Adjuvant Lapatinib and Trastuzumab for Early Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer: Results From the Randomized Phase III Adjuvant Lapatinib and/or Trastuzumab Treatment Optimization Trial

BACKGROUND

Lapatinib (L) plus trastuzumab (T) improves outcomes for metastatic human epidermal growth factor 2-positive breast cancer and increases the pathologic complete response in the neoadjuvant setting, but their role as adjuvant therapy remains uncertain.

METHODS

In the Adjuvant Lapatinib and/or Trastuzumab Treatment Optimization trial, patients with centrally confirmed human epidermal growth factor 2-positive early breast cancer were randomly assigned to 1 year of adjuvant therapy with T, L, their sequence (T→L), or their combination (L+T). The primary end point was disease-free survival (DFS), with 850 events required for 80% power to detect a hazard ratio (HR) of 0.8 for L+T versus T.

RESULTS

Between June 2007 and July 2011, 8,381 patients were enrolled. In 2011, due to futility to demonstrate noninferiority of L versus T, the L arm was closed, and patients free of disease were offered adjuvant T. A protocol modification required P ≤ .025 for the two remaining pairwise comparisons. At a protocol-specified analysis with a median follow-up of 4.5 years, a 16% reduction in the DFS hazard rate was observed with L+T compared with T (555 DFS events; HR, 0.84; 97.5% CI, 0.70 to 1.02; P = .048), and a 4% reduction was observed with T→L compared with T (HR, 0.96; 97.5% CI, 0.80 to 1.15; P = .61). L-treated patients experienced more diarrhea, cutaneous rash, and hepatic toxicity compared with T-treated patients. The incidence of cardiac toxicity was low in all treatment arms.

CONCLUSION

Adjuvant treatment that includes L did not significantly improve DFS compared with T alone and added toxicity. One year of adjuvant T remains standard of care.

Infraclavicular axillary vein cannulation using ultrasound in a mechanically ventilated general intensive care population

Central venous catheter (CVC) insertion is commonly undertaken in the ICU. The use of ultrasound (US) to facilitate CVC insertion is standard and is supported by guidelines. Because the subclavian vein cannot be insonated where it underlies the clavicle, its use as a CVC site is now less common. The axillary vein, however, can be seen on US just distal to the subclavian vein and placement of a CVC at this site gives a result which is functionally indistinguishable from a subclavian CVC. We evaluated placement of US-guided axillary CVCs in mechanically ventilated intensive care patients. Data were collected for 125 consecutive US-guided axillary CVC procedures in ventilated patients in an adult intensive care setting. All lines were inserted using real-time US guidance with an out-of-plane technique. One hundred and twenty-five procedures occurred in 119 patients. Successful line placement was achieved in 117 out of 125 (94%) procedures. Complications included four procedures that required repeating due to catheter malposition and one arterial puncture. The median number of attempts per procedure was one (IQR 1 to 2). Thirty-nine (31%) patients had a body mass index of 30 or above, 43 (34%) patients had a coagulopathy and 70 (56%) patients had significant ventilator dependence (FiO2 of 0.5 or above, or positive end expiratory pressure 10 cmH20 or above). The technique of US-guided axillary CVC access can be undertaken successfully in ventilated intensive care patients, even in challenging circumstances. Taken together with existing work on the utility and safety of this technique, we suggest that it be adopted more widely in the intensive care population.

Abstract P5-19-02: Everolimus in combination with exemestane in hormone receptor-positive locally advanced or metastatic breast cancer (BC) patients progressing on prior non-steroidal AI (NSAIs): Ballet study (CRAD001YIC04)

Background:

Despite progress, a large number of breast cancer patients experience metastatic relapse and death.

Hyperactivation of the mTOR pathway has been observed in patients (pts) with BC progressing on endocrine therapy. The BOLERO-2* trial demonstrated significant doubling of PFS obtained via dual blockade with everolimus (EVE) and exemestane (EXE), versus EXE alone in pts refractory to NSAIs.

Methods:

BALLET is a European multi-center open-label, single-arm, expanded-access study to evaluate the safety of EVE (10 mg/day) and EXE (25 mg/day) in postmenopausal women with hormone receptor-positive HER2 negative locally advanced or metastatic BC progressing on prior NSAIs. Study treatment continued until disease progression, unacceptable toxicity, death, drug locally reimbursed, discontinuation from the study for any other reason or last patient last visit (June 30th, 2014), whichever occurred first. Here we report an ad hoc-analysis that includes all pts recruited from May 12th 2012 till Dec 31st 2013 with cut-off date March 17th 2014 (final database will be available on October 31st 2014).

Results:

2.133 pts were recruited in 269 sites across 14 European countries. Baseline characteristics were median age: 64 yrs; PS (ECOG) 0/1/2: 64%/30%/3%; median time from first diagnosis: 8 yrs; Stage IV pts: 99%. At the data cut off, a total of 1795 pts (84%) had discontinued the treatment. Reasons for discontinuation were: disease progression (38%), drug reimbursement (35%), adverse events (15 %), consent withdrawn (4%), death (1.5%) and others (6.5%). EVE and EXE were administered as first line treatment in 10% of pts, as second line in 23%, as third line in 22% and as fourth line or beyond in 45% of pts. 74% of pts received more than 1 line of chemotherapy in the metastatic setting. 80% of pts experienced at least one adverse event (AE) referred by the investigators as related to EVE [45% stomatitis, 7% non-infectious pneumonitis (NIP)]. The most frequent grade 3-4 drug related AEs were stomatitis (8.9%), asthenia (3.2%), GGT increase (2.4%), hyperglycemia (2.4%), and NIP (1.8%).The median time to onset of stomatitis and NIP was 3-4 weeks and 2-3 months respectively.

Conclusions:

These results confirm that the combination of EVE + EXE is a tolerable treatment in a real world setting even in pts more heavily pretreated by chemotherapy compared to BOLERO 2. The better understanding of side effects leading to treatment discontinuation in this large European study where investigators frequently administered the drug for the first time, will allow defining priority actions for better management of side effects including patient education and early interventions.

Longer follow up with mature data (expected in October 2014) will give additional information on the safety profile, stratified by line of treatment.

* Everolimus in Postmenopausal Hormone- Receptor–Positive Advanced Breast Cancer. J. Baselga et al, NEJM 2012.

Citation Format: Guy Jerusalem, Gabriella Mariani, Eva M Ciruelos, Miguel Martin, Vivianne CG Tjan-Heijnen, Patrick Neven, Joaquin Gavila Gregori, Andrea Michelotti, Filippo Montemurro, Istvan Lang, Josef Mardiak, Bjoem Naume, Maura Camozzi, Katia Lorizzo, Dariusz Brenski, Pierfranco Conte. Everolimus in combination with exemestane in hormone receptor-positive locally advanced or metastatic breast cancer (BC) patients progressing on prior non-steroidal AI (NSAIs): Ballet study (CRAD001YIC04) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-19-02.

Abstract S3-08: Randomized comparison of adjuvant tamoxifen (T) plus ovarian function suppression (OFS) versus tamoxifen in premenopausal women with hormone receptor-positive (HR+) early breast cancer (BC): Analysis of the SOFT trial

Background It is uncertain if the addition of OFS to adjuvant endocrine therapy with T improves outcomes in premenopausal HR+ BC. The SOFT trial was designed to determine the value of OFS in women who remain premenopausal and are treated with T (OFS question) and also to test whether an AI improves outcome in premenopausal women with HR+ BC treated with OFS (AI question). In the combined analysis of the TEXT and SOFT trials (AI question), the group treated with the AI exemestane+OFS had a significantly better disease-free survival (DFS) than those with T+OFS. This abstract presents the results of the OFS question (n=2,045).

Patients and Methods Between November 2003 and January 2011, the SOFT phase 3 trial randomized 3066 premenopausal women with HR+ BC to 5 years of adjuvant endocrine therapy with exemestane+OFS versus T+OFS versus T alone, with OFS initiated by choice of GnRH agonist triptorelin, oophorectomy or ovarian irradiation. Prior chemotherapy was allowed, provided women had confirmed premenopausal estradiol levels within 8 months of completing chemotherapy. The primary end point was DFS which included invasive local, regional, distant and contralateral breast events, second non-breast malignancies and deaths without prior cancer. Because of a lower-than expected overall event rate and to ensure results within a reasonable time-frame, a protocol amendment in 2011 changed the originally event-driven analysis plan. The amendment (1) designated the comparison of T+OFS versus T alone as the primary analysis for SOFT (n=2045), recognizing that the statistical power for the original three pairwise comparisons would be substantially reduced and (2) specified that the primary analysis of T+OFS versus T be undertaken when median follow-up was at least 5 years. The comparison would be tested at the 2-sided 0.05 level with no interim analysis. Based on the projected number of events at the lower rates, the estimated power to detect hazard ratios of 0.75, 0.70, and 0.66 for the comparison would be 52%, 69%, and 80%.

Results The SOFT trial completed planned patient enrollment with an international collaboration involving 426 centres from BIG and NABCG led by the International Breast Cancer Study Group (IBCSG). Numbers of patients randomized, randomization strata, and pt age are summarized in the Table. The database lock for the primary analysis of the OFS question will occur in September 2014 and the final analysis will be completed by October 15, 2014.

SOFT Patients (%)Tamoxifen alone1021 (33%)Tamoxifen+OFS1024 (33%)Exemestane+OFS1021 (33%)*  Prior Chemotherapy54%Lymph node positive35%Median age (% < 40 years)43 years (30%)*Patients randomized to Exemestane+OFS are not part of the current analysis

Conclusions We will present the primary analysis of outcomes and toxicities by treatment for women randomized to receive T+OFS versus T and address the value of OFS in addition to T as adjuvant endocrine therapy for premenopausal women with HR+ BC.

Citation Format: Aron Goldhirsch, Richard D Gelber, Prudence A Francis, Meredith M Regan, Gini F Fleming, Istvan Lang, Eva M Ciruelos, Meritxell Bellet, Herve Bonnefoi, Miguel A Climent, Lorenzo Pavesi, Harold J Burstein, Silvana Martino, Nancy E Davidson, Charles E Geyer Jr, Barbara A Walley, Robert E Coleman, Pierre Kerbrat, Manuela Rabaglio-Poretti, Alan S Coates. Randomized comparison of adjuvant tamoxifen (T) plus ovarian function suppression (OFS) versus tamoxifen in premenopausal women with hormone receptor-positive (HR+) early breast cancer (BC): Analysis of the SOFT trial [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr S3-08.

Abstract OT1-1-05: Phase III study of palbociclib in combination with exemestane vs. capecitabine, in hormonal receptor (HR) positive/HER2 negative metastatic breast cancer (MBC) patients with resistance to non-steroidal aromatase inhibitors (NSAI): PEARL study (GEICAM/2013-02_CECOG/BC.1.3.006)

Background: Endocrine therapy (ET) is the cornerstone treatment for HR–positive, HER2-negative breast cancer (BC) patients. AIs have become the treatment of choice in postmenopausal patients. The high response rates with ET in these patients are partially undermined by the resistance developed by most of them over time. On early disease recurrence/progression to AIs, the treatment options include other AI, estrogen-receptor antagonists or chemotherapy (being capecitabine one of the best options). Preclinical data suggest that ER+/HER2- BC are dependent on cyclin-dependent kinases 4/6 (CDK4/6) function; the inhibition of this target may be effective in delaying/reverting endocrine resistance. Palbociclib is an oral novel CDK4/6 inhibitor that seems to be synergistic with ET in preclinical and clinical studies.

Trial Design: This is an international (6 countries) randomized phase III study. Patients are randomized 1:1 to exemestane (25 mg daily) plus palbociclib (125 mg daily x3 weeks every 4 weeks) vs. capecitabine (1,250 mg/m2 twice daily x2 weeks every 3 weeks). Postmenopausal patients with HR+/HER2- MBC are eligible if resistant to previous NSAI (letrozole or anastrozole) defined as: recurrence while on or within 12 months after the end of adjuvant treatment or progression while on or within 1 month after the end of treatment for MBC. Previous chemotherapy is permitted either in the (neo)adjuvant setting and/or as first line for MBC. Patients must have measurable disease according to RECIST 1.1 or lytic bone lesions in the absence of measurable disease. The primary objective is Progression-Free Survival (PFS); secondary objectives are overall survival, response rate, clinical benefit rate, response duration, safety, quality of life and biomarker’s defined changes. The study will recruit 348 patients to detect a difference of 2.75 months in the median PFS (from 6 to 8.75 months; hazard ratio= 0.686), with a power of 80% and a 5% two sided significance level. The study started recruitment in March 2014 and 14 patients have been included so far (ClinTrials.gov reference NCT02028507).

Citation Format: Miguel Martín, Semir Beslija, Eva Carrasco, Zsuzanna Kahan, Ma José Escudero, Istvan Lang, Begoña Bermejo, Moshe Inbar, José Ignacio Chacón, Dan Jinga, José Ángel García-Saenz, Juan de la Haba, Serafín Morales, Miguel Gil, Laura Murillo, Antonio Antón, Manuel Ruiz-Borrego, Christoph Zielinski, Günther Steger, Bella Nisenbaum. Phase III study of palbociclib in combination with exemestane vs. capecitabine, in hormonal receptor (HR) positive/HER2 negative metastatic breast cancer (MBC) patients with resistance to non-steroidal aromatase inhibitors (NSAI): PEARL study (GEICAM/2013-02_CECOG/BC.1.3.006) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr OT1-1-05.

Lapatinib combined with ECF/x as first-line metastatic gastric cancer (GC) according to HER2 and EGFR status: A randomized placebo controlled phase II (EORTC 40071)

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Background: ECF/X (epirubicin (E) + cisplatin (C) + 5-fluoruracil (F) or capecitabine (X)) is a reference chemotherapy (CT) regimen in metastatic GC. Trastuzumab with CF/X prolonged survival (OS) of metastatic HER2+ gastric or esophagogastric junction cancer (GC) patients (pts). Lapatinib (LAP) inhibits both, EGFR1 and HER2, and showed activity in phase II GC trials. This double-blind Phase II study prospectively addressed efficacy and safety of LAP with ECF/X in GC pts with discordant FISH or IHC HER2 status or EGFR1+. Methods: Pts without prior palliative CT, screened centrally for HER2/EGFR1 (by FISH and IHC) were enrolled into 3 strata: 1) HER2 FISH+ and IHC 2/3+, 2) HER2 FISH- and IHC 2/3+, or 3) HER2 IHC 0/+ and EGFR1 FISH+ or IHC 2/3+. Pts without HER2 + or EGFR1+, by FISH or IHC, were excluded. Pts were randomized to LAP 1250mg (arm 1) or placebo (arm 2), with ECF or ECX (investigator-selected) for 6 cycles. Primary endpoint was progression free survival (PFS). Secondary endpoints were toxicity, response rates, OS, HER2 concordance and correlation of HER2/EGFR. Results: The trial was prematurely closed to patient accrual given the LOGIC trial results at ASCO 2013. A total of 69 pts were tested in central lab of whom 9 (13%), 5 (7.2%) and 25 (36.2%) were in stratum 1, 2 and 3. Of these, 28 patients (6/4/18) were randomized (14 in arm 1, 14 in arm 2) and followed up. Due to the low number of pts accrued, no formal statistical tests were carried out. No safety concerns were found in arm 1. No complete responses were seen. 6 pts had partial responses in arm 1 vs. 3 pts in arm 2. Median PFS was 7.1 months in arm 1 vs. 5.9 months in arm 2 (HR=0.94, 95% CI: 0.41-2.14) for all pts, and 6.2 months in arm 1 vs. 6.3 months in arm 2 (HR=0.99, 95% CI: 0.36-2.75) for stratum 3 pts, respectively. Median overall survival was 13.8 months in arm 1 vs. 10.1 months in arm 2 (HR=0.90, 95% CI: 0.35-2.27) for all pts. Conclusions: Lapatinib with ECF/X did not show appealing activity in EGFR+ metastatic GC patients in this small phase 2 trial. The combination was well tolerated. Clinical trial information: NCT01123473.

The cyclin-dependent kinase 4/6 inhibitor palbociclib in combination with letrozole versus letrozole alone as first-line treatment of oestrogen receptor-positive, HER2-negative, advanced breast cancer (PALOMA-1/TRIO-18): a randomised phase 2 study

BACKGROUND

Palbociclib (PD-0332991) is an oral, small-molecule inhibitor of cyclin-dependent kinases (CDKs) 4 and 6 with preclinical evidence of growth-inhibitory activity in oestrogen receptor-positive breast cancer cells and synergy with anti-oestrogens. We aimed to assess the safety and efficacy of palbociclib in combination with letrozole as first-line treatment of patients with advanced, oestrogen receptor-positive, HER2-negative breast cancer.

METHODS

In this open-label, randomised phase 2 study, postmenopausal women with advanced oestrogen receptor-positive and HER2-negative breast cancer who had not received any systemic treatment for their advanced disease were eligible to participate. Patients were enrolled in two separate cohorts that accrued sequentially: in cohort 1, patients were enrolled on the basis of their oestrogen receptor-positive and HER2-negative biomarker status alone, whereas in cohort 2 they were also required to have cancers with amplification of cyclin D1 (CCND1), loss of p16 (INK4A or CDKN2A), or both. In both cohorts, patients were randomly assigned 1:1 via an interactive web-based randomisation system, stratified by disease site and disease-free interval, to receive continuous oral letrozole 2.5 mg daily or continuous oral letrozole 2.5 mg daily plus oral palbociclib 125 mg, given once daily for 3 weeks followed by 1 week off over 28-day cycles. The primary endpoint was investigator-assessed progression-free survival in the intention-to-treat population. Accrual to cohort 2 was stopped after an unplanned interim analysis of cohort 1 and the statistical analysis plan for the primary endpoint was amended to a combined analysis of cohorts 1 and 2 (instead of cohort 2 alone). The study is ongoing but closed to accrual; these are the results of the final analysis of progression-free survival. The study is registered with the ClinicalTrials.gov, number NCT00721409.

FINDINGS

Between Dec 22, 2009, and May 12, 2012, we randomly assigned 165 patients, 84 to palbociclib plus letrozole and 81 to letrozole alone. At the time of the final analysis for progression-free survival (median follow-up 29.6 months [95% CI 27.9-36.0] for the palbociclib plus letrozole group and 27.9 months [25.5-31.1] for the letrozole group), 41 progression-free survival events had occurred in the palbociclib plus letrozole group and 59 in the letrozole group. Median progression-free survival was 10.2 months (95% CI 5.7-12.6) for the letrozole group and 20.2 months (13.8-27.5) for the palbociclib plus letrozole group (HR 0.488, 95% CI 0.319-0.748; one-sided p=0.0004). In cohort 1 (n=66), median progression-free survival was 5.7 months (2.6-10.5) for the letrozole group and 26.1 months (11.2-not estimable) for the palbociclib plus letrozole group (HR 0.299, 0.156-0.572; one-sided p<0.0001); in cohort 2 (n=99), median progression-free survival was 11.1 months (7.1-16.4) for the letrozole group and 18.1 months (13.1-27.5) for the palbociclib plus letrozole group (HR 0.508, 0.303-0.853; one-sided p=0.0046). Grade 3-4 neutropenia was reported in 45 (54%) of 83 patients in the palbociclib plus letrozole group versus one (1%) of 77 patients in the letrozole group, leucopenia in 16 (19%) versus none, and fatigue in four (4%) versus one (1%). Serious adverse events that occurred in more than one patient in the palbociclib plus letrozole group were pulmonary embolism (three [4%] patients), back pain (two [2%]), and diarrhoea (two [2%]). No cases of febrile neutropenia or neutropenia-related infections were reported during the study. 11 (13%) patients in the palbociclib plus letrozole group and two (2%) in the letrozole group discontinued the study because of adverse events.

INTERPRETATION

The addition of palbociclib to letrozole in this phase 2 study significantly improved progression-free survival in women with advanced oestrogen receptor-positive and HER2-negative breast cancer. A phase 3 trial is currently underway.

FUNDING

Pfizer.

Selecting first-line bevacizumab-containing therapy for advanced breast cancer: TURANDOT risk factor analyses

BACKGROUND

The randomised phase III TURANDOT trial compared first-line bevacizumab-paclitaxel (BEV-PAC) vs bevacizumab-capecitabine (BEV-CAP) in HER2-negative locally recurrent/metastatic breast cancer (LR/mBC). The interim analysis revealed no difference in overall survival (OS; primary end point) between treatment arms; however, progression-free survival (PFS) and objective response rate were significantly superior with BEV-PAC. We sought to identify patient populations that may be most appropriately treated with one or other regimen.

METHODS

Patients with HER2-negative LR/mBC who had received no prior chemotherapy for advanced disease were randomised to either BEV-PAC (bevacizumab 10 mg kg(-1) days 1 and 15 plus paclitaxel 90 mg m(-2) days 1, 8 and 15 q4w) or BEV-CAP (bevacizumab 15 mg kg(-1) day 1 plus capecitabine 1000 mg m(-2) bid days 1-14 q3w). The study population was categorised into three cohorts: triple-negative breast cancer (TNBC), high-risk hormone receptor-positive (HR+) and low-risk HR+. High- and low-risk HR+ were defined, respectively, as having ⩾2 vs ⩽1 of the following four risk factors: disease-free interval ⩽24 months; visceral metastases; prior (neo)adjuvant anthracycline and/or taxane; and metastases in ⩾3 organs.

RESULTS

The treatment effect on OS differed between cohorts. Non-significant OS trends favoured BEV-PAC in the TNBC cohort and BEV-CAP in the low-risk HR+ cohort. In all three cohorts, there was a non-significant PFS trend favouring BEV-PAC. Grade ⩾3 adverse events were consistently less common with BEV-CAP.

CONCLUSIONS

A simple risk factor index may help in selecting bevacizumab-containing regimens, balancing outcome, safety profile and patient preference. Final OS results are expected in 2015 (ClinicalTrials.gov NCT00600340).

Economic inequalities in burden of illness, diagnosis and treatment of five long-term conditions in England: panel study

OBJECTIVE

We compared the distribution by wealth of self-reported illness burden (estimated from validated scales, biomarker and reported symptoms) for angina, cataract, depression, diabetes and osteoarthritis, with the distribution of self-reported medical diagnosis and treatment. We aimed to determine if the greater illness burden borne by poorer participants was matched by appropriately higher levels of diagnosis and treatment.

DESIGN

The English Longitudinal Study of Ageing, a panel study of 12,765 participants aged 50 years and older in four waves from 2004 to 2011, selected using a stratified random sample of households in England. Distribution of illness burden, diagnosis and treatment by wealth was estimated using regression analysis.

OUTCOME MEASURES

The main outcome measures were ORs for the illness burden, diagnosis and treatment, respectively, adjusted for age, sex and wealth. We estimated the illness burden for angina with the Rose Angina scale, diabetes with fasting glycosylated haemoglobin, depression with the Centre for Epidemiologic Studies Depression Scale, osteoarthritis with self-reported pain and disability and cataract with self-reported poor vision. Medical diagnoses were self-reported for all conditions. Treatment was defined as β-blocker prescription for angina, surgery for osteoarthritis and cataract, and receipt of predefined effective interventions for diabetes and depression.

RESULTS

Compared with the wealthiest, the least wealthy participant had substantially higher odds for illness burden from any of the five conditions at all four time points, with ORs ranging from 4.2 (95% CI 2.6 to 6.8) for diabetes to 15.1 (11.4 to 20.0) for osteoarthritis. The ORs for diagnosis and treatment were smaller in all five conditions, and ranged from 0.9 (0.5 to 1.4) for diabetes treatment to 4.5 (3.3 to 6.0) for angina diagnosis.

CONCLUSIONS

The substantially higher illness burden in less wealthy participants was not matched by appropriately higher levels of diagnosis and treatment.