequenced in pts age >70; in those age < 70, 1383 metastatic and 784 primary tumors were sequenced (for age < 50 [n=857] and 50-69 [n=1310]). Older pts were more likely to present with HR+/HER2- tumors (70.9% v. 62.4% v. 52.4%), and less likely to present with HER2+ (9.4% v. 14.4% v. 22.8%) or triple-negative breast cancer (TNBC) (18.8% v. 21.9% vs. 24.0%) at MBC diagnosis (listed >70, 50-69, < 50; P=1e-7). Older pts had higher average TMB vs. younger pts (9.57 in pts > 70, 8.56 in ages 50-69, 7.34 in ages < 50; P=3.5e-5). This was due to older pts having a higher incidence of hypermutation status as defined as TMB >10: 26.3% in age >70, 23.2% in ages 50-69, 16.8% in age < 50. Using q=0.1 as the threshold of significance, the presence of CDH1, PIK3CA, MAP3K1, TET2, and AKT oncogenic mutations were also enriched in older pts, while the presence of oncogenic GATA3, BRCA2, and TP53 mutations, as well as any mutation in BRCA1 were enriched in younger pts (too few oncogenic BRCA1 mutations were present for accurate modeling). The frequency of oncogenic PIK3CA mutations in HR+/HER2- tumors was highest in the oldest pts (44.4% in pts age >70 v. 31.6% in age 50-69 v. 26.7% in age < 50). Of pts who had oncogenic BRCA1/2 mutations identified on tumor-only NGS testing and underwent clinical germline testing (n=7 v. 60 v. 67, oldest to youngest), older pts had the lowest incidence of germline BRCA pathogenic variants (14.3% vs. 47.2.% vs. 67.2%; p=0.01); most BRCA mutations identified on NGS testing in older patients were considered likely somatic. When assessing enrichment in copy number events, ERBB2, RAD21, and BRIP1 amplifications were all significantly less frequent in older pts (q< 0.1), even when accounting for tumor subtype. Conclusions. In a large cohort of pts with MBC, the mutational and copy number landscape for older pts differs from that in younger pts, even after controlling for tumor subtype. Key actionable findings include a higher proportion of high TMB and PIK3CA-mutated tumors, emphasizing the importance of genomic profile testing in this pt population and further exploration of efficacy and tolerability of relevant therapies in those age >70 years.
Citation Format: Hersh V. Gupta, Rachel Freedman, Melissa E. Hughes, Yvonne Y. Li, Gregory Kirkner, Janet L. Files, Sarah Strauss, Ana C. Garrido-Castro, Lauren Buckley, Romualdo Barroso-Sousa, Brittany Bychkovsky, Sara Tolaney, Laura MacConaill, Neal Lindeman, Bruce Johnson, Matthew Meyerson, Eric Winer, Deborah A. Dillon, Andrew Cherniack, Nancy U. Lin. Tumor Genomic Landscape in Older Women with Metastatic Breast Cancer (MBC) [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 P5-14-06.
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Affiliation(s)
- Hersh V. Gupta
- 1Albert Einstein College of Medicine MSTP (previously: Medical Oncology, Dana-Farber Cancer Institute)
| | | | | | | | | | - Janet L. Files
- 6Medical Oncology, Dana-Farber Cancer Institute, Hull, Massachusetts
| | | | | | | | | | - Brittany Bychkovsky
- 11Comprehensive Breast Health Center, Brigham and Women’s Hospital; Breast Oncology Program, Dana-Farber Brigham Cancer Center Division of Cancer Genetics and Prevention; Dana-Farber Cancer Institute; Harvard Medical School
| | | | - Laura MacConaill
- 13Dana-Farber Cancer Institute; Harvard Medical School; Broad Institute of Harvard and MIT
| | - Neal Lindeman
- 14Brigham and Women’s Hospital; Harvard Medical School
| | - Bruce Johnson
- 15Medical Oncology, Dana-Farber Cancer Institute; Harvard Medical School
| | - Matthew Meyerson
- 16Medical Oncology, Dana-Farber Cancer Institute; Center for Cancer Genomics, Dana-Farber Cancer Institute; Harvard Medical School; Broad Institute
| | | | - Deborah A. Dillon
- 18Brigham and Women’s Hospital, Breast Oncology Program, Susan F. Smith Center for Women’s Cancers, Dana-Farber Brigham Cancer Center; Harvard Medical School
| | - Andrew Cherniack
- 19Medical Oncology, Dana-Farber Cancer Institute; Genome Data Analysis Center, Broad Institute; Genomic Data Analysis Network, National Cancer Institute
| | - Nancy U. Lin
- 20Dana-Farber Cancer Institute, Boston, Massachusetts
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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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Queiroz MM, Sacardo KP, Ribeiro MF, Gadotti LL, Saddi R, Oliveira LJDC, Linck RDM, Cruz MRDS, Barroso-Sousa R, Sahade M, Correa TS, Mano MS, Suzuki DA, Shimada AK, Katz A. Real-world treatment outcomes in HR+ HER2- metastatic breast cancer patients treated with CDK4/6 inhibitors: Results from a reference center in Brazil. Cancer Treat Res Commun 2023; 35:100683. [PMID: 36716534 DOI: 10.1016/j.ctarc.2023.100683] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 12/06/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) have been recently developed and introduced into clinical practice. METHODS We retrospectively analyzed data from patients with confirmed HR+/HER2 metastatic breast cancer treated with hormonal therapy in combination with ribociclib (R), palbociclib (P), or abemaciclib (A). OUTCOMES median progression-free survival (mPFS), time to treatment discontinuation (mTTD), and objective response rate (ORR). RESULTS Between January 2016 - June 2021, 142 patients were treated with an CDK4/6i (79 P, 42 R, 21 A). The median age was 59 years and 67.6% had recurrent disease. Roughly 35.2%, 36.6%, 28.2% of the patients had 1, 2 or 3+ metastatic sites, respectively, and 55.6% of the patients received CDK4/6i as a first-line treatment. The mPFS was 28m(R) vs. 14m(P) vs. 6m(A) (P = 0.002), with a higher proportion of patients receiving R in the first-line setting. However, no difference was seen when the analysis was restricted to the first-line scenario (P = 0.193). Sixty-four patients required one dose reduction, and 19 patients required two. ORR was 76.2% (R) vs 62% (P) vs 42.9% (A). More patients achieved a complete response with R and P, with no difference in the incidence of partial response and stable disease. Adverse events occurred in 94.4% of the population, with the most common grade 3-4 AE being neutropenia (59.1%). CONCLUSIONS Our results confirm the efficacy and tolerability of CDK4/6i in routine clinical practice. This is the first real-world data describing and comparing the efficacy and toxicity of CDK4/6i in the Brazilian population.
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Affiliation(s)
- Marcello Moro Queiroz
- Oncology Center, Hospital Sírio-Libanês, Street Dona Adma Jafet, number 115, zip-code 01308-050, São Paulo, SP, Brazil.
| | - Karina Perez Sacardo
- Oncology Center, DASA, Av. das Nações Unidas, number 7815, zip-code 05425-070, São Paulo, SP, Brazil
| | - Mauricio Fernando Ribeiro
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, zip-code ON M5G 2C1, Toronto, ON, Canada
| | - Luiza Lara Gadotti
- Oncology Center, Hospital Sírio-Libanês, Street Dona Adma Jafet, number 115, zip-code 01308-050, São Paulo, SP, Brazil
| | - Rodrigo Saddi
- Oncology Center, Hospital Sírio-Libanês, Street Dona Adma Jafet, number 115, zip-code 01308-050, São Paulo, SP, Brazil
| | | | - Rudinei Diogo Marques Linck
- Oncology Center, Hospital Sírio-Libanês, Street Dona Adma Jafet, number 115, zip-code 01308-050, São Paulo, SP, Brazil
| | - Marcelo Rocha de Souza Cruz
- Oncology Center, Hospital Sírio-Libanês, Street Dona Adma Jafet, number 115, zip-code 01308-050, São Paulo, SP, Brazil
| | - Romualdo Barroso-Sousa
- Oncology Center, DASA, Street Arariba, number 5, zip-code 71927-360, Brasília, DF, Brazil
| | - Marina Sahade
- Oncology Center, Hospital Sírio-Libanês, Street Dona Adma Jafet, number 115, zip-code 01308-050, São Paulo, SP, Brazil
| | - Tatiana Strava Correa
- Oncology Center, Hospital Sírio-Libanês, Street SSGAS 613, number 70.200, zip-code 70200-730, Brasília, DF, Brazil
| | - Max Senna Mano
- Oncology Center, Oncoclínicas, Av. Brg. Faria Lima, number 4300, zip-code 04538-132, São Paulo, SP, Brazil
| | - Daniele Assad Suzuki
- Oncology Center, Hospital Sírio-Libanês, Street SSGAS 613, number 70.200, zip-code 70200-730, Brasília, DF, Brazil
| | - Andrea Kazumi Shimada
- Oncology Center, Hospital Sírio-Libanês, Street Dona Adma Jafet, number 115, zip-code 01308-050, São Paulo, SP, Brazil
| | - Artur Katz
- Oncology Center, Hospital Sírio-Libanês, Street Dona Adma Jafet, number 115, zip-code 01308-050, São Paulo, SP, Brazil
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Oliveira LJC, Megid TBC, Rosa DD, Magliano CADS, Assad DX, Argolo DF, Sanches SM, Testa L, Bines J, Kaliks R, Caleffi M, de Melo Gagliato D, Sahade M, Barroso-Sousa R, Corrêa TS, Shimada AK, Batista DN, Musse Gomes D, Cesca MG, Gaudêncio D, Moura LMA, de Araújo JAP, Katz A, Mano MS. Cost-effectiveness analysis of Oncotype DX from a Brazilian private medicine perspective: a GBECAM multicenter retrospective study. Ther Adv Med Oncol 2022; 14:17588359221141760. [PMID: 36601632 PMCID: PMC9806428 DOI: 10.1177/17588359221141760] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/09/2022] [Indexed: 12/28/2022] Open
Abstract
Background Oncotype DX (ODX) is a validated assay for the prediction of risk of recurrence and benefit of chemotherapy (CT) in both node negative (N0) and 1-3 positive nodes (N1), hormone receptor positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) early breast cancer (eBC). Due to limited access to genomic assays in Brazil, treatment decisions remain largely driven by traditional clinicopathologic risk factors. ODX has been reported to be cost-effective in different health system, but limited data are available considering the reality of middle-income countries such as Brazil. We aim to evaluate the cost-effectiveness of ODX across strata of clinical risk groups using data from a dataset of patients from Brazilian institutions. Methods Clinicopathologic and ODX information were analyzed for patients with T1-T3, N0-N1, HR+/HER2- eBC who had an ODX performed between 2005 and 2020. Projections of CT indication by clinicopathologic criteria were based on binary clinical risk categorization based on the Adjuvant! Algorithm. The ODX score was correlated with the indication of CT according to TAILORx and RxPONDER data. Two decision-tree models were developed. In the first model, low and high clinical risk patients were included while in the second, only high clinical risk patients were included. The cost for ODX and CT was based on the Brazilian private medicine perspective. Results In all, 645 patients were analyzed; 411 patients (63.7%) had low clinical risk and 234 patients (36.3%) had high clinical risk disease. The ODX indicated low (<11), intermediate (11-25), and high (>25) risk in 119 (18.4%), 415 (64.3%), and 111 (17.2%) patients, respectively. Among 645 patients analyzed in the first model, ODX was effective (5.6% reduction in CT indication) though with an incremental cost of United States Dollar (US$) 2288.87 per patient. Among 234 patients analyzed in the second model (high clinical risk only), ODX led to a 57.7% reduction in CT indication and reduced costs by US$ 4350.66 per patient. Conclusions Our study suggests that ODX is cost-saving for patients with high clinical risk HR+/HER2- eBC and cost-attractive for the overall population in the Brazilian private medicine perspective. Its incorporation into routine practice should be strongly considered by healthcare providers.
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Affiliation(s)
| | | | - Daniela Dornelles Rosa
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Serviço de Oncologia, Hospital Moinhos de
Vento, Porto Alegre, Brazil
| | | | - Daniele Xavier Assad
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Centro de Oncologia - Hospital Sírio-Libanês,
Brasília, Brazil
| | - Daniel Fontes Argolo
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Clínica CLION – Grupo CAM, Salvador,
Brazil
| | - Solange Moraes Sanches
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil AC,Camargo Cancer Center, São Paulo, Brazil
| | - Laura Testa
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Clínica OncoStar - Rede D’Or São Luiz, São
Paulo, Brazil,Instituto D’Or de pesquisa e ensino (IDOR),
São Paulo, Brazil
| | - José Bines
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Clínica São Vicente - Rede D’Or São Luiz, Rio
de Janeiro, Brazil,Instituto D’Or de pesquisa e ensino (IDOR),
São Paulo, Brazil
| | - Rafael Kaliks
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Centro de Oncologia - Hospital Israelita
Albert Einstein, São Paulo, Brazil
| | - Maira Caleffi
- Serviço de Oncologia, Hospital Moinhos de
Vento, Porto Alegre, Brazil
| | - Debora de Melo Gagliato
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Centro de Oncologia - Hospital Beneficência
Portuguesa, São Paulo, Brazil
| | - Marina Sahade
- Centro de Oncologia - Hospital Sírio-Libanês,
São Paulo, Brazil
| | - Romualdo Barroso-Sousa
- Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil,Centro de Oncologia - Hospital Sírio-Libanês,
Brasília, Brazil
| | | | - Andrea Kazumi Shimada
- Centro de Oncologia - Hospital Sírio-Libanês,
São Paulo, Brazil,Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil
| | - Daniel Negrini Batista
- Clínica OncoStar - Rede D’Or São Luiz, São
Paulo, Brazil,Instituto D’Or de pesquisa e ensino (IDOR),
São Paulo, Brazil
| | - Daniel Musse Gomes
- Clínica São Vicente - Rede D’Or São Luiz, Rio
de Janeiro, Brazil,Instituto D’Or de pesquisa e ensino (IDOR),
São Paulo, Brazil
| | | | | | | | | | - Artur Katz
- Centro de Oncologia - Hospital Sírio-Libanês,
São Paulo, Brazil
| | - Max Senna Mano
- Centro de Oncologia - Hospital Sírio-Libanês,
São Paulo, Brazil,Grupo Brasileiro de Estudos em Câncer de Mama
(GBECAM), São Paulo, Brazil
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Wanderley CWS, Maganin A, Adjafre B, Mendes AS, Anibal Silva CE, Quadros AU, Luiz JPM, Silva CMS, Silva NR, Oliveira FF, Gomes FIF, Restrepo JLJ, Speck-Hernandez CA, Turaça F, Silva GVL, Pigatto GR, Nakaya HI, Mota JM, Barroso-Sousa R, Alves-Filho JC, Cunha TM, Cunha FQ. PD-1/PD-L1 inhibition enhances chemotherapy-induced neuropathic pain by suppressing neuroimmune antinociceptive signaling. Cancer Immunol Res 2022; 10:1299-1308. [DOI: 10.1158/2326-6066.cir-22-0003] [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] [Received: 01/03/2022] [Revised: 07/12/2022] [Accepted: 09/01/2022] [Indexed: 11/16/2022]
Abstract
Abstract
Cytotoxic agents synergize with immune checkpoint inhibitors and improve outcomes for patients with several cancer types. Nonetheless, a parallel increase in the incidence of dose-limiting side effects, such as peripheral neuropathy, is often observed. Here, we investigated the role of the PD-1/PD-L1 axis in the modulation of paclitaxel-induced neuropathic pain. We found that human and mouse neural tissues, including the dorsal root ganglion (DRG), expressed basal levels of PD-1 and PD-L1. During the development of paclitaxel-induced neuropathy, an increase in PD-L1 expression was observed in macrophages from the DRG. This effect depended on Toll-like receptor 4 (TLR4) activation by paclitaxel. Furthermore, PD-L1 inhibited pain behavior triggered by paclitaxel or formalin in mice, suggesting that PD-1/PD-L1 signaling attenuates peripheral neuropathy development. Consistent with this, we observed that the combined use of anti–PD-L1 plus paclitaxel increased mechanical allodynia and chronic neuropathy development induced by single agents. This effect was associated with higher expression of inflammatory markers (Tnf, Il6, and Cx3cr1) in peripheral nervous tissue. Together, these results suggest that PD-1/PD-L1 inhibitors enhance paclitaxel-induced neuropathic pain by suppressing PD-1/PD-L1 antinociceptive signaling.
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Affiliation(s)
| | - Alexandre Maganin
- Ribeirao Preto Medical School, University of Sao Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Beatriz Adjafre
- Ribeirao Preto Medical School, University of Sao Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Atlante S. Mendes
- Ribeirao Preto Medical School, University of Sao Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Andreza Urba. Quadros
- Ribeirao Preto Medical School, University of Sao Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Joao Paulo Mesquita. Luiz
- Center for Research in Inflammatory Diseases (CRID), Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | | | - Nicole R. Silva
- Center for Research in Inflammatory Diseases (CRID) Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil, Ribeirao Preto, Sao Paulo, Brazil
| | - Francisco F. Oliveira
- Center for Research in Inflammatory Diseases (CRID), Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | | | | | - Cesar A. Speck-Hernandez
- Center for Research in Inflammatory Diseases (CRID), Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
| | - Fernanda Turaça
- Ribeirao Preto Medical School, University of Sao Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Glauce R. Pigatto
- Ribeirao Preto Medical School, University of Sao Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Jose Mauricio Mota
- Instituto do Cancer do Estado de Sao Paulo, University of Sao Paulo, Sao Paulo, SP, Brazil
| | | | - Jose C. Alves-Filho
- Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Fernando Q. Cunha
- Center for Research in Inflammatory Diseases (CRID), Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
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17
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Leite ACR, Suzuki DA, Pereira AAL, Machado NP, Barroso-Sousa R, Correa TS, Moura FC, Morbeck IAP, Gumz BP, Faria LDBB, Fernandes GDS, Sandoval RL. What can we learn from more than 1,000 Brazilian patients at risk of hereditary cancer? Front Oncol 2022; 12:963910. [PMID: 36132150 PMCID: PMC9484549 DOI: 10.3389/fonc.2022.963910] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIdentifying individuals at a higher risk of developing cancer is a major concern for healthcare providers. Cancer predisposition syndromes are the underlying cause of cancer aggregation and young-onset tumors in many families. Germline genetic testing is underused due to lack of access, but Brazilian germline data associated with cancer predisposition syndromes are needed.MethodsMedical records of patients referred for genetic counseling at the Oncogenetics Department at the Hospital Sírio-Libanês (Brasília, DF, Brazil) from July 2017 to January 2021 were reviewed. The clinical features and germline findings were described. Detection rates of germline pathogenic/likely pathogenic variant (P/LPV) carriers were compared between international and Brazilian guidelines for genetic testing.ResultsA total of 1,091 individuals from 985 families were included in this study. Most patients (93.5%) had a family history of cancer, including 64% with a family member under 50 with cancer. Sixty-six percent of patients (720/1091) had a personal history of cancer. Young-onset cancers (<50 years old) represented 62% of the patients affected by cancer and 17% had multiple primary cancers. The cohort included patients with 30 different cancer types. Breast cancer was the most prevalent type of cancer (52.6%). Germline testing included multigene panel (89.3%) and family variant testing (8.9%). Approximately 27% (236/879) of the tested patients harbored germline P/LPVs in cancer susceptibility genes. BRCA2, BRCA1, and TP53 were the most frequently reported genes, corresponding to 18.6%, 14.4%, and 13.5% of the positive results, respectively. Genetic testing criteria from international guidelines were more effective in identifying carriers than the Brazilian National Agency of Supplementary Health (ANS) criteria (92% vs. 72%, p<0.001). Forty-six percent of the cancer-unaffected patients who harbored a germline P/LPV (45/98) would not be eligible for genetic testing according to ANS because they did not have a family variant previously identified in a cancer-affected relative.ConclusionThe high detection rate of P/LPVs in the present study is possibly related to the genetic testing approach with multigene panels and cohort’s characteristics, represented mainly by individuals with a personal or family history of young-onset cancer. Testing asymptomatic individuals with suspicious family history may also have contributed to a higher detection rate. A significant number of carriers would not have been identified using ANS criteria for genetic testing.
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18
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Bonadio RC, Tarantino P, Testa L, Punie K, Pernas S, Barrios C, Curigliano G, Tolaney SM, Barroso-Sousa R. Management of patients with early-stage triple-negative breast cancer following pembrolizumab-based neoadjuvant therapy: What are the evidences? Cancer Treat Rev 2022; 110:102459. [PMID: 35998514 DOI: 10.1016/j.ctrv.2022.102459] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 11/28/2022]
Abstract
New therapy options have changed the treatment landscape of early-stage triple-negative breast cancer (TNBC) in recent years. Most patients are candidates for neoadjuvant chemotherapy, which helps to downstage the tumor and tailor adjuvant systemic therapy based on pathologic response. Capecitabine, pembrolizumab, and olaparib have been incorporated into the armamentarium of adjuvant treatment for selected patients. The KEYNOTE-522 trial, that demonstrated the benefit of pembrolizumab, given in addition to neoadjuvant chemotherapy and adjuvantly after surgery, represented a paradigm shift for early-stage TNBC treatment. Pembrolizumab was continued in the adjuvant setting irrespective of response to neoadjuvant therapy, and other adjuvant therapies were not administered in the trial. Many questions were then raised on the selection of adjuvant therapy regimens for patients with residual disease (RD). Prior to the routine use of immune-checkpoint inhibitors (ICI), the value of adjuvant capecitabine for patients with RD after neoadjuvant polychemotherapy was demonstrated. Given the poor prognosis of some patients with RD after neoadjuvant chemo-immunotherapy, while the survival advantage of adding capecitabine during the adjuvant phase of pembrolizumab is unknown, it does appear safe and can be considered. Regarding patients harboring germline BRCA mutations with RD after neoadjuvant ICI-containing regimens, the combination of olaparib with pembrolizumab can be an option based on existing safety data.
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Affiliation(s)
- Renata Colombo Bonadio
- Instituto D'Or de Pesquisa e Ensino (IDOR), São Paulo, Brazil; Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, Brazil
| | - Paolo Tarantino
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; European Institute of Oncology, IRCCS
| | - Laura Testa
- Instituto D'Or de Pesquisa e Ensino (IDOR), São Paulo, Brazil; Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, São Paulo, Brazil
| | - Kevin Punie
- Department of General Medical Oncology and Multidisciplinary Breast Centre, Leuven Cancer Institute, University Hospitals Leuven, Leuven, Belgium
| | - Sonia Pernas
- Catalan Institute of Oncology; IDIBELL, L'Hospitalet de Llobregat (Barcelona), Spain
| | - Carlos Barrios
- Latin American Cooperative Oncology Group (LACOG), Grupo Oncoclínicas, Porto Alegre, Brazil
| | | | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Romualdo Barroso-Sousa
- Oncology Center, Hospital Sirio-Libanes, Brasília, Brazil; DASA Oncology, Brasília, Brazil.
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19
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Barroso-Sousa R, Forman J, Collier K, Weber ZT, Jammihal TR, Kao KZ, Richardson ET, Keenan T, Cohen O, Manos MP, Brennick RC, Ott PA, Hodi FS, Dillon DA, Attaya V, O'Meara T, Lin NU, Van Allen EM, Rodig S, Winer EP, Mittendorf EA, Wu CJ, Wagle N, Stover DG, Shukla SA, Tolaney SM. Multidimensional Molecular Profiling of Metastatic Triple-Negative Breast Cancer and Immune Checkpoint Inhibitor Benefit. JCO Precis Oncol 2022; 6:e2100413. [PMID: 35797509 PMCID: PMC9848556 DOI: 10.1200/po.21.00413] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE In metastatic triple-negative breast cancer (mTNBC), consistent biomarkers of immune checkpoint inhibitor (ICI) therapy benefit remain elusive. We evaluated the immune, genomic, and transcriptomic landscape of mTNBC in patients treated with ICIs. METHODS We identified 29 patients with mTNBC treated with pembrolizumab or atezolizumab, either alone (n = 9) or in combination with chemotherapy (n = 14) or targeted therapy (n = 6), who had tumor tissue and/or blood available before ICI therapy for whole-exome sequencing. RNA sequencing and CIBERSORTx-inferred immune population analyses were performed (n = 20). Immune cell populations and programmed death-ligand 1 expression were assessed using multiplexed immunofluorescence (n = 18). Clonal trajectories were evaluated via serial tumor/circulating tumor DNA whole-exome sequencing (n = 4). Association of biomarkers with progression-free survival and overall survival (OS) was assessed. RESULTS Progression-free survival and OS were longer in patients with high programmed death-ligand 1 expression and tumor mutational burden. Patients with longer survival also had a higher relative inferred fraction of CD8+ T cells, activated CD4+ memory T cells, M1 macrophages, and follicular helper T cells and enrichment of inflammatory gene expression pathways. A mutational signature of defective repair of DNA damage by homologous recombination was enriched in patients with both shorter OS and primary resistance. Exploratory analysis of clonal evolution among four patients treated with programmed cell death protein 1 blockade and a tyrosine kinase inhibitor suggested that clonal stability post-treatment was associated with short time to progression. CONCLUSION This study identified potential biomarkers of response to ICIs among patients with mTNBC: high tumor mutational burden; presence of CD8+, CD4 memory T cells, follicular helper T cells, and M1 macrophages; and inflammatory gene expression pathways. Pretreatment deficiencies in the homologous recombination DNA damage repair pathway and the absence of or minimal clonal evolution post-treatment may be associated with worse outcomes.
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Affiliation(s)
| | - Juliet Forman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.,Broad Institute of MIT and Harvard, Cambridge, MA.,Translational Immunogenomics Lab, Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Tejas R Jammihal
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Katrina Z Kao
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Tanya Keenan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ofir Cohen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Michael P Manos
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ryan C Brennick
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Patrick A Ott
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - F Stephen Hodi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Deborah A Dillon
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - Victoria Attaya
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Tess O'Meara
- Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.,Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
| | | | - Scott Rodig
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.,Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
| | - Elizabeth A Mittendorf
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA.,Divison of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Catherine J Wu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Nikhil Wagle
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.,Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
| | | | - Sachet A Shukla
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.,Broad Institute of MIT and Harvard, Cambridge, MA.,Translational Immunogenomics Lab, Dana-Farber Cancer Institute, Boston, MA
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.,Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
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20
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Oliveira LC, Megid TBC, Rosa DD, Magliano CADS, Suzuki DA, Argolo DF, Sanches SM, Testa L, Bines J, Kaliks RA, Caleffi M, Gagliato DDM, Sahade M, Barroso-Sousa R, Correa TS, Shimada A, Katz A, Mano MS. Cost-effectiveness analysis of Oncotype DX from a Brazilian private medicine perspective: A GBECAM multicenter retrospective study. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e18822] [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
e18822 Background: Oncotype DX (ODX) is a validated tool for the prediction of risk of recurrence and benefit of chemotherapy (CH) in both node negative (N0) and positive (N1), hormone receptor positive (HR+), HER2 negative (HER2-) early breast cancer (eBC). Due to limited access to novel genomic assays in Brazil, treatment decisions remain largely driven by traditional clinicopathologic risk factors. ODX has been reported to be cost-effective, but limited data is available considering the reality of middle-income countries such as Brazil. We aim to evaluate the cost-effectiveness of ODX across strata of clinical risk groups using data from a large dataset of patients from various Brazilian institutions. Methods: Clinicopathologic and ODX information were analyzed for patients with T1-T3, N0-N1, HR+/HER2- eBC who had an ODX performed between 2005 and 2020. Projections of CH indication by clinicopathologic criteria were based on binary clinical risk categorization based on the Adjuvant! algorithm, as used in the MINDACT study. The ODX score was correlated with the indication of CH according to TAILORx and RxPONDER data. Two decision-tree models were developed. In the first model, low and high clinical risk patients were included the model. In the second model, only high clinical risk patients were included. The cost for ODX and CH (U$2,846 and U$14,464, respectively) were based on the Brazilian private medicine perspective. Uncertainty was assessed using deterministic and probabilistic sensitivity analyses. Results: Six hundred and forty-five patients were analyzed. 411 patients (63.7%) had low clinical risk and 234 patients (36.3%) had high clinical risk disease. The ODX indicated low (< 11), intermediate (11-25) and high (> 25) risk in 119 (18.4%), 415 (64.3%) and 111 (17.2%) patients, respectively. Among 645 patients analyzed in the first model, 234 (36.2%) had clinical and 198 (30.6%) had genomic indication for CH, respectively. In this model, ODX was modestly effective (5.6% reduction in CH indication) though with an incremental cost of US$ 2,040 per patient. Among 234 patients analyzed in the second model (high clinical risk only), 99 (42.3%) patients had genomic indication of CH. In this model, ODX led to a 57.7% reduction in CH indication and reduced costs by US$5,491 per patient (table). The results remained robust in the 1,000 probabilistic simulations. Conclusions: Our study suggests that ODX is cost-saving for patients with high clinical risk HR+/HER2- eBC in the perspective of the Brazilian private health system. Its incorporation into routine practice should be strongly considered by health care providers.[Table: see text]
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Affiliation(s)
| | | | | | | | | | | | | | - Laura Testa
- Instituto D’Or de pesquisa e ensino (IDOR), São Paulo, Brazil
| | - Jose Bines
- Instituto D’Or de Pesquisa e Ensino (IDOR), Rio De Janeiro, Brazil
| | | | | | | | | | | | | | | | - Artur Katz
- Hospital Sírio-Libanês, São Paulo, Brazil
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21
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Wanderley CWS, Correa TS, Scaranti M, Cunha FQ, Barroso-Sousa R. Targeting PARP1 to Enhance Anticancer Checkpoint Immunotherapy Response: Rationale and Clinical Implications. Front Immunol 2022; 13:816642. [PMID: 35572596 PMCID: PMC9094400 DOI: 10.3389/fimmu.2022.816642] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
Reinvigorating the antitumor immune response using immune checkpoint inhibitors (ICIs) has revolutionized the treatment of several malignancies. However, extended use of ICIs has resulted in a cancer-specific response. In tumors considered to be less immunogenic, the response rates were low or null. To overcome resistance and improve the beneficial effects of ICIs, novel strategies focused on ICI-combined therapies have been tested. In particular, poly ADP-ribose polymerase inhibitors (PARPi) are a class of agents with potential for ICI combined therapy. PARPi impairs single-strand break DNA repair; this mechanism involves synthetic lethality in tumor cells with deficient homologous recombination. More recently, novel evidence indicated that PAPRi has the potential to modulate the antitumor immune response by activating antigen-presenting cells, infiltrating effector lymphocytes, and upregulating programmed death ligand-1 in tumors. This review covers the current advances in the immune effects of PARPi, explores the potential rationale for combined therapy with ICIs, and discusses ongoing clinical trials.
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Affiliation(s)
- Carlos Wagner S. Wanderley
- Center for Research in Inflammatory Diseases (CRID), Ribeirao Preto Medical School, Ribeirao Preto, Brazil
- Department of Pharmacology, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto, Brazil
| | | | | | - Fernando Queiroz Cunha
- Center for Research in Inflammatory Diseases (CRID), Ribeirao Preto Medical School, Ribeirao Preto, Brazil
- Department of Pharmacology, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto, Brazil
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22
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Zanudo JGT, Barroso-Sousa R, Jain E, Buendia-Buendia J, Li T, Tayob N, Rees R, Pereslete A, Ferreira AR, Abravanel DL, Helvie K, Partridge AH, Overmoyer B, Winer EP, Wagle N, Tolaney SM. Abstract P4-01-06: Genomic and transcriptomic analysis reveals known and novel resistance mechanisms to CDK4/6 inhibitors and sensitivity factors for the response to triplet therapy (palbociclib + everolimus + exemestane) in a phase I/IIb study in hormone-receptor positive (HR+)/HER2- metastatic breast cancer (MBC) after progression on a CDK4/6 inhibitor (CDK4/6i). Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-p4-01-06] [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: Multiple studies in HR+/HER2- MBC have identified a variety of genomic resistance mechanisms to CDK4/6 inhibitors, but the complete landscape of resistance mechanisms is still being elucidated. A clinical trial evaluating the benefit of continued CDK4/6 blockade after disease progression on a prior CDK4/6i provides a unique setting to study the landscape of resistance to CDK4/6 inhibitors. Methods: We analyzed genomic data from a Phase I/II trial (NCT02871791) of triplet therapy: palbociclib (CDK4/6i) + everolimus (mTOR inhibitor) + exemestane (endocrine therapy) in patients (pts) with HR+/HER2− MBC who had progressed on prior CDK4/6i. For the phase IIa pts, a research tumor biopsy at baseline and serial research blood collection for circulating tumor DNA (ctDNA) analysis were mandatory. Additionally, when possible, we acquired tumor biopsies that preceded the patient's prior exposure to a CDK4/6i, which would allow us to identify acquired genomic resistance mechanisms to the prior CDK4/6i. The genomic data consisted of whole exome sequencing (WES) data from 23 tumor biopsies (19 pts) and 17 ctDNA samples (12 pts), and RNA sequencing (RNA-seq) from 27 tumors (22 pts). 4 pts had a biopsy or ctDNA sample at baseline and a biopsy that preceded their prior exposure to a CDK4/6i. WES data was used to identify mutations and copy number alterations, which was used to perform evolutionary analysis on the pts with multiple biopsies or ctDNA samples. RNA-seq data was used to make research-grade PAM50 calls and calculate gene expression signature scores. Results: For the baseline biopsy or ctDNA sample of most pts, we found genomic alterations in previously identified pathways and genes that could explain the tumor’s resistance to the prior CDK4/6i (16/19 pts) or to the prior endocrine therapies (17/19 pts). These pathways and genes include the PI3K/AKT/MTOR pathway (e.g. PTEN, AKT), the RAS/MAPK pathway (e.g. NF1), receptor tyrosine kinases (RTKs) (e.g. ERBB2, FGFR1), cell-cycle genes (e.g. RB1), and estrogen receptor signaling (e.g. ESR1, FOXA1). Two novel potential genomic resistance mechanisms in these pathways were identified: an activating MTOR T1977R mutation (PI3K/AKT/MTOR pathway) and an activating BRAF V600E mutation (RAS/MAPK pathway). Notably, the patient with the activating MTOR mutation responded to the triplet therapy (progression free survival of 8 months), consistent with prior work linking these mutations to sensitivity to everolimus. Evolutionary analysis revealed metastatic tumors with distinct lineages but derived from the same primary tumor (e.g. two lineages, one with activating ESR1 mutations and one with an activating MTOR mutation), some of which converged to activating the same pathway (e.g. two lineages with distinct activating ERBB2 mutations). Transcriptomic analysis found that activating mutations in ERBB2 and BRAF were correlated with the HER2-E PAM50 and that the expression signatures for MTOR and RTKs were correlated with clinical benefit to triplet therapy. Conclusions: Analysis of the genomic and transcriptomic data of baseline biopsies and ctDNA samples from NCT02871791 not only recapitulates genes and pathways previously implicated in resistance to endocrine therapy and CDK4/6i but also identified novel potential mechanisms of resistance including activating mutations in BRAF and MTOR. Evolutionary analysis demonstrates the complexity of resistance including both convergent and divergent paths to resistance. Integration of genomic and transcriptomic data may better identify pts likely to respond to CDK4/6i combinations.
Citation Format: Jorge Gomez Tejeda Zanudo, Romualdo Barroso-Sousa, Esha Jain, Jorge Buendia-Buendia, Tianyu Li, Nabihah Tayob, Rebecca Rees, Alyssa Pereslete, Arlindo R. Ferreira, Daniel L. Abravanel, Karla Helvie, Ann H. Partridge, Beth Overmoyer, Eric P. Winer, Nikhil Wagle, Sara M. Tolaney. Genomic and transcriptomic analysis reveals known and novel resistance mechanisms to CDK4/6 inhibitors and sensitivity factors for the response to triplet therapy (palbociclib + everolimus + exemestane) in a phase I/IIb study in hormone-receptor positive (HR+)/HER2- metastatic breast cancer (MBC) after progression on a CDK4/6 inhibitor (CDK4/6i) [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 P4-01-06.
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Affiliation(s)
| | | | - Esha Jain
- Broad Institute of MIT and Harvard, Cambridge, MA
| | | | - Tianyu Li
- Dana-Farber Cancer Institute, Boston, MA
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23
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Barroso-Sousa R, Li T, Reddy S, Emens LA, Overmoyer B, Lange P, Dilullo MK, Attaya V, Kimmel J, Winer EP, Mittendorf EA, Tayob N, Tolaney SM. Abstract GS2-10: Nimbus: A phase 2 trial of nivolumab plus ipilimumab for patients with hypermutated her2-negative metastatic breast cancer (MBC). Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-gs2-10] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: While high tumor mutational burden (TMB-H) has been used as a tissue-agnostic biomarker for approval of immune checkpoint inhibitors (ICI), there is a paucity of data regarding efficacy of ICI in TMB-H MBC. The aim of this study was to evaluate if patients with TMB-H HER2-negative MBC benefit from the combination of nivolumab plus ipilimumab. Methods: This is an open-label, single-arm, multicenter, phase 2 study assessing the efficacy of nivolumab 3 mg/kg intravenously (IV) every 14 days plus ipilimumab 1 mg/kg IV every 6 weeks in subjects with TMB-H HER2-negative MBC. Eligible patients were required to have measurable HER2-negative MBC, TMB ≥9 Mut/Mb assessed by a cancer-gene panel evaluating > 300 genes and performed in a CLIA-certified laboratory, and 0-3 prior lines of chemotherapy in the advanced setting. The primary objective was overall response rate (ORR) according to RECIST 1.1. Secondary objectives include safety and tolerability, progression-free survival (PFS), and overall survival (OS). The study followed a two-stage design. In the first stage, 14 patients were enrolled. The study required at least 1 objective response in order to continue to the second stage where an additional 16 patients were enrolled. At least 4 objective responses among the 30 patients would suggest the regimen is worthy of further study. If the true response rate is 25%, the chance that the regimen is declared worthy of further study is > 90%. Tumor biopsies, peripheral blood mononuclear cells, circulating tumor DNA, and stool collection were mandatory and were obtained at baseline and on treatment (end of cycle 1). Results: From February 2019 to June 2021, 31 patients were enrolled across 3 different academic institutions. Among 30 patients who initiated study treatment, the median age was 63 yo, 20 had hormone-receptor positive (HR+) breast cancer and 10 had triple-negative breast cancer (TNBC), and median number of prior lines of chemotherapy was 1.5 (0-3). Among the 10 patients with TNBC, PD-L1 status was known in 7 patients (3 positive and 4 negative). Median TMB was 10.9 Mut/Mb and 16.7% (n = 5) of patients had a TMB ≥14 mut/Mb. After a median follow-up of 9.7 (4.4 - 16.4) months, 4 (13.3%) patients achieved a confirmed objective response (all partial responses) meeting the primary endpoint of this study. The median duration of response has not been reached and 3 of these patients are still progression-free for at least 15 months. Two patients have short follow-up, and one has an unconfirmed partial response and the other has a stable disease at the time of the data cut. Median PFS and OS was respectively 1.4 (95% CI 1.3 - 9.5) months and 8.8 (95% CI 4.2 - not reached). Exploratory analysis did not show a difference in response rate according to HR status and PD-L1 status (data not shown) but tumors with TMB ≥14 mut/Mb had a response rate of 60% vs 4% in the group with TMB between ≥9 and <14 mut/Mb (p = 0.01). The treatment was associated with a favorable toxicity profile, with only three patients developing grade 3 immune-related adverse events (1 had adrenal insufficiency and cardiac troponin elevation, and two other had hepatitis). There were no reported grade 4-5 events. Data regarding TIL, PD-L1 and CD8 immunohistochemistry will be presented at the symposium. Conclusion: This study of nivolumab plus ipilimumab in TMB-H MBC achieved the primary endpoint and demonstrated a confirmed ORR of 13.3%. While patients with TMB ≥ 14 Mut/Mb were minority in this study, the 60% of ORR in this subgroup highlights the need to better evaluate the optimal TMB cutoff to predict benefit to immunotherapy in MBC.
Citation Format: Romualdo Barroso-Sousa, Tianyu Li, Sangeetha Reddy, Leisha A. Emens, Beth Overmoyer, Paulina Lange, Molly K Dilullo, Victoria Attaya, Jeffrey Kimmel, Eric P. Winer, Elizabeth A. Mittendorf, Nabihah Tayob, Sara M. Tolaney. Nimbus: A phase 2 trial of nivolumab plus ipilimumab for patients with hypermutated her2-negative metastatic breast cancer (MBC) [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 GS2-10.
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Affiliation(s)
| | - Tianyu Li
- Dana-Farber Cancer Institute, Boston, MA
| | - Sangeetha Reddy
- University of Texas Southwestern Medical Center, Houston, TX
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Tarantino P, Barroso-Sousa R, Garrido-Castro AC, McAllister SS, Guerriero JL, Mittendorf E, Curigliano G, Tolaney SM. Understanding resistance to immune checkpoint inhibitors in advanced breast cancer. Expert Rev Anticancer Ther 2021; 22:141-153. [PMID: 34919490 DOI: 10.1080/14737140.2022.2020650] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The addition of immune checkpoint inhibitors (ICIs) to frontline chemotherapy has improved survival for patients with advanced triple-negative breast cancer (TNBC) expressing programmed death-ligand 1 (PD-L1). Nonetheless, most patients develop resistance, with outcomes remaining poor for this population. Moreover, unsatisfactory activity has been observed with ICIs in PD-L1-negative TNBC and in other breast cancer (BC) subtypes, warranting a deeper understanding of resistance to ICIs in BC. AREAS COVERED We discuss the immune landscape of distinct BC subtypes, review the clinical activity of immunotherapy in BC, and highlight strategies under development to overcome resistance to ICIs. EXPERT OPINION Activity and resistance to ICIs in BC are strongly related to the intrinsic immunophenotype of the tumor tissue. Several promising biomarkers reflecting the immunological state of BC are emerging, with only PD-L1 expression currently adopted into clinical practice. However, limitations make of PD-L1 a sub-optimal biomarker for patient selection, which require efforts to integrate this marker with other immunological features. Concomitantly, a wide variety of drug combinations designed to overcome immune-resistance are being evaluated, with some encouraging signals observed in early-phase trials. Combination strategies tailored to patient and tumor immunophenotype may allow to overcome resistance and fully exploit the potential of ICIs.
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Affiliation(s)
- Paolo Tarantino
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.,Breast Oncology Program Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Ana C Garrido-Castro
- Breast Oncology Program Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sandra S McAllister
- Harvard Medical School, Boston, MA, USA.,Hematology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jennifer L Guerriero
- Breast Oncology Program Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Elizabeth Mittendorf
- Breast Oncology Program Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Sara M Tolaney
- Breast Oncology Program Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Barrios CH, Werutsky G, Mohar A, Ferrigno AS, Müller BG, Bychkovsky BL, Castro E CJ, Uribe CJ, Villarreal-Garza C, Soto-Perez-de-Celis E, Gutiérrez-Delgado F, Kim JS, Ismael J, Delgado L, Santini LA, Teich N, Chavez PC, Liedke PER, Exman P, Barroso-Sousa R, Stefani SD, Cáceres SAB, Rebelatto TF, Pastrana T, Chavarri-Guerra Y, Vargas Y, Cazap E. Cancer control in Latin America and the Caribbean: recent advances and opportunities to move forward. Lancet Oncol 2021; 22:e474-e487. [PMID: 34735817 DOI: 10.1016/s1470-2045(21)00492-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/03/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
The increasing burden of cancer represents a substantial problem for Latin America and the Caribbean. Two Lancet Oncology Commissions in 2013 and 2015 highlighted potential interventions that could advance cancer care in the region by overcoming existing challenges. Areas requiring improvement included insufficient investment in cancer control, non-universal health coverage, fragmented health systems, inequitable concentration of cancer services, inadequate registries, delays in diagnosis or treatment initiation, and insufficient palliative services. Progress has been made in key areas but remains uneven across the region. An unforeseen challenge, the COVID-19 pandemic, strained all resources, and its negative effect on cancer control is expected to continue for years. In this Series paper, we summarise progress in several aspects of cancer control since 2015, and identify persistent barriers requiring commitment of additional resources to reduce the cancer burden in Latin America and the Caribbean.
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Affiliation(s)
- Carlos H Barrios
- Oncology Department, Oncoclinicas Group, Porto Alegre, Brazil; Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil.
| | - Gustavo Werutsky
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | - Alejandro Mohar
- Unidad de Epidemiología, Instituto Nacional de Cancerología, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Ana S Ferrigno
- Breast Cancer Center, Hospital Zambrano Hellion TecSalud, Tecnologico de Monterrey, San Pedro Garza Garcia, Nuevo León, Mexico
| | - Bettina G Müller
- Department of Medical Oncology, Instituto Nacional del Cáncer, Santiago, Chile
| | - Brittany L Bychkovsky
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | | | - Cynthia Villarreal-Garza
- Breast Cancer Center, Hospital Zambrano Hellion TecSalud, Tecnologico de Monterrey, San Pedro Garza Garcia, Nuevo León, Mexico
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Francisco Gutiérrez-Delgado
- Centro de Estudios y Prevención del Cancer Tuxtla Gutiérrez, Chiapas, México; Latin American School of Oncology (ELO), México City, México
| | - Ji Seok Kim
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Dewpoint Therapeutics, Boston, MA, USA
| | | | - Lucia Delgado
- Faculty of Medicine, University of Uruguay, Montevideo, Uruguay; Honorary Commission for the Fight Against Cancer, Montevideo, Uruguay
| | - Luiz A Santini
- Center of Strategic Studies of FIOCRUZ (Fundação Oswaldo Cruz), Rio de Janeiro, Brazil
| | - Nelson Teich
- Teich Health Care Consulting, Rio de Janeiro, Brazil
| | - Pamela C Chavez
- Department of Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Pedro E R Liedke
- Oncology Department, Oncoclinicas Group, Porto Alegre, Brazil; Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil; Department of Oncology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil; Unidade de Pesquisa Clínica em Oncologia, Porto Alegre, Brazil
| | - Pedro Exman
- Department of Medical Oncology, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | | | - Suyapa A Bejarano Cáceres
- Medicine Universidad Católica de Honduras, San Pedro Sula, Honduras; Department of Clinical Oncology, Liga Contra el Cáncer, San Pedro Sula, Honduras
| | | | - Tania Pastrana
- Department of Palliative Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Yanin Chavarri-Guerra
- Department of Hemato-Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Mexico City, Mexico
| | - Yolanda Vargas
- Unidad de Cuidados Paliativos y Clínica de Alivio del Dolor Oncológico, Instituto Oncológico Nacional, Ciudad de Panamá, Panamá
| | - Eduardo Cazap
- Latin American and Caribbean Society of Medical Oncology (SLACOM), Buenos Aires, Argentina
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Weis LN, Tolaney SM, Barrios CH, Barroso-Sousa R. Tissue-agnostic drug approvals: how does this apply to patients with breast cancer? NPJ Breast Cancer 2021; 7:120. [PMID: 34518552 PMCID: PMC8437983 DOI: 10.1038/s41523-021-00328-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 03/03/2021] [Accepted: 08/20/2021] [Indexed: 02/08/2023] Open
Abstract
Precision medicine has provided new perspectives in oncology, yielding research on the use of targeted therapies across different tumor types, regardless of their site of origin, a concept known as tissue-agnostic indication. Since 2017, the Food and Drug Administration (FDA) has approved the use of three different agents for tumor-agnostic treatment: pembrolizumab (for patients with microsatellite instability or high tumor mutational burden) and larotrectinib and entrectinib (both for use in patients harboring tumors with NTRK fusions). Importantly, the genomic alterations targeted by these agents are uncommon or rare in breast cancer, and little information exists regarding their efficacy in advanced breast cancer. In this review, we discuss the prevalence of these targets in breast cancer, their detection methods, the clinical characteristics of patients whose tumors have these alterations, and available data regarding the efficacy of these agents in breast cancer.
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Affiliation(s)
- Luiza N Weis
- Instituto de Ensino e Pesquisa Hospital Sírio-Libanês, São Paulo-SP, Brazil
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Romualdo Barroso-Sousa
- Instituto de Ensino e Pesquisa Hospital Sírio-Libanês, São Paulo-SP, Brazil.
- Oncology Center, Hospital Sírio-Libanês Brasília, Brasília-DF, Brazil.
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Barroso-Sousa R, Vaz-Luis I, Di Meglio A, Hu J, Li T, Rees R, Sinclair N, Milisits L, Leone JP, Constantine M, Faggen M, Briccetti F, Block C, Partridge A, Burstein H, Waks AG, Tayob N, Trippa L, Tolaney SM, Hassett MJ, Winer EP, Lin NU. Prospective Study Testing a Simplified Paclitaxel Premedication Regimen in Patients with Early Breast Cancer. Oncologist 2021; 26:927-933. [PMID: 34472667 PMCID: PMC8571744 DOI: 10.1002/onco.13960] [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] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 08/16/2021] [Indexed: 12/02/2022] Open
Abstract
Background In early trials, hypersensitivity reactions (HSRs) to paclitaxel were common, thus prompting the administration of antihistamines and corticosteroids before every paclitaxel dose. We tested the safety of omitting corticosteroids after cycle 2 during the paclitaxel portion of the dose‐dense (DD) doxorubicin‐cyclophosphamide (AC)–paclitaxel regimen. Patients, Materials, and Methods In this prospective, single‐arm study, patients who completed four cycles of DD‐AC for stage I–III breast cancer received paclitaxel 175 mg/m2 every 2 weeks for four cycles. Patients received a standard premedication protocol containing dexamethasone, diphenhydramine, and a histamine H2 blocker prior to the first two paclitaxel cycles. Dexamethasone was omitted in cycles three and four if there were no HSRs in previous cycles. We estimated the rate of grade 3–4 HSRs. Results Among 127 patients enrolled, 125 received more than one dose of protocol therapy and are included in the analysis. Fourteen (11.2%; 90% confidence interval, 6.9%–20.0%) patients had any‐grade HSRs, for a total of 22 (4.5%; 3.1%–6.4%) HSRs over 486 paclitaxel cycles. Any‐grade HSRs occurred in 1.6% (0.3%–5.0%), 6.5% (3.3%–11.3%), 7.4% (3.9%–12.5%), and 2.6% (0.7%–6.6%) of patients after paclitaxel cycles 1, 2, 3, and 4, respectively. Dexamethasone use was decreased by 92.8% in cycles 3 and 4. Only one patient experienced grade 3 HSR in cycles 3 or 4, for a rate of grade 3/4 HSR 0.4% (0.02%–2.0%) (1/237 paclitaxel infusions). That patient had grade 2 HSR during cycle 2, and the subsequent grade 3 event occurred despite usual dexamethasone premedication. A sensitivity analysis restricted to patients not known to have received dexamethasone in cycles 3 and 4 found that any‐grade HSRs occurred in 2.7% (3/111; 0.7%–6.8%) and 0.9% (1/109; 0.05%–4.3%) of patients in cycle 3 and 4, respectively. Conclusion Corticosteroid premedication can be safely omitted in cycles 3 and 4 of dose‐dense paclitaxel if HSRs are not observed during cycles 1 and 2. Implications for Practice Because of the potential for hypersensitivity reactions (HSRs) to paclitaxel, corticosteroids are routinely prescribed prior to each dose, on an indefinite basis. This prospective study, including 125 patients treated with 486 paclitaxel cycles, demonstrates that corticosteroids can be safely omitted in future cycles if HSRs did not occur during cycles 1 and 2 of paclitaxel and that this strategy reduces the use of corticosteroids in cycles 3 and 4 by 92.8% relative to current standard of care. To avoid hypersensitivity reactions, corticosteroids are routinely prescribed before each dose of paclitaxel. This article reports the results of a study that focused on whether corticosteroids could be safely omitted in later cycles of treatment if reactions did not occur during earlier cycles.
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Affiliation(s)
- Romualdo Barroso-Sousa
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Oncology Center, Hospital Sírio-Libanês, Brasília, Brazil
| | - Ines Vaz-Luis
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Institut Gustave Roussy, Unit INSERM 981, Prédicteurs moléculaires et nouvelles cibles en oncologie, Villejuif, France
| | - Antonio Di Meglio
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Institut Gustave Roussy, Unit INSERM 981, Prédicteurs moléculaires et nouvelles cibles en oncologie, Villejuif, France
| | - Jiani Hu
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tianyu Li
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Rebecca Rees
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | | | | | | | - Meredith Faggen
- Dana-Farber Cancer Institute at South Shore Hospital, South Weymouth, Massachusetts, USA
| | - Frederick Briccetti
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Dana-Farber Cancer Institute/New Hampshire Oncology-Hematology, Londonderry, New Hampshire, USA
| | - Caroline Block
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, Massachusetts, USA
| | - Ann Partridge
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | | | - Nabihah Tayob
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lorenzo Trippa
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard School of Public Health, Boston, Massachusetts, USA
| | - Sara M Tolaney
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | - Eric P Winer
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Nancy U Lin
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Tolaney S, Barroso-Sousa R, Jiang Z, Park Y, Rimawi M, Saura Manich C, Schneeweiss A, Toi M, Yu T, Shetty J, Herbolsheimer P, Loibl S. 328TiP Phase III study of trastuzumab deruxtecan (T-DXd) with or without pertuzumab vs a taxane, trastuzumab and pertuzumab in first-line (1L), human epidermal growth factor receptor 2–positive (HER2+) metastatic breast cancer (mBC): DESTINY-Breast09. Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.08.611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Barroso-Sousa R, Keenan TE, Li T, Tayob N, Trippa L, Pastorello RG, Richardson Iii ET, Dillon D, Amoozgar Z, Overmoyer B, Schnitt SJ, Winer EP, Mittendorf EA, Van Allen E, Duda DG, Tolaney SM. Nivolumab in combination with cabozantinib for metastatic triple-negative breast cancer: a phase II and biomarker study. NPJ Breast Cancer 2021; 7:110. [PMID: 34433812 PMCID: PMC8387440 DOI: 10.1038/s41523-021-00287-9] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 05/27/2021] [Indexed: 02/07/2023] Open
Abstract
This single-arm phase II study investigated the efficacy and safety of cabozantinib combined with nivolumab in metastatic triple-negative breast cancer (mTNBC). The primary endpoint was objective response rate (ORR) by RECIST 1.1. Biopsies at baseline and after cycle 1 were analyzed for tumor-infiltrating lymphocytes (TILs), PD-L1, and whole-exome and transcriptome sequencing. Only 1/18 patients achieved a partial response (ORR 6%), and the trial was stopped early. Toxicity led to cabozantinib dose reduction in 50% of patients. One patient had a PD-L1-positive tumor, and three patients had TILs > 10%. The responding patient had a PD-L1-negative tumor with low tumor mutational burden but high TILs and enriched immune gene expression. High pretreatment levels of plasma immunosuppressive cytokines, chemokines, and immune checkpoint molecules were associated with rapid progression. Although this study did not meet its primary endpoint, immunostaining, genomic, and proteomic studies indicated a high degree of tumor immunosuppression in this mTNBC cohort.
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Affiliation(s)
- Romualdo Barroso-Sousa
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
- Oncology Center, Hospital Sírio-Libanês, Brasilia, Brazil
| | - Tanya E Keenan
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Tianyu Li
- Biostatistics, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Nabihah Tayob
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Lorenzo Trippa
- Biostatistics, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | - Deborah Dillon
- Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Zohreh Amoozgar
- Steele Laboratories for Tumor Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Beth Overmoyer
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | | | - Eric P Winer
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Eliezer Van Allen
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Dan G Duda
- Steele Laboratories for Tumor Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Sara M Tolaney
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
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30
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Weber ZT, Collier KA, Tallman D, Forman J, Shukla S, Asad S, Rhoades J, Freeman S, Parsons HA, Williams NO, Barroso-Sousa R, Stover EH, Mahdi H, Cibulskis C, Lennon NJ, Ha G, Adalsteinsson VA, Tolaney SM, Stover DG. Modeling clonal structure over narrow time frames via circulating tumor DNA in metastatic breast cancer. Genome Med 2021; 13:89. [PMID: 34016182 PMCID: PMC8136103 DOI: 10.1186/s13073-021-00895-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 08/27/2020] [Accepted: 04/23/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Circulating tumor DNA (ctDNA) offers minimally invasive means to repeatedly interrogate tumor genomes, providing opportunities to monitor clonal dynamics induced by metastasis and therapeutic selective pressures. In metastatic cancers, ctDNA profiling allows for simultaneous analysis of both local and distant sites of recurrence. Despite the promise of ctDNA sampling, its utility in real-time genetic monitoring remains largely unexplored. METHODS In this exploratory analysis, we characterize high-frequency ctDNA sample series collected over narrow time frames from seven patients with metastatic triple-negative breast cancer, each undergoing treatment with Cabozantinib, a multi-tyrosine kinase inhibitor (NCT01738438, https://clinicaltrials.gov/ct2/show/NCT01738438 ). Applying orthogonal whole exome sequencing, ultra-low pass whole genome sequencing, and 396-gene targeted panel sequencing, we analyzed 42 plasma-derived ctDNA libraries, representing 4-8 samples per patient with 6-42 days between samples. Integrating tumor fraction, copy number, and somatic variant information, we model tumor clonal dynamics, predict neoantigens, and evaluate consistency of genomic information from orthogonal assays. RESULTS We measured considerable variation in ctDNA tumor faction in each patient, often conflicting with RECIST imaging response metrics. In orthogonal sequencing, we found high concordance between targeted panel and whole exome sequencing in both variant detection and variant allele frequency estimation (specificity = 95.5%, VAF correlation, r = 0.949), Copy number remained generally stable, despite resolution limitations posed by low tumor fraction. Through modeling, we inferred and tracked distinct clonal populations specific to each patient and built phylogenetic trees revealing alterations in hallmark breast cancer drivers, including TP53, PIK3CA, CDK4, and PTEN. Our modeling revealed varied responses to therapy, with some individuals displaying stable clonal profiles, while others showed signs of substantial expansion or reduction in prevalence, with characteristic alterations of varied literature annotation in relation to the study drug. Finally, we predicted and tracked neoantigen-producing alterations across time, exposing translationally relevant detection patterns. CONCLUSIONS Despite technical challenges arising from low tumor content, metastatic ctDNA monitoring can aid our understanding of response and progression, while minimizing patient risk and discomfort. In this study, we demonstrate the potential for high-frequency monitoring of evolving genomic features, providing an important step toward scalable, translational genomics for clinical decision making.
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Affiliation(s)
- Zachary T Weber
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 460 W. 12th Avenue, Columbus, OH, 43210, USA
| | - Katharine A Collier
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 460 W. 12th Avenue, Columbus, OH, 43210, USA
- Division of Medical Oncology, Department of Medicine, College of Medicine, The Ohio State University, 320 W. 10th Avenue, Columbus, OH, 43210, USA
| | - David Tallman
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 460 W. 12th Avenue, Columbus, OH, 43210, USA
| | - Juliet Forman
- Broad Institute of Harvard & MIT, 415 Main St., Cambridge, MA, 02412, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
- Translational Immunogenomics Lab, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Sachet Shukla
- Broad Institute of Harvard & MIT, 415 Main St., Cambridge, MA, 02412, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
- Translational Immunogenomics Lab, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Sarah Asad
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 460 W. 12th Avenue, Columbus, OH, 43210, USA
| | - Justin Rhoades
- Broad Institute of Harvard & MIT, 415 Main St., Cambridge, MA, 02412, USA
| | - Samuel Freeman
- Broad Institute of Harvard & MIT, 415 Main St., Cambridge, MA, 02412, USA
| | - Heather A Parsons
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Nicole O Williams
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 460 W. 12th Avenue, Columbus, OH, 43210, USA
- Division of Medical Oncology, Department of Medicine, College of Medicine, The Ohio State University, 320 W. 10th Avenue, Columbus, OH, 43210, USA
| | | | - Elizabeth H Stover
- Broad Institute of Harvard & MIT, 415 Main St., Cambridge, MA, 02412, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Haider Mahdi
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, 44195, USA
- Department of Surgery, Case Comprehensive Cancer Center, Cleveland, OH, 44106, USA
| | - Carrie Cibulskis
- Broad Institute of Harvard & MIT, 415 Main St., Cambridge, MA, 02412, USA
| | - Niall J Lennon
- Broad Institute of Harvard & MIT, 415 Main St., Cambridge, MA, 02412, USA
| | - Gavin Ha
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, 98109, USA
| | | | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Daniel G Stover
- The Ohio State University Comprehensive Cancer Center, The Ohio State University, 460 W. 12th Avenue, Columbus, OH, 43210, USA.
- Division of Medical Oncology, Department of Medicine, College of Medicine, The Ohio State University, 320 W. 10th Avenue, Columbus, OH, 43210, USA.
- Biomedical Research Tower, Room 984, Ohio State University Comprehensive Cancer Center, Stefanie Spielman Comprehensive Breast Center, Columbus, OH, 43210, USA.
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Barroso-Sousa R, Forman J, Weber ZT, Collier K, Kao KZ, Richardson ET, Keenan T, Cohen O, Manos MP, Brennick RC, Ott P, Hodi FS, Dillon DA, Lin NU, Van Allen EE, Rodig S, Winer EP, Mittendorf EA, Wu CJ, Stover D, Wagle N, Shukla S, Tolaney S. Abstract PS4-25: Comprehensive genomic analysis reveals molecular correlates of response to immune checkpoint inhibitors (ICI) in metastatic triple-negative breast cancer (mTNBC). Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-ps4-25] [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: Genomic mechanisms associated with response to ICI in mTNBC are largely unknown. The aim of this work is to assess the genomic and immune profiles of mTNBC samples collected from patients (pts) treated with ICI. Methods: We identified 31 women with mTNBC treated with ICI (pembrolizumab, n=6, NCT02447003; atezolizumab, n=4, NCT01375842; nivolumab + cabozantinib, n = 6, NCT03316586; pembrolizumab + eribulin, n=8, NCT02513472; atezolizumab + nab-paclitaxel, n=7, NCT01633970) who had tumor tissue or blood available for sequencing obtained before and after ICI. Clinical benefit (CB), here defined as any objective response or stable disease (SD) for > 24 weeks, was observed in 20 pts (65%). An extraordinary responder was defined as having CB ≥ 2 yrs; 5 pts were considered extraordinary responders (range 26-60months). Whole exome sequencing (WES) was done on each tumor and on germline DNA from blood (23 pts had successful WES performed on samples collected before ICI; 5 of these had WES on samples taken after disease progression). RNA sequencing (RNAseq) was successfully performed in 18 of the tumors with WES performed on samples before ICI; and 3 of these had RNAseq on samples taken after disease progression. 18 pts had tumors assessed by multiplex immunofluorescence (mIF) panels encompassing CD4, CD8, PD-1, PD-L1, and cytokeratin on samples collected before ICI. WES, deep targeted panel and low coverage whole genome sequencing were performed on serially collected plasma samples from 22 pts to evaluate tumor fraction and specific mutations. The association between biomarkers and clinical benefit to ICI was assessed. Results: 21 of 31 pts (67%) had received ≥1 prior lines of systemic therapy in the metastatic setting before starting ICI. Among the most frequently mutated genes at baseline are: TP53 (57%); PIK3CA (18%); DNAH5, MYH8 (both 13%); KMT2C, AKT1, LAMA2 (all 9%). Pts with CB had a higher tumor mutational burden (TMB) than pts with no CB (p=0.018). Differential expression analysis of RNAseq data revealed an upregulation of several immune-related genes in pts with CB, indicating increased immune infiltration in that group. Gene set enrichment analysis of this expression data using hallmark and canonical pathway gene sets from MSigDB (nominal p-val < 0.05) showed that, compared to samples from pts without CB, extraordinary responders had elevated transcriptional signatures of several cancer-related pathways associated with cell survival, proliferation and metabolism, as well as genes associated with increased immune infiltration and upregulation of inflammatory response programs. The mIF showed that the tumor microenvironment (TME) of pts with CB were enriched in Cytokeratin-negative/PD-L1-positive cells compared to those without CB (p=0.014). Expression of CD4, CD8 and PD-1 was not significantly different between pts with and without CB. Genomic analysis of circulating tumor DNA, and tumor evolutionary analysis for pts with both pre- and post-ICI samples (acquired resistance) will be presented. Conclusions: Clinical benefit to ICI in mTNBC was associated with upregulation of immune-related pathways, enrichment of non-tumoral PD-L1-positive cells in TME, and high TMB.
Citation Format: Romualdo Barroso-Sousa, Juliet Forman, Zachary T. Weber, Katherine Collier, Katrina Z. Kao, Edward T. Richardson, III, Tanya Keenan, Ofir Cohen, Michael P. Manos, Ryan C. Brennick, Patrick Ott, F. Steve Hodi, Deborah A. Dillon, Nancy U. Lin, Eliezer E. Van Allen, Scott Rodig, Eric P. Winer, Elizabeth A. Mittendorf, Catherine J. Wu, Daniel Stover, Nikhil Wagle, Sachet Shukla, Sara Tolaney. Comprehensive genomic analysis reveals molecular correlates of response to immune checkpoint inhibitors (ICI) in metastatic triple-negative breast cancer (mTNBC) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS4-25.
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Affiliation(s)
| | | | | | | | | | | | | | - Ofir Cohen
- 2Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | | | | | - Scott Rodig
- 4Dana-Farber Cancer Institute/Brigham Women's Hospital, Boston, MA
| | | | | | | | - Daniel Stover
- 3Ohio State University College of Medicine, Columbus, OH
| | | | - Sachet Shukla
- 4Dana-Farber Cancer Institute/Brigham Women's Hospital, Boston, MA
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32
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Stover DG, Collier KA, Tallman D, Forman J, Shukla S, Asad S, Rhoades J, Freeman S, Cherian M, Sardesai S, Barroso-Sousa R, Cibulskis C, Lennon N, Ha G, Tolaney SM, Adalsteinsson VA, Weber Z. Abstract PD9-08: Modeling clonal structure over narrow time frames via circulating tumor DNA in metastatic breast cancer. Cancer Res 2021. [DOI: 10.1158/1538-7445.sabcs20-pd9-08] [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
Introduction: Circulating tumor DNA (ctDNA) offers the ability to repeatedly interrogate tumor genomic information, providing an opportunity for real-time monitoring of tumor genomic dynamics. In this study, we deeply analyzed multiple ctDNA samples collected over narrow time frames (days-to-weeks) from seven patients with metastatic triple-negative breast cancer (mTNBC), a cancer type known to have high ctDNA content. Methods: Patients with mTNBC were enrolled in a clinical trial of multi-kinase inhibitor cabozantinib, providing uniform and targeted treatment, and samples were collected day 1, day 8, then every 21 to 42 days on study. ctDNA was extracted from each plasma sample and underwent ultra-low pass whole genome sequencing (ULP-WGS; average depth 0.1x; n=42 samples), deep targeted panel sequencing (TPS) of 402 cancer-related genes with unique molecular identifier indexing (depth 10,000x; n=42 samples), and samples with tumor fraction (TFx) >10% underwent whole exome sequencing (WES; depth 200x; n=31 samples), with whole blood germline sequencing of both TPS and WES for subsequent analyses. Somatic copy number alterations (SCNAs) were identified from ULP-WGS and WES. PyClone with TPS was employed for clonal dynamic analyses. Predicted neoantigens were determined from WES using HLAthena. Results: A total of 42 total plasma samples from 7 patients (range 4-8 samples per patient) were collected at narrow time intervals, median 21 days (range 6 to 42 days) between samples. The median TFx across all samples was 18.1% (range 2.5% to 44.3%). TFx estimates were concordant when comparing orthogonal sequencing approaches (ULP-WGS, WES) and tumor fraction estimation algorithms (ichorCNA, FACETS). Despite all seven patients having ‘stable disease’ as best objective response, TFx dynamics were widely variable with TFx declining to lower limit of detection in three of seven patients. Of all samples, 31/42 (73.8%) had tumor fraction >10% and underwent WES; each patient had at least 3 samples that underwent both WES and TPS. There was strong agreement between TPS and WES: across all 31 shared samples, mutation recall in TPS versus WES (gold standard) was 95.5%. Variant allele frequency across all mutations detected in both TPS and WES was highly concordant (Pearson’s r=0.949). Clonal mutations were consistently detected across multiple samples within patients. When comparing genome-wide copy number from last to first available sample within each patient, copy number log ratios were largely stable within patients (union Pearson’s r=0.924) and there were not recurrent shifts in SCNAs across patients. Through statistical modeling of TPS data, we tracked distinct clonal populations for each patient over their sampling windows. Modeled clonal architecture in most patients revealed stable, polyclonal profiles, with important breast cancer driver alterations (e.g. TP53 and PIK3CA) recurrently presenting at high prevalence. Infrequently, we also detected emergence and expansion of clones over narrow time frames (weeks) containing acquired alterations poorly annotated in the breast cancer literature. We successfully predicted neoantigens from ctDNA WES at multiple time points in each patient, with evidence that patients acquired new mutations predicted to be ‘strong binder’ neoantigens over time on therapy. Conclusions: Analysis of serial ctDNA samples collected at narrow time intervals (days-to-weeks) provides unique insight into the dynamics of ctDNA. We demonstrate strong concordance across ctDNA sequencing appraoches. Evolving genomic features of tumor populations can be identified via ctDNA while on treatment, potentially providing real time insight for clinical decision-making.
Citation Format: Daniel G Stover, Katharine A Collier, David Tallman, Juliet Forman, Sachet Shukla, Sarah Asad, Justin Rhoades, Samuel Freeman, Mathew Cherian, Sagar Sardesai, Romualdo Barroso-Sousa, Carrie Cibulskis, Niall Lennon, Gavin Ha, Sara M Tolaney, Viktor A Adalsteinsson, Zachary Weber. Modeling clonal structure over narrow time frames via circulating tumor DNA in metastatic breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD9-08.
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Affiliation(s)
- Daniel G Stover
- 1Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - David Tallman
- 1Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | | | - Sarah Asad
- 1Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | | | - Mathew Cherian
- 1Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Sagar Sardesai
- 1Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | | | - Niall Lennon
- 2Broad Institute of Harvard and MIT, Cambridge, MA
| | - Gavin Ha
- 4Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | - Zachary Weber
- 1Ohio State University Comprehensive Cancer Center, Columbus, OH
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Garrido-Castro AC, Spurr LF, Hughes ME, Li YY, Cherniack AD, Kumari P, Lloyd MR, Bychkovsky B, Barroso-Sousa R, Di Lascio S, Jain E, Files J, Mohammed-Abreu A, Krevalin M, MacKichan C, Barry WT, Guo H, Xia D, Cerami E, Rollins BJ, MacConaill LE, Lindeman NI, Krop IE, Johnson BE, Wagle N, Winer EP, Dillon DA, Lin NU. Genomic Characterization of de novo Metastatic Breast Cancer. Clin Cancer Res 2020; 27:1105-1118. [PMID: 33293374 DOI: 10.1158/1078-0432.ccr-20-1720] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/05/2020] [Accepted: 12/02/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE In contrast to recurrence after initial diagnosis of stage I-III breast cancer [recurrent metastatic breast cancer (rMBC)], de novo metastatic breast cancer (dnMBC) represents a unique setting to elucidate metastatic drivers in the absence of treatment selection. We present the genomic landscape of dnMBC and association with overall survival (OS). EXPERIMENTAL DESIGN Targeted DNA sequencing (OncoPanel) was prospectively performed on either primary or metastatic tumors from 926 patients (212 dnMBC and 714 rMBC). Single-nucleotide variants, copy-number variations, and tumor mutational burden (TMB) in treatment-naïve dnMBC primary tumors were compared with primary tumors in patients who ultimately developed rMBC, and correlated with OS across all dnMBC. RESULTS When comparing primary tumors by subtype, MYB amplification was enriched in triple-negative dnMBC versus rMBC (21.1% vs. 0%, P = 0.0005, q = 0.111). Mutations in KMTD2, SETD2, and PIK3CA were more prevalent, and TP53 and BRCA1 less prevalent, in primary HR+/HER2- tumors of dnMBC versus rMBC, though not significant after multiple comparison adjustment. Alterations associated with shorter OS in dnMBC included TP53 (wild-type: 79.7 months; altered: 44.2 months; P = 0.008, q = 0.107), MYC (79.7 vs. 23.3 months; P = 0.0003, q = 0.011), and cell-cycle (122.7 vs. 54.9 months; P = 0.034, q = 0.245) pathway genes. High TMB correlated with better OS in triple-negative dnMBC (P = 0.041). CONCLUSIONS Genomic differences between treatment-naïve dnMBC and primary tumors of patients who developed rMBC may provide insight into mechanisms underlying metastatic potential and differential therapeutic sensitivity in dnMBC. Alterations associated with poor OS in dnMBC highlight the need for novel approaches to overcome potential intrinsic resistance to current treatments.
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Affiliation(s)
- Ana C Garrido-Castro
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts
| | - Liam F Spurr
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Melissa E Hughes
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Yvonne Y Li
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Andrew D Cherniack
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Priti Kumari
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Maxwell R Lloyd
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Brittany Bychkovsky
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Simona Di Lascio
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Esha Jain
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Janet Files
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Max Krevalin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Colin MacKichan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - William T Barry
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Hao Guo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Daniel Xia
- Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Brigham and Women' Hospital, Boston, Massachusetts
| | - Ethan Cerami
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Barrett J Rollins
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Laura E MacConaill
- Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Brigham and Women' Hospital, Boston, Massachusetts.,Center for Cancer Genome Discovery, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Neal I Lindeman
- Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Brigham and Women' Hospital, Boston, Massachusetts.,Center for Cancer Genome Discovery, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ian E Krop
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Bruce E Johnson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Nikhil Wagle
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Deborah A Dillon
- Harvard Medical School, Boston, Massachusetts.,Department of Pathology, Brigham and Women' Hospital, Boston, Massachusetts
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Garrido-Castro AC, Saura C, Barroso-Sousa R, Guo H, Ciruelos E, Bermejo B, Gavilá J, Serra V, Prat A, Paré L, Céliz P, Villagrasa P, Li Y, Savoie J, Xu Z, Arteaga CL, Krop IE, Solit DB, Mills GB, Cantley LC, Winer EP, Lin NU, Rodon J. Phase 2 study of buparlisib (BKM120), a pan-class I PI3K inhibitor, in patients with metastatic triple-negative breast cancer. Breast Cancer Res 2020; 22:120. [PMID: 33138866 PMCID: PMC7607628 DOI: 10.1186/s13058-020-01354-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [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: 05/05/2020] [Accepted: 10/11/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Treatment options for triple-negative breast cancer remain limited. Activation of the PI3K pathway via loss of PTEN and/or INPP4B is common. Buparlisib is an orally bioavailable, pan-class I PI3K inhibitor. We evaluated the safety and efficacy of buparlisib in patients with metastatic triple-negative breast cancer. METHODS This was a single-arm phase 2 study enrolling patients with triple-negative metastatic breast cancer. Patients were treated with buparlisib at a starting dose of 100 mg daily. The primary endpoint was clinical benefit, defined as confirmed complete response (CR), partial response (PR), or stable disease (SD) for ≥ 4 months, per RECIST 1.1. Secondary endpoints included progression-free survival (PFS), overall survival (OS), and toxicity. A subset of patients underwent pre- and on-treatment tumor tissue biopsies for correlative studies. RESULTS Fifty patients were enrolled. Median number of cycles was 2 (range 1-10). The clinical benefit rate was 12% (6 patients, all SD ≥ 4 months). Median PFS was 1.8 months (95% confidence interval [CI] 1.6-2.3). Median OS was 11.2 months (95% CI 6.2-25). The most frequent adverse events were fatigue (58% all grades, 8% grade 3), nausea (34% all grades, none grade 3), hyperglycemia (34% all grades, 4% grade 3), and anorexia (30% all grades, 2% grade 3). Eighteen percent of patients experienced depression (12% grade 1, 6% grade 2) and anxiety (10% grade 1, 8% grade 2). Alterations in PIK3CA/AKT1/PTEN were present in 6/27 patients with available targeted DNA sequencing (MSK-IMPACT), 3 of whom achieved SD as best overall response though none with clinical benefit ≥ 4 months. Of five patients with paired baseline and on-treatment biopsies, reverse phase protein arrays (RPPA) analysis demonstrated reduction of S6 phosphorylation in 2 of 3 patients who achieved SD, and in none of the patients with progressive disease. CONCLUSIONS Buparlisib was associated with prolonged SD in a very small subset of patients with triple-negative breast cancer; however, no confirmed objective responses were observed. Downmodulation of key nodes in the PI3K pathway was observed in patients who achieved SD. PI3K pathway inhibition alone may be insufficient as a therapeutic strategy for triple-negative breast cancer. TRIAL REGISTRATION NCT01790932 . Registered on 13 February 2013; NCT01629615 . Registered on 27 June 2012.
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Affiliation(s)
- Ana C Garrido-Castro
- Department of Medical Oncology, Susan F. Smith Center for Women's Cancers, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Cristina Saura
- Department of Medical Oncology, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- Vall d'Hebron Institute of Oncology, VHIO, Barcelona, Spain
- SOLTI Breast Cancer Research Group, Barcelona, Spain
| | - Romualdo Barroso-Sousa
- Department of Medical Oncology, Susan F. Smith Center for Women's Cancers, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
- Present Address: Hospital Sírio-Libanês, Brasilia, Brazil
| | - Hao Guo
- Division of Biostatistics, Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Begoña Bermejo
- Clinic University Hospital, INCLIVA Biomedical Research Institute, CIBERONC-ISCIII, Valencia, Spain
| | - Joaquin Gavilá
- Fundación Instituto Valenciano De Oncología, Valencia, Spain
| | - Violeta Serra
- Experimental Therapeutics Group, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Aleix Prat
- Department of Medical Oncology, Translational Genomics and Targeted Therapeutics in Solid Tumors, IDIBAPS, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Laia Paré
- SOLTI Breast Cancer Research Group, Barcelona, Spain
| | - Pamela Céliz
- SOLTI Breast Cancer Research Group, Barcelona, Spain
| | | | - Yisheng Li
- Department of Biostatistics, Division of Basic Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer Savoie
- Department of Medical Oncology, Susan F. Smith Center for Women's Cancers, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Zhan Xu
- School of Communication, Northern Arizona University, Flagstaff, AZ, USA
| | - Carlos L Arteaga
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ian E Krop
- Department of Medical Oncology, Susan F. Smith Center for Women's Cancers, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - David B Solit
- Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gordon B Mills
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
- Present Address: Division of Basic Science Research, Department of Systems Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lewis C Cantley
- Sandra and Edward Meyer Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Eric P Winer
- Department of Medical Oncology, Susan F. Smith Center for Women's Cancers, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Nancy U Lin
- Department of Medical Oncology, Susan F. Smith Center for Women's Cancers, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA.
| | - Jordi Rodon
- Department of Medical Oncology, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
- SOLTI Breast Cancer Research Group, Barcelona, Spain
- Present Address: Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
INTRODUCTION In 2019, the PD-L1 inhibitor atezolizumab became the first immune checkpoint inhibitor approved for treatment in patients with breast cancer. The approval is restricted to patients with metastatic triple-negative breast cancer (TNBC) whose tumors are PD-L1 positive. There is a rationale to believe that using PD-1/L1 inhibitors in the early disease setting may be associated with even greater benefit than seen in the metastatic setting. AREAS COVERED We review the results of pembrolizumab studies in the metastatic setting as well as the rationale for using immunotherapy in the preoperative setting. We also present current data pembrolizumab in the treatment of breast cancer with focus on the early-stage setting and discuss areas of uncertainty. EXPERT OPINION The KEYNOTE-552 study showed, for the first time, that the addition of pembrolizumab to preoperative chemotherapy increases pathologic complete response rates. Event-free survival data are promising and longer follow-up is needed to determine whether the addition of pembrolizumab significantly improves long-term outcomes for patients with early-stage TNBC.
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Affiliation(s)
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute , Boston, MA, USA
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36
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Tolaney SM, Barroso-Sousa R, Keenan T, Li T, Trippa L, Vaz-Luis I, Wulf G, Spring L, Sinclair NF, Andrews C, Pittenger J, Richardson ET, Dillon D, Lin NU, Overmoyer B, Partridge AH, Van Allen E, Mittendorf EA, Winer EP, Krop IE. Effect of Eribulin With or Without Pembrolizumab on Progression-Free Survival for Patients With Hormone Receptor-Positive, ERBB2-Negative Metastatic Breast Cancer: A Randomized Clinical Trial. JAMA Oncol 2020; 6:1598-1605. [PMID: 32880602 PMCID: PMC7489368 DOI: 10.1001/jamaoncol.2020.3524] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [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: 03/06/2020] [Accepted: 06/09/2020] [Indexed: 12/17/2022]
Abstract
Importance Prior studies have shown that only a small proportion of patients with hormone receptor (HR)-positive metastatic breast cancer (MBC) experience benefit from programmed cell death 1 (PD-1)/programmed cell death ligand 1 (PD-L1) inhibitors given as monotherapy. There are data suggesting that activity may be greater with combination strategies. Objective To compare the efficacy of eribulin plus pembrolizumab vs eribulin alone in patients with HR-positive, ERBB2 (formerly HER2)-negative MBC. Design, Setting, and Participants Multicenter phase 2 randomized clinical trial of patients with HR-positive, ERBB2-negative MBC who had received 2 or more lines of hormonal therapy and 0 to 2 lines of chemotherapy. Interventions Patients were randomized 1:1 to eribulin, 1.4 mg/m2 intravenously, on days 1 and 8 plus pembrolizumab, 200 mg/m2 intravenously, on day 1 of a 21-day cycle or eribulin alone. At time of progression, patients in the eribulin monotherapy arm could cross over and receive pembrolizumab monotherapy. Main Outcomes and Measures The primary end point was progression-free survival (PFS). Secondary end points were objective response rate (ORR) and overall survival (OS). Exploratory analyses assessed the association between PFS and PD-L1 status, tumor-infiltrating lymphocytes (TILs), tumor mutational burden (TMB), and genomic alterations. Results Eighty-eight patients started protocol therapy; the median (range) age was 57 (30-76) years, median (range) number of prior lines of chemotherapy was 1 (0-2), and median (range) number of prior lines of hormonal therapy was 2 (0-5). Median follow-up was 10.5 (95% CI, 0.4-22.8) months. Median PFS and ORR were not different between the 2 groups (PFS, 4.1 vs 4.2 months; hazard ratio, 0.80; 95% CI, 0.50-1.26; P = .33; ORR, 27% vs 34%, respectively; P = .49). Fourteen patients started crossover treatment with pembrolizumab; 1 patient experienced stable disease. All-cause adverse events occurred in all patients (grade ≥3, 65%) including 2 treatment-related deaths in the combination group, both from immune-related colitis in the setting of sepsis, attributed to both drugs. The PD-L1 22C3 assay was performed on archival tumor samples in 65 patients: 24 (37%) had PD-L1-positive tumors. Analysis indicated that PD-L1 status, TILs, TMB, and genomic alterations were not associated with PFS. Conclusions and Relevance In this randomized clinical trial of patients with HR-positive, ERBB2-negative MBC, the addition of pembrolizumab to eribulin did not improve PFS, ORR, or OS compared with eribulin alone in either the intention-to-treat or PD-L1-positive populations. Further efforts to explore the benefits of adding checkpoint inhibition to chemotherapy among less heavily pretreated patients are needed. Trial Registration ClinicalTrials.gov Identifier: NCT03051659.
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Affiliation(s)
- Sara M. Tolaney
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Romualdo Barroso-Sousa
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Oncology Center, Hospital Sírio-Libanês, Brasília, Brazil
| | - Tanya Keenan
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Broad Institute of MIT and Harvard, Boston, Massachusetts
| | - Tianyu Li
- Division of Biostatistics, Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lorenzo Trippa
- Division of Biostatistics, Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Gerburg Wulf
- Medical Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Laura Spring
- Medical Oncology, Massachusetts General Hospital, Boston
| | | | - Chelsea Andrews
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jessica Pittenger
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Deborah Dillon
- Pathology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Nancy U. Lin
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Beth Overmoyer
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ann H. Partridge
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Eliezer Van Allen
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Broad Institute of MIT and Harvard, Boston, Massachusetts
| | - Elizabeth A. Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Breast Oncology Program, Dana-Farber/Brigham and Women’s Cancer Center, Boston, Massachusetts
| | - Eric P. Winer
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ian E. Krop
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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37
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Exman P, Garrido-Castro AC, Hughes ME, Freedman RA, Li T, Trippa L, Bychkovsky BL, Barroso-Sousa R, Di Lascio S, Mackichan C, Lloyd MR, Krevalin M, Cerami E, Merrill MS, Santiago R, Crowley L, Kuhnly N, Files J, Lindeman NI, MacConaill LE, Kumari P, Tolaney SM, Krop IE, Bose R, Johnson BE, Ma CX, Dillon DA, Winer EP, Wagle N, Lin NU. Identifying ERBB2 Activating Mutations in HER2-Negative Breast Cancer: Clinical Impact of Institute-Wide Genomic Testing and Enrollment in Matched Therapy Trials. JCO Precis Oncol 2020; 3:1900087. [PMID: 32923853 DOI: 10.1200/po.19.00087] [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] [Accepted: 10/26/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The yield of comprehensive genomic profiling in recruiting patients to molecular-based trials designed for small subgroups has not been fully evaluated. We evaluated the likelihood of enrollment in a clinical trial that required the identification of a specific genomic change based on our institute-wide genomic tumor profiling. PATIENTS AND METHODS Using genomic profiling from archived tissue samples derived from patients with metastatic breast cancer treated between 2011 and 2017, we assessed the impact of systematic genomic characterization on enrollment in an ongoing phase II trial (ClinicalTrials.gov identifier: NCT01670877). Our primary aim was to describe the proportion of patients with a qualifying ERBB2 mutation identified by our institutional genomic panel (OncoMap or OncoPanel) who enrolled in the trial. Secondary objectives included median time from testing result to trial registration, description of the spectrum of ERBB2 mutations, and survival. Associations were calculated using Fisher's exact test. RESULTS We identified a total of 1,045 patients with metastatic breast cancer without ERBB2 amplification who had available genomic testing results. Of these, 42 patients were found to have ERBB2 mutation and 19 patients (1.8%) were eligible for the trial on the basis of the presence of an activating mutation, 18 of which were identified by OncoPanel testing. Fifty-eight percent of potentially eligible patients were approached, and 33.3% of eligible patients enrolled in the trial guided exclusively by OncoPanel testing. CONCLUSION More than one half of eligible patients were approached for trial participation and, significantly, one third of those were enrolled in NCT01670877. Our data illustrate the ability to enroll patients in trials of rare subsets in routine clinical practice and highlight the need for these broadly based approaches to effectively support the success of these studies.
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Affiliation(s)
| | | | | | | | - Tianyu Li
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ian E Krop
- Dana-Farber Cancer Institute, Boston, MA
| | - Ron Bose
- Washington University School of Medicine, St. Louis, MO
| | | | - Cynthia X Ma
- Washington University School of Medicine, St. Louis, MO
| | - Deborah A Dillon
- Dana-Farber Cancer Institute, Boston, MA.,Brigham and Women's Hospital, Boston, MA
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38
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Kabraji SK, Spurr LF, Hughes ME, Li YY, Leone JP, Garrido-Castro AC, Barroso-Sousa R, Files J, Kirkner G, Johnson BE, Winer EP, Cherniack AD, Lin NU. Genomic profiling of breast cancer brain metastases reveals targetable alterations. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.2525] [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
2525 Background: Genomic characterization of breast cancer brain metastases (BCBMs) has thus far been limited. The objective of this study was to describe the landscape of genomic alterations in patients (pts) with BCBMs. Methods: Targeted next-generation DNA sequencing of > 300 cancer-related genes (OncoPanel) was prospectively performed on primary and metastatic (met) tumors in 321 pts with a diagnosis of BCBM between August 2016 and April 2019 at Dana-Farber Cancer Institute (table). Enrichment analysis of genomic alterations was performed using a two-sided Fisher exact test and differences in tumor mutation burden (TMB) between groups were assessed using two-sided Mann-Whitney U test. Multiple comparison correction was performed using the Benjamini-Hochberg procedure. Results: All subtypes were represented in BCBM (25 HR+/HER2-; 24 HR+/HER2+; 27 HR-/HER2+; 18 TNBC; 5 unknown; n = 99) and extracranial (EC) samples: (96 HR+/HER2-; 32 HR+/HER2+; 22 HR-/HER2+; 41 TNBC; 31 unknown; n = 222). BCBMs were found most commonly to have mutations or copy number alterations in TP53, ERBB2, PIK3CA, GATA3, PTEN, ESR1, CDH1, BRCA2, ARID1A, BRCA1 (>5% frequency, table). Two pts acquired ERBB2 amplification (amp) between the matched primary breast sample and brain met. In pair-wise comparisons of BCBMs to unmatched primaries or EC mets, only ERBB2 amp was significantly enriched (table, † = adjusted p < 0.05). There was no significant difference in TMB between BCBM and EC mets (median 9.12 vs 7.26, p = 0.15). In contrast, TMB was significantly higher in BCBMs compared to unmatched primaries (median 9.12 vs 7.26, p=0.005). Conclusions: BCBMs display similar mutations and copy number alterations compared to primary tumors and EC mets in pts with BCBM. These data suggest that BCBMs contain actionable genomic alterations that are most often also reflected in EC disease. Alterations in ERBB2, PIK3CA/PTEN, and BRCA1/2 represent potentially targetable alterations in pts with BCBM. [Table: see text]
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Eric P. Winer
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Vaz-Luis I, Barroso-Sousa R, Di Meglio A, Hu J, Rees R, Sinclair N, Milisits L, Leone JP, Constantine M, Faggen M, Briccetti F, Block C, O'Neil K, Partridge A, Burstein H, Waks AG, Trippa L, Tolaney SM, Hassett M, Winer EP, Lin NU. Avoiding Peg-Filgrastim Prophylaxis During the Paclitaxel Portion of the Dose-Dense Doxorubicin-Cyclophosphamide and Paclitaxel Regimen: A Prospective Study. J Clin Oncol 2020; 38:2390-2397. [PMID: 32330102 PMCID: PMC7367545 DOI: 10.1200/jco.19.02484] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE The use of growth factors adds considerable expense and some toxicity to adjuvant breast cancer chemotherapy. We tested the feasibility and safety of omitting routine peg-filgrastim use during the paclitaxel portion of the dose-dense doxorubicin-cyclophosphamide-paclitaxel regimen. PATIENTS AND METHODS This was a prospective, single-arm study in which patients 18 to 65 years of age who completed 4 cycles of dose-dense doxorubicin-cyclophosphamide for stage I-III breast cancer received paclitaxel 175 mg/m2 every 2 weeks. Peg-filgrastim was administered after paclitaxel only if patients had had febrile neutropenia in a prior cycle or at investigator discretion if patients had infections or treatment delays of > 1 week. Once a patient received peg-filgrastim, it was administered in all future cycles. The primary end point was the rate of paclitaxel completion within 7 weeks from cycle 1 day 1 to cycle 4 day 1. If ≥ 100 out of 125 patients completed 4 cycles of paclitaxel without dose delay, the regimen would be considered feasible. RESULTS The enrollment goal of 125 patients was met. Median age was 46 years (range, 21-65 years), and 112 patients (90% [95% CI, 83% to 94%]) completed dose-dense paclitaxel within 7 weeks. Omission of peg-filgrastim was not causally related to noncompletion of paclitaxel in any patients. The most common reasons for dose reduction or delays were nonhematologic. One patient experienced febrile neutropenia but was able to complete paclitaxel on time. Eight patients (6.4%) received peg-filgrastim during the trial. Overall, peg-filgrastim was administered in only 4.3% of paclitaxel cycles. CONCLUSION Omission of routine peg-filgrastim during dose-dense paclitaxel according to a prespecified algorithm seems to be safe and feasible and was associated with a 95.7% reduction in the use of peg-filgrastim relative to the current standard of care.
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Affiliation(s)
- Ines Vaz-Luis
- Dana-Farber Cancer Institute, Boston, MA.,Institut Gustave Roussy, Villejuif, France
| | | | - Antonio Di Meglio
- Dana-Farber Cancer Institute, Boston, MA.,Institut Gustave Roussy, Villejuif, France
| | - Jiani Hu
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | - Meredith Faggen
- Dana-Farber Cancer Institute at South Shore Hospital, South Weymouth, MA
| | - Frederick Briccetti
- Dana-Farber Cancer Institute, Boston, MA.,Dana-Farber Cancer Institute/New Hampshire Oncology-Hematology, Londonderry, NH
| | - Caroline Block
- Dana-Farber Cancer Institute, Boston, MA.,Dana-Farber Cancer Institute at St Elizabeth's Medical Center, Boston, MA
| | | | | | | | | | - Lorenzo Trippa
- Dana-Farber Cancer Institute, Boston, MA.,Harvard School of Public Health, Boston, MA
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40
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Barroso-Sousa R, Trippa L, Li T, Keenan TE, Winship G, Andrews C, Osmani W, Overmoyer B, Winer EP, Mittendorf EA, Duda DG, Tolaney SM. Abstract P3-09-10: A phase II study of nivolumab in combination with cabozantinib for metastatic triple-negative breast cancer (mTNBC). Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p3-09-10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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 (pts) with mTNBC have a poor prognosis, and new therapies are needed. Cabozantinib is a multikinase inhibitor that blocks VEGF receptor 2, reduces myeloid-derived suppressor cells, and increases T cell infiltration, suggesting it may enhance the activity of the anti-PD-1 checkpoint blockade agent nivolumab. Here, we report the safety and efficacy of nivolumab plus cabozantinib in a phase II single-arm study in mTNBC pts.
Methods: Eligible pts had metastatic breast cancer that was estrogen and progesterone receptor < 10% and HER2 negative, measurable disease, and received 0-3 prior lines of chemotherapy in the advanced setting. Pts received nivolumab (480 mg intravenously on day 1, every 28 days) plus cabozantinib (40 mg daily by mouth). The primary endpoint was objective response rate (ORR) by RECIST v1.1. Using the Simons “optimal” method, if ≥ 3/18 pts responded during the first stage, 17 more would be enrolled. If ≥ 7/35 responded, the null hypothesis (ORR=10%) would be rejected in favor of a 30% ORR. Predefined secondary endpoints included progression free survival (PFS), clinical benefit rate (CBR), and toxicity. CBR was defined as the fraction of pts with any objective response or stable disease (SD) ≥ 24 weeks. Analyses associating PD-L1 expression, tumor-infiltrating lymphocytes (TIL), and genomic alterations (assessed by next generation sequencing on archival tissue) with outcomes were exploratory.
Results: From 12/15/2017 to 01/24/2019, 18 pts were enrolled into the first stage of the trial; one partial response was seen (ORR 5.6%; 95% CI: 0.3-29.4), and the study was closed to further accrual. The median age was 58y, all pts had ECOG PS 0, and 7 (38.9%) had liver metastases. The median number of prior cytotoxic therapies for mTNBC pts was 1 (range 0 to 3). Three pts had SD ≥24 weeks and two had progressive disease best response. The CBR was 22.2%. After a median follow up of 3.7 months, the median PFS was 4.4 months (95% CI: 1.9-12.8), and the median OS was 6.9 months (95% CI: 3.4-NR). All-cause adverse events occurred in 100% of pts (G3-4, 78%) including elevated liver enzymes (any 50%; G3-4 16.7%), hand-foot syndrome (any 38.9%; G3-4 16.7%), fatigue (any 38.9%; G3-4 11.1%), and hypothyroidism (any 33.3%; no G3-4). Of the 9 pts with available genomic data, none had tumor mutational burden ≥ 10 mutations per megabase. Updated data with TIL, PD-L1, whole exome sequencing and RNA-sequencing results will be presented.
Conclusions: The combination of nivolumab plus cabozantinib was not associated with any unexpected adverse events, however, with an ORR of 5.6%, the study did not achieve its primary endpoint. Exploratory genomic and immunological correlative studies are ongoing. Clinical trial information: NCT03316586.
Citation Format: Romualdo Barroso-Sousa, Lorenzo Trippa, Tianyu Li, Tanya E Keenan, Grace Winship, Chelsea Andrews, Wafa Osmani, Beth Overmoyer, Eric P Winer, Elizabeth A Mittendorf, Dan G Duda, Sara M Tolaney. A phase II study of nivolumab in combination with cabozantinib for metastatic triple-negative breast cancer (mTNBC) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-09-10.
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Affiliation(s)
| | | | - Tianyu Li
- 2Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | | | | | - Dan G Duda
- 3Massachusetts General Hospital, Boston, MA
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41
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Barroso-Sousa R, Keenan TE, Pernas S, Exman P, Jain E, Garrido-Castro AC, Hughes M, Bychkovsky B, Umeton R, Files JL, Lindeman NI, MacConaill LE, Hodi FS, Krop IE, Dillon D, Winer EP, Wagle N, Lin NU, Mittendorf EA, Van Allen EM, Tolaney SM. Tumor Mutational Burden and PTEN Alterations as Molecular Correlates of Response to PD-1/L1 Blockade in Metastatic Triple-Negative Breast Cancer. Clin Cancer Res 2020; 26:2565-2572. [PMID: 32019858 DOI: 10.1158/1078-0432.ccr-19-3507] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/20/2019] [Accepted: 01/30/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE Few patients with metastatic triple-negative breast cancer (mTNBC) benefit from immune checkpoint inhibitors (ICI). On the basis of immunotherapy response correlates in other cancers, we evaluated whether high tumor mutational burden (TMB) ≥10 nonsynonymous mutations/megabase and PTEN alterations, defined as nonsynonymous mutations or 1 or 2 copy deletions, were associated with clinical benefit to anti-PD-1/L1 therapy in mTNBC. EXPERIMENTAL DESIGN We identified patients with mTNBC, who consented to targeted DNA sequencing and were treated with ICIs on clinical trials between April 2014 and January 2019 at Dana-Farber Cancer Institute (Boston, MA). Objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) were correlated with tumor genomic features. RESULTS Sixty-two women received anti-PD-1/L1 inhibitors alone (23%) or combined with targeted therapy (19%) or chemotherapy (58%). High TMB (18%) was associated with significantly longer PFS (12.5 vs. 3.7 months; P = 0.04), while PTEN alterations (29%) were associated with significantly lower ORR (6% vs. 48%; P = 0.01), shorter PFS (2.3 vs. 6.1 months; P = 0.01), and shorter OS (9.7 vs. 20.5 months; P = 0.02). Multivariate analyses confirmed that these associations were independent of performance status, prior lines of therapy, therapy regimen, and visceral metastases. The survival associations were additionally independent of PD-L1 in patients with known PD-L1 and were not found in mTNBC cohorts treated with chemotherapy (n = 90) and non-ICI regimens (n = 169). CONCLUSIONS Among patients with mTNBC treated with anti-PD-1/L1 therapies, high TMB and PTEN alterations were associated with longer and shorter survival, respectively. These observations warrant validation in larger datasets.
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Affiliation(s)
- Romualdo Barroso-Sousa
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Tanya E Keenan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sonia Pernas
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Department of Medical Oncology, Institut Catala d'Oncologia-H.U.Bellvitge-IDIBELL, Barcelona, Spain
| | - Pedro Exman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Esha Jain
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Informatics and Analytics, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ana C Garrido-Castro
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Melissa Hughes
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Brittany Bychkovsky
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Renato Umeton
- Department of Informatics and Analytics, Dana-Farber Cancer Institute, Boston, Massachusetts.,Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Janet L Files
- Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Neal I Lindeman
- Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - F Stephen Hodi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Ian E Krop
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Deborah Dillon
- Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Nikhil Wagle
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Elizabeth A Mittendorf
- Harvard Medical School, Boston, Massachusetts.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Eliezer M Van Allen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts.,Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts
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42
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Barroso-Sousa R, Krop IE, Trippa L, Tan-Wasielewski Z, Li T, Osmani W, Andrews C, Dillon D, Richardson ET, Pastorello RG, Winer EP, Mittendorf EA, Bellon JR, Schoenfeld JD, Tolaney SM. A Phase II Study of Pembrolizumab in Combination With Palliative Radiotherapy for Hormone Receptor-positive Metastatic Breast Cancer. Clin Breast Cancer 2020; 20:238-245. [PMID: 32113750 DOI: 10.1016/j.clbc.2020.01.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [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: 12/20/2019] [Accepted: 01/22/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The purpose of this study was to investigate whether combining pembrolizumab with palliative radiation therapy (RT) improves outcomes in patients with hormone receptor-positive (HR+) metastatic breast cancer (MBC). PATIENTS AND METHODS Eligible patients had HR+/human epidermal growth factor receptor 2-negative MBC; were candidates for RT to ≥ 1 bone, soft tissue, or lymph node lesion; and had ≥ 1 lesion outside the RT field. Patients received 200 mg pembrolizumab intravenously 2 to 7 days prior to RT and on day 1 of repeating 21-day cycles. RT was delivered to a previously unirradiated area in 5 treatments each of 4 Gy. The primary endpoint was objective response rate. The study used a 2-stage design: 8 women were enrolled into the first stage, and if at least 1 of 8 patients experienced an objective response, 19 more would be enrolled. Secondary endpoints included progression-free survival, overall survival, and safety. Exploratory endpoints included association of overall response rate with programmed death-ligand 1 status and tumor-infiltrating lymphocytes. RESULTS Eight patients were enrolled in stage 1. The median age was 59 years, and the median prior lines of chemotherapy for metastatic disease was 2. There were no objective responses, and the study was closed to further accrual. The median progression-free survival was 1.4 months (95% confidence interval, 0.4-2.1 months), and the median overall survival was 2.9 months (95% confidence interval, 0.9-3.6 months). All-cause adverse events occurred in 87.5% of patients, including just 1 grade 3 event (elevation of aspartate aminotransferase). CONCLUSIONS RT combined with pembrolizumab did not produce an objective response in patients with heavily pre-treated HR+ MBC. Future studies should consider alternative radiation dosing and fractionation in patients with less heavily pre-treated HR+ MBC.
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Affiliation(s)
- Romualdo Barroso-Sousa
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA; Current affiliation: Oncology Center, Hospital Sírio-Libanês, Brasília, Brazil
| | - Ian E Krop
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA
| | - Lorenzo Trippa
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA
| | - Zhenying Tan-Wasielewski
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA
| | - Tianyu Li
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA
| | - Wafa Osmani
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Chelsea Andrews
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Deborah Dillon
- Harvard Medical School, Boston, MA; Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - Edward T Richardson
- Harvard Medical School, Boston, MA; Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - Ricardo G Pastorello
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital; Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA
| | - Elizabeth A Mittendorf
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA; Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital; Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | - Jennifer R Bellon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Jonathan D Schoenfeld
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA.
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Barroso-Sousa R, Jain E, Cohen O, Kim D, Buendia-Buendia J, Winer E, Lin N, Tolaney SM, Wagle N. Prevalence and mutational determinants of high tumor mutation burden in breast cancer. Ann Oncol 2020; 31:387-394. [PMID: 32067680 DOI: 10.1016/j.annonc.2019.11.010] [Citation(s) in RCA: 191] [Impact Index Per Article: 47.8] [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: 05/21/2019] [Revised: 11/14/2019] [Accepted: 11/17/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND High tumor mutation burden (TMB) can benefit immunotherapy for multiple tumor types, but the prevalence of hypermutated breast cancer is not well described. The aim of this study was to evaluate the frequency, mutational patterns, and genomic profile of hypermutated breast cancer. PATIENTS AND METHODS We used de-identified data from individuals with primary or metastatic breast cancer from six different publicly available genomic studies. The prevalence of hypermutated breast cancer was determined among 3969 patients' samples that underwent whole exome sequencing or gene panel sequencing. The samples were classified as having high TMB if they had ≥10 mutations per megabase (mut/Mb). An additional eight patients were identified from a Dana-Farber Cancer Institute cohort for inclusion in the hypermutated cohort. Among the patients with high TMB, the mutational patterns and genomic profiles were determined. A subset of patients was treated with regimens containing PD-1 inhibitors. RESULTS The median TMB was 2.63 mut/Mb. The median TMB significantly varied according to the tumor subtype (HR-/HER2- >HER2+ >HR+/HER2-, P < 0.05) and sample type (metastatic > primary, P = 2.2 × 10-16). Hypermutated tumors were found in 198 patients (5%), with enrichment in metastatic versus primary tumors (8.4% versus 2.9%, P = 6.5 × 10-14). APOBEC activity (59.2%), followed by mismatch repair deficiency (MMRd; 36.4%), were the most common mutational processes among hypermutated tumors. Three patients with hypermutated breast cancer-including two with a dominant APOBEC activity signature and one with a dominant MMRd signature-treated with pembrolizumab-based therapies derived an objective and durable response to therapy. CONCLUSION Hypermutation occurs in 5% of all breast cancers with enrichment in metastatic tumors. Different mutational signatures are present in this population with APOBEC activity being the most common dominant process. Preliminary data suggest that hypermutated breast cancers are more likely to benefit from PD-1 inhibitors.
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Affiliation(s)
- R Barroso-Sousa
- Department of Medical Oncology; Center for Cancer Precision Medicine, Dana-Farber Cancer Institute, Boston, USA
| | - E Jain
- Center for Cancer Precision Medicine, Dana-Farber Cancer Institute, Boston, USA; Broad Institute of MIT and Harvard, Cambridge, USA
| | - O Cohen
- Center for Cancer Precision Medicine, Dana-Farber Cancer Institute, Boston, USA; Broad Institute of MIT and Harvard, Cambridge, USA
| | - D Kim
- Center for Cancer Precision Medicine, Dana-Farber Cancer Institute, Boston, USA; Broad Institute of MIT and Harvard, Cambridge, USA
| | - J Buendia-Buendia
- Center for Cancer Precision Medicine, Dana-Farber Cancer Institute, Boston, USA; Broad Institute of MIT and Harvard, Cambridge, USA
| | - E Winer
- Department of Medical Oncology; Harvard Medical School, Boston, USA; Department of Medicine, Brigham and Women's Hospital, Boston, USA
| | - N Lin
- Department of Medical Oncology; Harvard Medical School, Boston, USA; Department of Medicine, Brigham and Women's Hospital, Boston, USA
| | - S M Tolaney
- Department of Medical Oncology; Harvard Medical School, Boston, USA; Department of Medicine, Brigham and Women's Hospital, Boston, USA
| | - N Wagle
- Department of Medical Oncology; Center for Cancer Precision Medicine, Dana-Farber Cancer Institute, Boston, USA; Broad Institute of MIT and Harvard, Cambridge, USA; Harvard Medical School, Boston, USA; Department of Medicine, Brigham and Women's Hospital, Boston, USA.
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Barroso-Sousa R, Barry WT, Garrido-Castro AC, Hodi FS, Min L, Krop IE, Tolaney SM. Incidence of Endocrine Dysfunction Following the Use of Different Immune Checkpoint Inhibitor Regimens: A Systematic Review and Meta-analysis. JAMA Oncol 2019; 4:173-182. [PMID: 28973656 DOI: 10.1001/jamaoncol.2017.3064] [Citation(s) in RCA: 634] [Impact Index Per Article: 126.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance If not promptly recognized, endocrine dysfunction can be life threatening. The incidence and risk of developing such adverse events (AEs) following the use of immune checkpoint inhibitor (ICI) regimens are unknown. Objective To compare the incidence and risk of endocrine AEs following treatment with US Food and Drug Administration-approved ICI regimens. Data Sources A PubMed search through July 18, 2016, using the following keywords was performed: "ipilimumab," "MDX-010," "nivolumab," "BMS-963558," "pembrolizumab," "MK-3475," "atezolizumab," "MPDL3280A," and "phase." Study Selection Thirty-eight randomized clinical trials evaluating the usage of these ICIs for treatment of advanced solid tumors were identified, resulting in a total of 7551 patients who were eligible for a meta-analysis. Regimens were categorized by class into monotherapy with a PD-1 (programmed cell death protein 1) inhibitor, a CTLA-4 (cytotoxic T-lymphocyte-associated protein-4) inhibitor, or a PD-L1 (programmed cell death 1 ligand 1) inhibitor, and combination therapy with PD-1 plus CTLA-4 inhibitors. Data Extraction and Synthesis The data were extracted by 1 primary reviewer (R.B.-S.) and then independently reviewed by 2 secondary reviewers (W.T.B. and A.C.G.-C.) following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Inferences on the incidence of AEs were made using log-odds random effects models. Main Outcomes and Measures Incidence of all-grade hypothyroidism, hyperthyroidism, hypophysitis, primary adrenal insufficiency, and insulin-deficient diabetes. Results Overall, 38 randomized clinical trials comprising 7551 patients were included in this systematic review and meta-analysis. The incidence of both hypothyroidism and hyperthyroidism was highest in patients receiving combination therapy. Patients on the combination regimen were significantly more likely to experience hypothyroidism (odds ratio [OR], 3.81; 95% CI, 2.10-6.91, P < .001) and hyperthyroidism (OR, 4.27; 95% CI, 2.05-8.90; P = .001) than patients on ipilimumab. Compared with patients on ipilimumab, those on PD-1 inhibitors had a higher risk of developing hypothyroidism (OR, 1.89; 95% CI, 1.17-3.05; P = .03). The risk of hyperthyroidism, but not hypothyroidism, was significantly greater with PD-1 than with PD-L1 inhibitors (OR, 5.36; 95% CI, 2.04-14.08; P = .002). While patients who received PD-1 inhibitors were significantly less likely to experience hypophysitis than those receiving ipilimumab (OR, 0.29; 95% CI, 0.18-0.49; P < .001), those who received combination therapy were significantly more likely to develop it (OR, 2.2; 95% CI, 1.39-3.60; P = .001). For primary adrenal insufficiency and insulin-deficient diabetes no statistical inferences were made due to the smaller number of events. Conclusions and Relevance Our study provides more precise data on the incidence of endocrine dysfunctions among patients receiving ICI regimens. Patients on combination therapy are at increased risk of thyroid dysfunction and hypophysitis.
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Affiliation(s)
| | - William T Barry
- Department of Biostatistics and Computation Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ana C Garrido-Castro
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - F Stephen Hodi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Le Min
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ian E Krop
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Exman P, Barroso-Sousa R, Tolaney SM. Evidence to date: talazoparib in the treatment of breast cancer. Onco Targets Ther 2019; 12:5177-5187. [PMID: 31303769 PMCID: PMC6612288 DOI: 10.2147/ott.s184971] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 06/03/2019] [Indexed: 12/15/2022] Open
Abstract
Approximately 5-10% of all patients diagnosed with breast cancer have germline BRCA1/2 mutations, which make their disease more susceptible to DNA-damaging agents and a new class of drugs known as poly(ADP-ribose) polymerase (PARP) inhibitors. Talazoparib is a new PARP inhibitor that has been recently approved for use in patients with metastatic breast cancer with germline BRCA mutations after a phase III trial showed superior progression-free survival when compared to standard chemotherapy. In this review, we analyze the development of talazoparib as well as its safety profile and the potential role of the combination therapy with standard cytotoxic drugs and with novel therapies.
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Affiliation(s)
- Pedro Exman
- Breast Oncology Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Romualdo Barroso-Sousa
- Breast Oncology Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sara M Tolaney
- Breast Oncology Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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Barroso-Sousa R, Guo H, Srivastava P, James T, Birch W, Siu LL, Tew WP, Tolaney SM. Utilization of tumor genomics in clinical practice: an international survey among ASCO members. Future Oncol 2019; 15:2463-2470. [DOI: 10.2217/fon-2019-0010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aim: To identify patterns of use and barriers to tumor genomic testing among oncologists. Methods: We surveyed American Society of Clinical Oncology physician members about their use of genomic testing. Results: Among 11,900 members surveyed, a total of 1000 responded to the survey (participation rate, 8.4%). A total of 75% of the respondents included in the analysis reported ordering tests for at least 1–10% of their patients. Practice setting (academic vs community) was only a determinant in the ordering frequency in North America. Regardless of location, academic oncologists were more likely to prescribe medicine in the context of a clinical trial. Access to clinical trials and costs associated with testing were the barriers identified worldwide. Conclusion: There is substantial variation in the use of genomic tools according to region and practice setting; yet, the barriers are similar worldwide.
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Affiliation(s)
- Romualdo Barroso-Sousa
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
- Current affiliation: Oncology Center, Hospital Sírio-Libanês, Brasilia-DF, 70200-730, Brazil
| | - Hao Guo
- Department of Biostatistics & Computational Biology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Piyush Srivastava
- Division of Hematology/Oncology, Kaiser Permanente, Walnut Creek, CA 94596, USA
| | - Ted James
- Division of Surgical Oncology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Walter Birch
- Division of Practice Management, American Society of Clinical Oncology, Alexandria, VA 22314, USA
| | - Lillian L Siu
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada
| | - William P Tew
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
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Garrido-Castro AC, Spurr L, Hughes ME, Li YY, Cherniack AD, Bychkovsky BL, Barroso-Sousa R, Di Lascio S, Files J, Kumari P, Cerami E, Krop IE, MacConaill LE, Lindeman NI, Rollins BJ, Johnson BE, Wagle N, Winer EP, Dillon D, Lin NU. Genomic landscape of de novo stage IV breast cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.1022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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
1022 Background: Genomic profiling of primary and recurrent metastatic breast cancer (rMBC) has revealed potential resistance mechanisms to therapy. In contrast, de novo stage IV breast cancer (DNIV) represents an opportunity to elucidate metastatic drivers in the absence of treatment selection. Methods: Targeted NGS (Oncopanel, OP) using multiplexed copy number variation (CNV) and mutation (mut) detection across the full coding regions of 300 genes and selected intronic regions of 35 genes was performed on either primary or metastatic samples collected in patients (pts) with DNIV or rMBC. Mut/CNV in primary and metastatic tumors were compared per subtype between DNIV and rMBC using Fisher´s exact test (significant p<0.05). FDR were computed ( q<0.25). Results: Between 8/2013-9/2016, of 929 pts who underwent OP testing 212 presented with DNIV; 136 HR+/HER2- (64%); 35 HR+/HER2+ (17%); 25 TNBC (12%); 16 HR-/HER2+ (8%). In 168 (79%) pts, the primary was tested; 44 had a metastatic site tested. Comparison of primary HR+/HER2- tumors showed that DNIV pts were more likely to harbor mut in CDKN1B, SETD2 and PMS2 and less likely to have TP53 mut than rMBC (Table). Metastases in HR+/HER2- DNIV (n=29) had higher mut in CDH1, PTCH1 and CTNNB1 and fewer CCND1 amplification (amp) than rMBC (n=121), albeit these findings lost significance after FDR correction. DNIV primary TNBC (n=19) was significantly enriched for CIITA mut (26% vs. 0%; q=0.046) and MYB amp (21% vs. 0%, q=0.098) compared to rMBC (n=101). TP53 mut, amp in RAD21, MYC, MYB, PTK2 and EGFR, and deletions in CDKN2A/2B and MAP2K4 significantly predicted poorer overall survival in DNIV. Conclusions: DNIV primary and metastatic tumors have distinct genomic profiles compared to rMBC. Alterations in genes involved in epigenetic modulation ( KMT2D, SETD2) and epithelial-mesenchymal transition ( CDH1, PTCH1, CTNNB1) are more prevalent in HR+/HER2- DNIV. DNIV TNBC is enriched for CIITA mut, described to promote immune escape via reduced MHC class II expression. If validated, these findings may provide insight into mechanisms underlying metastatic potential. [Table: see text]
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Affiliation(s)
| | - Liam Spurr
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | - Simona Di Lascio
- Oncological Institute Of Southern Switzerland, Bellinzona, Switzerland
| | | | | | | | | | - Laura E MacConaill
- Center for Cancer Genome Discovery, Dana-Farber Cancer Institute, Boston, MA
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Barroso-Sousa R, Trippa L, Lange P, Andrews C, McArthur HL, Haley BB, Rugo HS, Emens LA, Winer EP, Mittendorf EA, Tolaney SM. Nimbus: A phase II study of nivolumab plus ipilimumab in metastatic hypermutated HER2-negative breast cancer. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.tps1115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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
TPS1115 Background: A previous study from our group showed that approximately 9% of metastatic breast cancer (MBC) is hypermutated, defined as a tumor mutational burden (TMB) ≥10 Mutations/Megabase (Mut/Mb). The aim of this study is to evaluate if patients with hypermutated HER2-negative MBC benefit from the combination of nivolumab plus ipilimumab. Methods: This is an open-label, single-arm, multicenter, phase 2 study assessing the efficacy of nivolumab 3 mg/Kg intravenously (IV) every 14 days plus Ipilimumab 1 mg/Kg IV every 6 weeks in subjects with hypermutated metastatic HER2-negative breast cancer. Patients with measurable HER2-negative MBC, TMB ≥10 Mut/Mb assessed by a cancer-gene panel evaluating > 300 genes and performed in a CLIA-certified laboratory, and 0-3 prior lines of chemotherapy in the advanced setting are eligible. The primary objective is overall response rate according to RECIST 1.1. Secondary objectives include the safety and tolerability of the combination, progression-free survival, and overall survival. The study will follow a two-stage design. In the first stage 14 patients will be enrolled. If there is at least one patient with objective response, accrual will continue to the second stage where an additional 16 patients will be enrolled. If there are at least 4 patients with an objective response among the 30 patients, the regimen will be considered worthy of further study. If the true response rate is 5%, the chance the regimen is declared worthy of further study is less than 5%. If the true response rate is 25%, the chance that the regimen is declared worthy of further study is > 90%. Tumor biopsies, peripheral blood, and stool collection are mandatory and will be obtained at baseline, on treatment (end of cycle 1), and at disease progression and will be assessed for potential biomarkers of treatment response. The trial was activated in February 2019, and accrual should be completed in 18 months. Clinical trial information: NCT03789110.
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Affiliation(s)
| | - Lorenzo Trippa
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | - Barbara B. Haley
- University of Texas Southwestern Medical Center, Internal Medicine, Dallas, TX
| | - Hope S. Rugo
- University of California San Francisco Comprehensive Cancer Center, San Francisco, CA
| | | | | | - Elizabeth A. Mittendorf
- Division of Breast Surgery, Department of Surgery, BWH, Breast Oncology Program, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA
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Barroso-Sousa R, Luis IMVD, Di Meglio A, Hu J, Rees R, Sinclair NF, Milisits L, Leone JP, Constantine M, Faggen MG, Briccetti F, Block CC, Partridge AH, Burstein HJ, Waks AG, Trippa L, Tolaney SM, Hassett MJ, Winer EP, Lin NU. Avoiding peg-filgrastim (Peg-F) prophylaxis during the paclitaxel (T) portion of the dose-dense (DD) doxorubicin-cyclophosphamide (AC)-T regimen: A prospective study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.517] [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
517 Background: Use of growth factors (GF) adds considerable expense and some toxicity to adjuvant breast cancer chemotherapy. We tested the feasibility and safety of omitting routine GF use during the T portion of DD AC-T. Methods: This is a prospective, single-arm study in which patients (pts) who completed 4 cycles of DD-AC proceeded to DD-T 175 mg/m2 every two weeks (wks) without routine GF (NCT02698891). Key inclusion: age≤ 65, ECOG PS≤1, absolute neutrophil count (ANC) ≥1500/mm3, and no febrile neutropenia (FN) during DD-AC. Criteria to treat for T included ANC ≥1000/mm3. Peg-F was given only if pts had FN in a prior cycle, or at investigator discretion if infection or treatment delay > 1 wk. Once Peg-F was given, pts received it in all future cycles. The primary endpoint was the rate of T completion ≤ 7 wks from cycle 1 day 1 (C1D1) to C4D1. Secondary endpoints included total use of Peg-F, rates of hematologic toxicity and FN, reasons for dose modification or hold. If ≥85% of pts completed T on time, the regimen would be considered feasible. If the true on-time completion rate is 75%, the chance the regimen would be declared infeasible is 91%, and if it is 85% the chance that the regimen is falsely declared infeasible is 10% (power = 0.899). ≥100/125 pts had to complete T on time for the regimen to be deemed successful. Results: Among 127 pts enrolled, 125 received ≥1 dose of protocol therapy and are included in the analysis. Median age at registration was 46 (range 21-65). Median C1D1 ANC was 7500/mm3 (range 1500-20500). 112 (90%) (95% CI 83-94%) pts completed DD-T ≤ 7 wks, and 3 (2%) completed within > 7 wks (2 due to neutropenia); 10 (8%) did not complete all cycles of T. Omission of Peg-F was not causally related to non-completion of T in any pts. The most common reasons for dose reduction or delays were non-hematologic. One pt had FN but was able to complete T on time. Eight (6.4%) pts received Peg-F during the trial. Conclusions: Omission of routine GF use during DD-T according to a pre-specified algorithm appears safe, feasible, and was associated with a 95.7% reduction in use of Peg-F, relative to the current standard of care. Additional analyses including cost implications are ongoing. Clinical trial information: NCT02698891.
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Affiliation(s)
| | | | | | - Jiani Hu
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | | | | | | | | | - Frederick Briccetti
- Dana-Farber Cancer Institute/New Hampshire Oncology-Hematology, Londonderry, NH
| | | | | | | | | | - Lorenzo Trippa
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA
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Tolaney SM, Barroso-Sousa R, Keenan T, Trippa L, Hu J, Luis IMVD, Wulf GM, Spring L, Sinclair NF, Andrews C, Pittenger JD, Richardson ET, Dillon D, Lin NU, Overmoyer B, Partridge AH, VanAllen E, Mittendorf EA, Winer EP, Krop IE. Randomized phase II study of eribulin mesylate (E) with or without pembrolizumab (P) for hormone receptor-positive (HR+) metastatic breast cancer (MBC). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.1004] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1004 Background: Studies of checkpoint inhibitor monotherapy show only modest activity in HR+ MBC. We report data from the first randomized study comparing E plus P versus E alone in HR+/HER2- MBC. Methods: Eligible patients (pts) had HR+/HER2- MBC, ≥2 lines of hormonal therapies and 0-2 lines of chemotherapy for MBC. Pts were randomized 1:1 to E 1.4mg/m2 intravenously (IV) on d1 and d8 with P 200 mg/m2 IV on d1 of a 21-day cycle (Arm A) or E alone (Arm B). At time of progression, pts in arm B could crossover and receive P alone. Primary endpoint was progression-free survival (PFS). Key secondary endpoints were: objective response rate (ORR) and overall survival (OS). Exploratory analyses assessed the association between PFS and PD-L1 status, tumor-infiltrating lymphocytes (TILs), neutrophil-lymphocyte ratio (NLR), tumor mutation burden (TMB), and genomic alterations by next generation sequencing on archival tissue. Results: 88 pts initiated protocol therapy; the median age was 58, median prior lines of chemotherapy 1, prior lines of hormonal therapy 2. Median follow-up was 6.3 months. Median PFS and ORR were not different between Arms A and B (PFS 4.1 vs 4.2 months p = 0.38; ORR 25% and 34% respectively (p = 0.49). 14 patients initiated crossover treatment with pembrolizumab; 1 patient experienced a PR (ORR 7%). All-cause AEs occurred in 100% of pts (G3-4, 54.6%) including 2 treatment related deaths on Arm A, both from known AEs attributed to both drugs. PD-L1 assay was performed in 65 pts: 24 (36.9%) had PD-L1 positive ( > 1% with 22C3, centrally tested) tumors. PD-L1 status, TILs, NLR, TMB, and genomic alterations were not associated with PFS (Table). Updated data, including OS and genomic results, will be presented. Conclusions: Among pts with HR+/HER2- MBC, the combination of E and P was not associated with longer PFS than E alone in the ITT or PD-L1+ population, though the PD-L1+ subgroup had very limited power to assess P benefit. Clinical trial information: NCT03051659. [Table: see text]
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Affiliation(s)
| | | | | | - Lorenzo Trippa
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Jiani Hu
- Dana-Farber Cancer Institute, Boston, MA
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