Pertuzumab plus trastuzumab plus docetaxel for metastatic breast cancer

Long‑term progression‑free survival in HR+/HER2+ advanced breast cancer with combination therapy with a CDK4/6 inhibitor and first‑line maintenance therapy: A case report

The current standard treatment for hormone receptor (HR)-positive and human epidermal growth factor receptor 2 (HER2)-positive advanced breast cancer (BC) involves the use of anti-HER2 monoclonal antibodies combined with chemotherapy, followed by sequential endocrine therapy. However, crosstalk between the HR and HER2 pathways may cause drug resistance. Combining therapies targeting both the HR and HER2 pathways may be a rational approach for patients with HR+/HER2+ tumors, as this strategy could counteract resistance by blocking crosstalk in the receptor pathway. However, clinical data in this field remain limited. The present report describes the case of a patient with HR+/HER2+ late-stage BC who achieved a long-term partial response rate after receiving anti-HER2 combination chemotherapy followed by sequential treatment with endocrine therapy and cyclin-dependent kinase 4/6 (CDK4/6) inhibitors. The present case provides additional evidence suggesting that incorporating CDK4/6 inhibitors into standard targeted chemotherapy regimens may be an effective treatment option for patients with HR+/HER2+ BC.

Options for postoperative radiation therapy in patients with de novo metastatic breast cancer

BACKGROUND

Although meta-analyses have demonstrated survival benefits associated with primary tumor resection in MBC, guidelines lack consensus on the survival benefit of postoperative radiation therapy (RT).

METHODS

In this study, we included 1392 patients with de novo metastatic breast cancer (dnMBC) by integrating data from the SEER database (2010-2019) to systematically assess the efficacy of postoperative RT and develop a machine learning-driven prognostic tool. The primary endpoint was overall survival (OS).

RESULTS

Propensity score matching (PSM) results showed that postoperative RT significantly improved OS (HR = 0.573, 95 % CI = 0.475-0.693), but this survival gain showed great heterogeneity among different subgroups. It is found that patients with HR-/HER2-or HR+/HER2-subtypes gained significant OS benefit from (p < 0.001) postoperative RT, whereas patients with HER2+ subtype did not gain any survival benefit since the effect of targeted therapy overshadowed the postoperative RT. Further risk stratification by the random survival forest (RSF) model revealed that high-risk patients with T4/N3 stage, high tumor grade and poor response to chemotherapy had significantly prolonged OS after receiving RT (p < 0.001), while low-risk patients showed no additional benefit. The model had excellent predictive efficacy (training set C-index = 0.741, validation set C-index = 0.720) with key predictors including HER2 status, chemotherapy response and tumor grade. The research team developed an interactive web application (https://lee2287171854.shinyapps.io/RSFshiny/) based on this model, which can generate individualized survival risk scores in real-time to guide clinical decision-making.

CONCLUSION

This study is the first to propose a risk stratification strategy for postoperative RT in dnMBC, and innovatively integrates machine learning and clinical tools to provide a new paradigm for optimizing precision therapy.

Trastuzumab-Pertuzumab Plus Eribulin or Taxane as First-Line Chemotherapy for Human Epidermal Growth Factor 2-Positive Locally Advanced/Metastatic Breast Cancer: The Randomized Noninferiority Phase III EMERALD Trial

PURPOSE

Trastuzumab-pertuzumab (HP) plus taxane is a current standard first-line therapy for recurrent or metastatic human epidermal growth factor 2 (HER2)+ breast cancer (BC). We investigated noninferiority of eribulin to a taxane when combined with dual HER2 blockade as first-line systemic treatment for locally advanced/metastatic HER2+ BC.

METHODS

In the phase III EMERALD trial (target sample size, 480; ClinicalTrials.gov identifier: NCT03264547/UMIN000027938), patients were randomly assigned (1:1) to receive eribulin 1.4 mg/m2 once daily on days 1 and 8 (eribulin group) or a taxane (docetaxel 75 mg/m2 once on day 1 or paclitaxel 80 mg/m2 once daily on days 1, 8, and 15; taxane group) intravenously in a 21-day cycle, each with HP on day 1. The primary end point was progression-free survival (PFS; intention-to-treat population). Secondary end points included objective response rate, overall survival (OS), patient-reported quality of life (QoL), and safety. Noninferiority was tested using the stratified Cox proportional hazards model to estimate hazard ratios (HRs) for PFS events, with a noninferiority HR margin of 1.33.

RESULTS

Between August 2017 and June 2021, 446 patients (median age, 56.0 years) were enrolled. The median PFS was 14.0 and 12.9 months in the eribulin group (n = 224) and taxane group (n = 222 [docetaxel/paclitaxel, n = 186/36]), respectively (HR, 0.95 [95% CI, 0.76 to 1.19]), which confirmed the noninferiority of the study regimen. The median OS was 65.3 months in the taxane group but has not been reached in the eribulin group. Median time to QoL deterioration was numerically longer with eribulin than with taxane. Adverse event (AE) rates were similar, despite the longer duration of eribulin use. Infusion reaction, skin-related AEs, diarrhea, and edema were more common with taxane, whereas neutropenia was more common with eribulin.

CONCLUSION

The results suggested that eribulin + HP is an option for first-line treatment of locally advanced/metastatic HER2+ BC.

A Structural Insight Into Two Important ErbB Receptors (EGFR and HER2) and Their Relevance to Non-Small Cell Lung Cancer

The epidermal growth factor receptor (EGFR) family, comprising receptor tyrosine kinases (RTK) such as EGFR and HER2, plays a critical role in various signaling pathways related to cell proliferation, differentiation, and growth. EGFR overactivation due to aberrant signaling can lead to various cancers, including non-small cell lung cancer (NSCLC). To develop treatment for EGFR-related NSCLC, several tyrosine kinase inhibitors (TKIs) were designed: gefitinib, erlotinib, as first-generation; neratinib, dacomitinib as second-generation; osimertinib, lazertinib as third-generation, as examples. However, due to the acquired resistance by the mutations such as EGFRT790M and EGFRC797S together with the exon 20 insertion mutations, these drugs do not provide promising results for NSCLC patients. The development of fourth-generation inhibitors like EAI045 and further innovative drugs to overcome this resistance problem is a must to cure EGFR-related NSCLC. Among these, pyrazoline-thiazole scaffolds are found effective as EGFR-HER2 inhibitors against NSCLC, making them promising drug candidates. Although structures obtained so far for the EGFR family provide meaningful insights into the mechanisms, the quality and the quantity of the EGFR family structures are insufficient to elucidate the complete structures and functions to overcome NSCLC. This review evaluates the structures of EGFR-HER2 and investigates their relation to NSCLC.

Clinicomolecular Profile and Efficacy of Human Epidermal Growth Factor Receptor 2 (HER2)-Targeted Therapy for HER2-Amplified Advanced Biliary Tract Cancer

PURPOSE

This study aimed to investigate the clinicomolecular profiles and the efficacy of human epidermal growth factor receptor 2 (HER2)-targeted therapy in HER2-amplified biliary tract cancer (BTC).

METHODS

This study was an international collaboration that used combined data from the prospective SCRUM-Japan GOZILA and MONSTAR-SCREEN in Japan and retrospective reviews in the United States; patients with advanced BTC who had received systemic therapy were included. The clinicomolecular profiles were evaluated in an exploratory cohort, whereas the efficacy of HER2-targeted therapy was assessed in a biomarker-selected cohort.

RESULTS

Of the 439 patients in the exploratory cohort, 43 (10%) had HER2 amplification. The frequencies of coalterations were higher in patients with HER2 amplification versus patients without HER2 amplification including HER2 mutations (26% v 5%, P < .001), TP53 mutations (84% v 61%, P = .003), and BRAF amplification (9% v 2%, P = .030). There were no KRAS mutations identified in patients with HER2-amplified BTC. No significant difference in overall survival (OS) was observed between patients with and without HER2 amplification (median, 17.7 v 16.9 months; hazard ratio [HR], 0.95 [95% CI, 0.65 to 1.40]). Of the 60 patients with HER2-amplified BTC in the biomarker-selected cohort (43 from Japan and 17 from the United States), the OS was significantly longer in 29 patients who received HER2-targeted therapy than in those who did not receive HER2-targeted therapy (median, 24.3 v 12.1 months; HR, 0.39 [95% CI, 0.23 to 0.82]). Multivariate analysis identified HER2-targeted therapy as an independent prognostic factor for OS (HR, 0.29 [95% CI, 0.14 to 0.58]; P < .001).

CONCLUSION

HER2 amplification was found in 10% of advanced BTC and was not identified as an independent prognostic factor for OS. Patients with HER2-amplified BTC derive significant benefit from HER2-targeted therapy.

Efficacy and safety of KN026 and docetaxel for HER2-positive breast cancer: a phase II clinical trial

BACKGROUND

The standard first-line treatment for human epidermal growth factor receptor 2 (HER2)-positive recurrent/metastatic breast cancer currently includes pertuzumab plus trastuzumab and docetaxel. This study aimed to evaluate the effectiveness of KN026, an anti-HER2 bispecific antibody, plus docetaxel in first-line treatment of HER2-positive recurrent/metastatic breast cancer.

METHODS

This open-label, single-arm, phase II study enrolled patients with HER2-positive recurrent/metastatic breast cancer in 19 centers across China from December 30, 2019 to May 27, 2021. Patients were administered KN026 (30 mg/kg) plus docetaxel (75 mg/m2) in 21-day cycles. Primary endpoints included the objective response rate (ORR) and duration of response (DOR). In addition, overall survival (OS), progression-free survival (PFS), clinical benefit rate (CBR) and safety profile were examined.

RESULTS

A total of 57 patients were included. In the efficacy analysis set of 55 patients, the ORR was 76.4% (95% confidence interval [CI], 63.0%-86.8%), and the CBR was 85.5% (95% CI, 73.3%-93.5%). The median DOR was not reached (95% CI, 20.7 months-not reached). In the safety set of 57 patients, the median PFS was 27.7 months (95% CI, 18.0 months-not reached). The median OS was not reached, with OS rates at 12, 24 and 30 months of 93.0%, 84.1% and 78.5%, respectively. Grade ≥3 treatment-emergent adverse events (AEs) were detected in 36 (63.2%) patients. No deaths were attributed to KN026 or docetaxel.

CONCLUSION

KN026 plus docetaxel showed promising efficacy and a manageable safety profile in first-line treatment of HER2-positive recurrent/metastatic breast cancer.

Safety and efficacy of combined trastuzumab-deruxtecan and concurrent radiation therapy in breast cancer. The TENDANCE multicentric French study

PURPOSE

Trastuzumab Deruxtecan (T DXD), a new antibody drug conjugate is a new treatment option for 2nd line metastatic breast cancer (MBC) for HER2 + or HER2 low tumors. Palliative or ablative radiotherapy (RT) may be required in patients who are being treated with T-DXd. However there is a lack of evidence regarding the safety profile of combining T-DXd with RT. TENDANCE study aimed to evaluate safety and efficacy of combined T-DXd and RT.

MATERIALS AND METHODS

This retrospective multicenter study included 54 patients treated concurrently with T-DXd and RT for HER2+ and HER2 low MBC between February 2021 and December 2023. All data were collected from a web-questionnaire, centralized after medical records and validation of the protocol by the local ethical committee. Primary endpoint was the safety of combined therapy.

RESULTS

Median age was 60 years. Patients who received T-DXD were further categorized into HER2+ (40.7 %), HER2 low/hormonal receptors HR+ (40.8 %) or HER2 low/HR- (18.5 %). In the HER2+ patients, T-DXd was administered as 2nd (18.2 %) or 3rd (31.8 %) or 4th (50 %) line therapy. RT was delivered using palliative (72.2 %) or ablative doses (27.8 %). Indications consisted mostly of palliative bone irradiation (46.3 %) and stereotactic radiosurgery (SRS) (25.9 %). With the median follow-up of 9 months, 22.2 % of patients had a complete response and 77.8 % had either a partial response or stable disease. Grade 1 or 2 asthenia was observed in 51.8 % of patients, while only 16.6 % experienced other grade 1 or 2 adverse effects. There was no T-DXd therapy discontinuation related to RT.

CONCLUSION

To our knowledge, TENDANCE is the largest study evaluating concurrent T-DXd and RT. This preliminary report suggests the feasibility of the combination of RT and T-DXd with manageable toxicity rate. Longer follow-up and further prospective studies are required to confirm these results.

Leveraging HER2-targeted biparatopic antibodies in solid tumors

Biparatopic antibodies (bpAbs), which target non-overlapping epitopes on the same antigen, offer unique mechanisms of action and therapeutic applications that surpass those of conventional monospecific antibodies. These distinctive properties have positioned bpAbs as effective therapeutic agents in the treatment of cancer and infectious diseases, especially in cases where current treatments face limitations. Among these, HER2-targeted bpAbs have shown significant improvements in survival outcomes for patients with solid tumors that depend on HER2 signaling. However, a comprehensive understanding of their clinical impact, mechanisms of action, and limitations in therapeutic use remains lacking. Here, we review and contrast the clinical performance of the well-established HER2-targeted bpAbs in current use, with a focus on their mechanisms of action, associated limitations, and potential combination strategies. We also highlight emerging investigational bpAbs-based agents that have shown promise in the treatment of HER2-positive solid cancers. These advancements may lead to enhanced therapeutic options and potentially broaden the scope of bpAbs in cancer therapy.

Triple-positive breast cancer: navigating heterogeneity and advancing multimodal therapies for improving patient outcomes

Triple-positive breast cancer (TPBC), a unique subtype of luminal breast cancer, is characterized by concurrent positivity for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Owing to the crosstalk between the ER and HER2 signaling pathways, the standard of care and drug resistance of this particular subtype are difficult challenges. Recent research and clinical trials have indicated a shift in the treatment paradigm for TPBC from single-target therapies to multi-pathway, multitarget strategies aiming to comprehensively modulate intricate signaling networks, thereby overcoming resistance and enhancing therapeutic outcomes. Among multiple strategies, triple-drug therapy has emerged as a promising treatment modality, demonstrating potential efficacy in patients with TPBC. Moving forward, there is a critical need to perform in-depth analyses of specific mechanisms of cancer pathogenesis and metastasis, decipher the complex interactions between different genes or proteins, and identify concrete molecular targets, thus paving the way for the development of tailored therapeutic strategies to combat TPBC effectively.

How are we allocating physicians to deal with breast cancer in men and women in Brazil?

BACKGROUND

Female breast cancer (FBC) is a well-known public health issue worldwide. However, male breast cancer (MBC), though rare, may be overlooked by both public health authorities and clinicians. Both diseases exhibit similarities, and understanding their behavior over time is crucial to grasping their annual impact on many citizens. Furthermore, analyzing if medical personnel are well allocated and influence disease outcomes in a limited setting such as the Public Health System (PHS) is of utmost importance.

METHODS

This ecological study utilized secondary data from 2008 to 2020 to explore the relationship between the number of doctors per 100,000 inhabitants and mortality from FBC and MBC in Brazil. All data were sourced from Brazil's PHS. Mortality rates were analyzed by age and standardized according to the World Health Organization's population figures. The number of physicians was calculated per 100,000 inhabitants. A linear regression analysis was performed using a stepwise selection/backward elimination approach.

RESULTS

Between 2008 and 2020, Brazil recorded 195,969 breast cancer-related deaths among adults, including 2,220 male victims. The majority of these deaths occurred in the Southeast region among patients older than 50 years. Although both MBC and FBC demonstrated increasing trends over the study period, no correlation was found between the number of physicians and mortality rates for MBC. Conversely, an increase in primary care physicians over the years was positively correlated with mortality rates for FBC (p < 0.05). In addition, the number of physicians in the PHS (β = -0.163; 95% CI: -0.240 to -0.085; p = 0.002), oncologists (β = -0.507; 95% CI: -0.881 to -0.134; p = 0.015), and radiotherapists (β = -6.402; 95% CI: -12.357 to -0.446; p = 0.039) all showed an inverse association with FBC mortality.

CONCLUSIONS

The increasing trends in FBC and MBC underscore the need for urgent monitoring. Lower FBC mortality correlates with higher numbers of physicians and specialized care, highlighting the critical role of healthcare workforce capacity and the strategic allocation of specialized personnel in enhancing patient outcomes.

The impact of breast surgery and systemic therapy on the survival of patients with de novo stage IV breast cancer

BACKGROUND

Systemic therapy (ST) is essential for de novo stage IV breast cancer (BC). Stage IV BCs are highly heterogeneous, and it seems inappropriate to treat all de novo stage IV BCs equally. The survival benefit of surgery for primary sites in patients with de novo stage IV BC remains inconclusive.

PATIENTS AND METHODS

We investigated 220 patients with clinical de novo stage IV BC. The relationship between primary site surgery and overall survival (OS) was analyzed. Factors such as tumor subtype, timing of surgery, and efficacy of ST were also evaluated.

RESULTS

The median follow-up time was 37.9 (0.5-201.7) months. In the total cohort, the median OS of the patients with and without primary site surgery was 70.5 months (95% confidence interval [CI] 58.4-107.3) and 42.7 months (95% CI 35.7-48.8), respectively. The OS was significantly longer in patients who underwent primary site surgery, especially in the hormone receptor (HR) + /HER2- and HER2 + subtypes, but not in the triple-negative subtype. OS prolongation was significant in patients who underwent surgery ≥ 24 months after the first diagnosis and in whom the first-line ST was effective for ≥ 24 months. Primary site surgery was a good prognostic factor in both univariate and multivariate analyses.

CONCLUSIONS

The OS was significantly longer in patients with de novo stage IV BC who underwent primary site surgery than in those who did not undergo surgery. Our results suggest that the tumor subtypes, efficacy of ST, and timing of surgery influenced the benefits of surgery.

Prognostic impact of caspase-8 mutation in oral cavity squamous cell carcinoma

OBJECTIVE

Identifying the drive genes and inhibiting their significant signals were persistently the main concepts in cancer treatment. However, for oral cavity squamous cell carcinoma (OCSCC), the most influential genes for overall survival (OS) remain unclear.

METHODS

A total of 120 OCSCC patients with corresponding pathologic specimens were collected in Taiwan. Whole-exome sequencing was done and the prognostic impact of each gene was analyzed. TCGA database was used to validate.

RESULTS

The incidences of caspase-8 mutation were 22.1% and 10.9% in the Taiwan and TCGA cohort, respectively. In the Taiwan cohort, caspase-8 mutation was the most significant independent for OS with an adjusted hazard ratio (HR) ([95% CI]: 3.83 [1.84-7.99]). It was validated by the TCGA database (HR [95% CI]: 1.51 [1.00-2.29]). The 5-year OSs of the patients with or without caspase-8 mutation were 38.1% vs. 75.3% (p < 0.001) (HR [95% CI]: 3.264 [1.645-6.438]) in the Taiwan cohort, and 26.1% vs. 49.0% (p = 0.048) (1.513 [1.001-2.288]) in the TCGA cohorts, respectively. Caspase-8 mutation was also individually associated with poor prognosis for TNM stage I/II/III/IV, respectively. CASP8 R127* and R494*, defined as pathogenic mutations in ClinVar, were presented in both cohorts.

CONCLUSIONS

Caspase-8 mutation was the most significant genetic alteration impacting prognosis.

Safety study on switching from intravenous to fixed‑dose subcutaneous formulation of pertuzumab and trastuzumab

To the best of our knowledge, there have been no reports from clinical settings regarding safety information on a fixed-dose combination of pertuzumab and trastuzumab for subcutaneous injection (PHESGO®) when switched from the intravenous formulation of pertuzumab and trastuzumab in Japan. The lack of information on switching from the intravenous formulation to PHESGO in clinical settings may contribute to hesitation in making the switch. The present study analyzed the safety of 51 patients with breast or colorectal cancer treated with PHESGO. The focus was on evaluating infusion reactions (IRs), and skin and subcutaneous tissue disorders. The study included patients who received PHESGO at the Saitama Cancer Center between January 1, 2024 and March 31, 2024. The group using it as initial induction therapy was compared with the group that switched from the intravenous formulation. IRs were assessed using the Common Terminology Criteria for Adverse Events version 5.0. Patients with grade 1 or higher symptoms on the day of administration or the following day were considered to have IRs. IRs occurred in 4 of 16 patients (25%) in the initial induction group and none in the switching group (P=0.0073). It was suggested that IRs with PHESGO were more likely to occur at the time of first administration, similar to existing intravenous formulations. The study also examined patients who switched to an intravenous formulation after receiving PHESGO; skin and subcutaneous tissue disorders occurred in five patients, three of whom continued on a slower dose rate, and two of whom discontinued PHESGO and switched to pertuzumab and trastuzumab for intravenous infusion. With PHESGO, IRs are also more likely to occur the first time, and when skin and subcutaneous tissue disorders occur, there is a tendency to switch formulations in groups with a history of intravenous formulation use.

Tucatinib and trastuzumab in HER2-mutated metastatic breast cancer: a phase 2 basket trial

Human epidermal growth factor receptor 2 (HER2, also known as ERBB2) signaling promotes cell growth and differentiation, and is overexpressed in several tumor types, including breast, gastric and colorectal cancer. HER2-targeted therapies have shown clinical activity against these tumor types, resulting in regulatory approvals. However, the efficacy of HER2 therapies in tumors with HER2 mutations has not been widely investigated. SGNTUC-019 is an open-label, phase 2 basket study evaluating tucatinib, a HER2-targeted tyrosine kinase inhibitor, in combination with trastuzumab in patients with HER2-altered solid tumors. The study included a cohort of 31 heavily pretreated female patients with HER2-mutated metastatic breast cancer who were also HER2 negative per local testing. Hormone receptor (HR)-positive patients also received fulvestrant. The overall response rate (primary endpoint) was 41.9% (90% confidence interval (CI): 26.9-58.2). Secondary endpoints of duration of response and progression-free survival were 12.6 months (90% CI: 4.7 to not estimable) and 9.5 months (90% CI: 5.4-13.8), respectively. No new safety signals were detected. Responses were observed across various HER2 mutations, including mutations in the tyrosine kinase and extracellular domains. The chemotherapy-free regimen of tucatinib and trastuzumab showed clinically meaningful antitumor activity with durable responses and favorable tolerability in heavily pretreated patients with HER2 mutations. These data support further investigation of HER2-targeted therapies in this patient population. ClinicalTrials.gov registration: NCT04579380 .

Adaptive Proteomic Changes in Protein Metabolism and Mitochondrial Alterations Associated with Resistance to Trastuzumab and Pertuzumab Therapy in HER2-Positive Breast Cancer

HER2 (human epidermal growth factor receptor 2) is overexpressed in approximately 15-20% of breast cancers, leading to aggressive tumour growth and poor prognosis. Anti-HER2 therapies, such as trastuzumab and pertuzumab, have significantly improved the outcomes for patients with HER2-positive breast cancer by blocking HER2 signalling. However, intrinsic and acquired resistance remains a major clinical challenge, limiting the long-term effectiveness of these therapies. Understanding the mechanisms of resistance is essential for developing strategies to overcome it and improve the therapeutic outcomes. We generated multiple HER2-positive breast cancer cell line models resistant to trastuzumab and pertuzumab combination therapy. Using mass spectrometry-based proteomics, we conducted a comprehensive analysis to identify the mechanisms underlying resistance. Proteomic analysis identified 618 differentially expressed proteins, with a core of 83 overexpressed and 118 downregulated proteins. Through a series of advanced bioinformatics analyses, we identified significant protein alterations and signalling pathways potentially responsible for the development of resistance, revealing key alterations in the protein metabolism, mitochondrial function, and signalling pathways, such as MAPK, TNF, and TGFβ. These findings identify mitochondrial activity and detoxification processes as pivotal mechanisms underlying the resistance to anti-HER2 therapy. Additionally, we identified key proteins, including ANXA1, SLC2A1, and PPIG, which contribute to the tumour progression and resistance phenotype. Our study suggests that targeting these pathways and proteins could form the basis of novel therapeutic strategies to overcome resistance in HER2-positive breast cancer.

Trastuzumab Duocarmazine in Pretreated Human Epidermal Growth Factor Receptor 2-Positive Advanced or Metastatic Breast Cancer: An Open-Label, Randomized, Phase III Trial (TULIP)

PURPOSE

Human epidermal growth factor receptor 2 (HER2)-targeted therapy is standard of care for HER2-positive (HER2+) breast cancer, but most patients develop progressive disease with persistent HER2 expression. No definitive treatment guidance currently exists beyond second line. Trastuzumab duocarmazine (T-Duo) is a third-generation, HER2-targeted antibody-drug conjugate that demonstrated efficacy and acceptable safety in phase I studies of heavily pretreated patients with HER2+/HER2-low breast cancer.

METHODS

In this open-label, randomized, phase III trial, T-Duo was compared with physician's choice (PC) in patients with unresectable locally advanced/metastatic HER2+ breast cancer with progression during/after ≥2 HER2-targeted therapies or after trastuzumab emtansine (T-DM1). The primary endpoint was progression-free survival (PFS) by blinded independent central review.

RESULTS

In total, 437 patients were randomly assigned 2:1 to T-Duo (n = 291) or PC (n = 146). The median age was 56.0 years (range, 24-86); most patients (93.6%) had metastatic disease. The median time from diagnosis of metastatic disease to trial entry was 3.5 years; the median number of prior HER2-targeted therapies in metastatic setting was three. The median PFS was 7.0 months (95% CI, 5.4 to 7.2) with T-Duo versus 4.9 months (95% CI, 4.0 to 5.5; hazard ratio [HR], 0.64 [95% CI, 0.49 to 0.84]; P = .002) with PC. PFS benefit was maintained across most predefined subgroups. The median overall survival (first analysis) was 20.4 (T-Duo) versus 16.3 months (PC; HR, 0.83 [95% CI, 0.62 to 1.09]; P = .153). Objective response rate was 27.8% (T-Duo) versus 29.5% (PC); other efficacy end points-clinical benefit rate, duration of response, and reduction in target lesion measurement-tended to favor T-Duo. Grade ≥3 treatment-emergent adverse events occurred in 52.8% (T-Duo) versus 48.2% (PC).

CONCLUSION

Treatment with T-Duo was manageable, but tolerability was affected by prevalent ocular toxicity, leading to a higher discontinuation rate in the T-Duo arm. T-Duo significantly reduced the risk of progression in patients with advanced HER2+ breast cancer who have progressed during/after ≥2 HER2-targeted therapies or after T-DM1.

Prognostic Value of the Baseline Systemic Immune-Inflammation Index in HER2-Positive Metastatic Breast Cancer: Exploratory Analysis of Two Prospective Trials

PURPOSE

The systemic immune-inflammation index (SII) is a hematological marker that reflects the immune status of the body. This study was designed to evaluate the prognostic significance of the baseline SII in HER2-positive metastatic breast cancer (MBC) patients receiving chemotherapy plus trastuzumab without or with pertuzumab.

METHODS

Data were collected from 774 patients from the CLEOPATRA trial, 196 patients from the H0648G trial, and 229 patients from six clinical centers in China. Patients were divided into the low and high SII subgroups according to the median SII value. The inverse probability of treatment weighting (IPTW) method was used to control bias. Associations between the SII and progression-free survival (PFS) and overall survival (OS) were analyzed.

RESULTS

In the CLEOPATRA trial, a lower SII was associated with better PFS (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.04-1.65, P = 0.02) and OS (HR 1.42, 95% CI 1.07-1.88, P = 0.02) in the trastuzumab and docetaxel groups, as well as improved PFS in the trastuzumab and pertuzumab and docetaxel groups (HR 1.39, 95% CI 1.10-1.77, P < 0.01) after IPTW. In the H0648G trial, a lower SII was associated with better PFS (P = 0.04) and OS (P = 0.02) in HER2-positive MBC patients receiving trastuzumab-based therapy. According to real-world data, a lower SII predicted an improvement in PFS for patients treated with docetaxel plus trastuzumab without or with pertuzumab (P = 0.02 and 0.01, respectively).

CONCLUSIONS

A low baseline SII is associated with better survival outcomes among HER2-positive MBC patients receiving trastuzumab-based first-line therapy.

Therapeutic Management in Elderly Male Breast Cancer Patients: A Scoping Review

PURPOSE OF REVIEW

Male breast cancer (MBC) is a rare entity which often arises in elderly people. Aim of this review is to evaluate the principal issues related to MBC in elderly, because the therapeutic management of disease is not only related to the biological behavior of the tumor, but also to the comorbidities and frailty of older population. A scoping literature review was performed on Pubmed and Cochrane Database using the following keywords: therapeutic management/ male/ breast cancer/ elderly patients. Papers published before 2000, not edited in English or French language, or not related to the main topic, were excluded. Only articles related to therapeutic issues in MBC and including more than 10 elderly (≥ 65 years) patients were selected for the qualitative outcome analysis.

RECENT FINDINGS

36 papers regarding surgery, radiotherapy, systemic therapy, racial disparities and therapeutic management in retrospective series of MBC in elderly were examined in details. MBC has a different biological behavior and a poorer prognosis than female, especially in cases with positive nodes at diagnosis. Elderly MBC patients have often larger tumors in more advanced stages at the time of diagnosis compared with younger patients. In spite of the advanced tumors at presentation, older patients present often cancers with more favorable biological characteristics, but they receive less guideline-concordant curative treatments (as adequate lymph node staging or adjuvant radiation therapy) compared to women. Moreover, racial differences in treatment of older MBC were observed. Therapeutic management of MBC in elderly patients is a subject rarely addressed in literature. Our review highlighted differences in the treatment and in guidelines-concordance for elderly MBC patients. Adequate geriatric assessment and use of therapeutic schemes adapted to age and comorbidities can avoid under/overtreatment, contributing to a better standard of care in this frail population.

MOUNTAINEER-03 phase III study design: first-line mFOLFOX6 + tucatinib + trastuzumab for HER2+ metastatic colorectal cancer

Patients diagnosed with metastatic colorectal cancer (mCRC) have a poor prognosis with survival ranging 2-3 years. The prevalence of human epidermal growth factor receptor 2 (HER2) amplification is approximately 3-4% in mCRC and increases up to 8% in patients with KRAS/NRAS/BRAF wild-type (WT) CRC tumors. Tucatinib is a highly selective HER2-directed tyrosine kinase inhibitor that, in combination with trastuzumab, has demonstrated clinically meaningful activity in patients with chemotherapy-refractory, HER2-positive (HER2+), RAS WT mCRC in the MOUNTAINEER trial. The MOUNTAINEER-03 phase III trial is designed to investigate the efficacy and safety of first-line tucatinib in combination with trastuzumab and modified FOLFOX6 (mFOLFOX6) versus standard of care (mFOLFOX6 plus bevacizumab or cetuximab) in patients with untreated HER2+, RAS WT locally advanced unresectable or mCRC. MOUNTAINEER-03 will include two arms of approximately 400 patients randomized 1:1 to either treatment arm. The primary endpoint is progression-free survival per RECIST v1.1 by blinded independent central review (BICR). Key secondary endpoints are overall survival and confirmed objective response rate (according to RECIST v1.1 per BICR). Safety assessments will include surveillance and recording of adverse events, physical examination findings, vital signs, cardiac assessments, Eastern Cooperative Oncology Group performance status, concomitant medications, and laboratory tests.Clinical trial registration: NCT05253651 (ClinicalTrials.gov).

ECD co-operates with ERBB2 to promote tumorigenesis through upregulation of unfolded protein response and glycolysis

The ecdysoneless (ECD) mRNA and protein are overexpressed in breast cancer (BC), and its overexpression correlates with poor prognosis and short patient survival, particularly in ERBB2/HER2-positive BC. This study investigates the co-operative oncogenic mechanism of ECD and ERBB2 by deriving transgenic mice overexpressing ECD and/or ERBB2 (huHER2) in mammary epithelium under MMTV promoter, as well as human mammary immortal epithelial cell lines (hMECs) overexpressing ECD and/or ERBB2. While huHER2 Tg mice developed more homogenous solid nodular carcinomas, double transgenic mice ( ECD;huHER2 Tg) developed heterogenous and histologically aggressive mammary tumors with basal-like phenotype and epithelial mesenchymal transition (EMT) features, like ECD Tg tumors, resembling more to patient tumors. Importantly, transcriptomic profile of ECD;huHER2 Tg tumors revealed upregulation of two major oncogenic pathways, unfolded protein response (UPR) and glycolysis. Similarly, hMECs expressing both ECD and ERBB2 as compared to single gene expressing cells showed increase in oncogenic traits, and RNA-seq analysis showed a significant upregulation of glycolysis and UPR pathways. ECD is an RNA binding protein, and directly associates with three key glycolytic enzymes ( LDHA , PKM2 and HK2 ) and mRNA of a major UPR regulated gene GRP78, that results in increased mRNA stability. Lastly, we show an increase in glucose uptake and enhanced glycolytic rate in ECD+ERBB2-overexpressing cells as compared to ECD- or ERBB2-overexpressing hMECs. Taken together, our findings support a co-operative role of ECD and ERBB2 in oncogenesis by enhancing two major oncogenic pathways, UPR and glycolysis.

Significance

This study provides mechanistic insights that overexpression of ECD in ERBB2+ breast cancer patients correlates with shorter patient survival, by identifying direct ECD binding to mRNAs for UPR and glycolysis pathways.

Neoadjuvant pyrotinib and trastuzumab in HER2-positive breast cancer with no early response (NeoPaTHer): efficacy, safety and biomarker analysis of a prospective, multicentre, response-adapted study

The potential benefits of pyrotinib for patients with trastuzumab-insensitive, HER2-positive early-stage breast cancer remain unclear. This prospective, multicentre, response-adapted study evaluated the efficacy and safety of adding pyrotinib to the neoadjuvant treatment of HER2-positive breast cancer patients with a poor response to initial docetaxel plus carboplatin and trastuzumab (TCbH). Early response was assessed using magnetic resonance imaging (MRI) after two cycles of treatment. Patients showing poor response, as defined by RECIST 1.1, could opt to receive additional pyrotinib or continue standard therapy. The primary endpoint was the total pathological complete response (tpCR; ypT0/isN0) rate. Of the 129 patients enroled, 62 (48.1%) were identified as MRI-responders (cohort A), 26 non-responders continued with four more cycles of TCbH (cohort B), and 41 non-responders received additional pyrotinib (cohort C). The tpCR rate was 30.6% (95% CI: 20.6-43.0%) in cohort A, 15.4% (95% CI: 6.2-33.5%) in cohort B, and 29.3% (95% CI: 17.6-44.5%) in cohort C. Multivariable logistic regression analyses demonstrated comparable odds of achieving tpCR between cohorts A and C (odds ratio = 1.04, 95% CI: 0.40-2.70). No new adverse events were observed with the addition of pyrotinib. Patients with co-mutations of TP53 and PIK3CA exhibited lower rates of early partial response compared to those without or with a single gene mutation (36.0% vs. 60.0%, P = 0.08). These findings suggest that adding pyrotinib may benefit patients who do not respond to neoadjuvant trastuzumab plus chemotherapy. Further investigation is warranted to identify biomarkers predicting patients' benefit from the addition of pyrotinib.

Magnetic polymeric ionic liquid for both catalysis application and magnetic solid phase extraction approach

In this project, a new heterogeneous polymeric ionic liquid catalyst based on vinylimidazole, stabilized on magnetic nanoparticles )Fe3O4@Al2O3@[PBVIm]HSO4) was prepared. Then the desired catalyst was identified by TGA, FT-IR, VSM, and TEM techniques. The efficiency of this catalyst was measured in the synthesis of chromene, xanthene, and dihydropyrimidinone. Moreover, the capability of the prepared sorbent for the extraction and determination of BPA (bisphenol A) was studied. Under the optimum conditions, the linearity range of the technique was between 0.5 and 100 µg L-1 with the coefficient of determination (r2) of 0.9948. Relative standard deviations for intra- and inter-day precision for the BPA (bisphenol A) at 20 µg L-1 were in the range of 3.1-3.9% and 3.7-4.2%, respectively. The limit of detection and limit of quantification were 0.07 and 0.48 µg L-1 respectively. Excellent efficiency, compatibility with environmental conditions, and easy recycling of the catalyst are among the most important features of the synthetic catalyst.

Novel anti-HER2 ADCs vs dual anti-HER2 antibody for HER2-positive metastatic breast cancer failed to tyrosine kinase inhibitor

BACKGROUND

Both novel anti-human epidermal growth factor receptor 2 (HER2) antibody-drug conjugates (ADCs) and pertuzumab and trastuzumab (HP) combined with chemotherapy(C) regimens are the choice of treatment for HER2 positive metastatic breast cancer (MBC) after tyrosine kinase inhibitors (TKIs). Our team's previous research has shown significant therapeutic effects of novel anti-HER2 ADCs in patients with TKIs treatment failure. Unfortunately, there is currently no data available to compare novel anti-HER2 ADCs with HP combined with chemotherapy regimens. This study was conducted to compare the efficacy and safety of novel anti-HER2 ADCs with that of the HP combined with chemotherapy regimen in patients for whom TKI treatment failed.

MATERIALS AND METHODS

HER2-positive MBC who used novel anti-HER2 ADCs and HP combined with a chemotherapy regimen from January 2019 to August 2023 were included, and all patients received TKIs. The primary study endpoint was progression-free survival (PFS), while the secondary study endpoints were objective response rate (ORR), clinical benefit rate (CBR), and safety.

RESULTS

A total of 150 patients, of which 83 are in the novel anti-HER2 ADCs group and 67 are in the HP combined with chemotherapy. Among these novel anti-HER2 ADCs, 36 patients received treatment with trastuzumab deruxtecan (T-Dxd), and 47 patients received treatment with other new types of ADCs. The median PFS of the novel anti-HER2 ADCs group and HP combined with the chemotherapy group were 7.0 months and 8.9 months, respectively, with ORR of 51.8% and 26.9%, and CBR of 69.9% and 65.7%, respectively. In subgroup, patients receiving T-Dxd showed improvement in PFS compared to the HP combined with chemotherapy group. The most common grade 3-4 adverse events in the novel anti-HER2 ADCs group and the HP combined with chemotherapy group were neutropenia and gastrointestinal symptoms.

CONCLUSIONS

In HER2-positive MBC for whom TKI treatment has failed, novel anti-HER2 ADCs and the HP combined with chemotherapy regimen both showed moderate efficacy and tolerable toxicity. Novel anti-HER2 ADCs are the preferred treatment recommendation for TKI failure patients. Meanwhile, based on the results of this study, the HP combined with chemotherapy regimen may also be an option, especially for patients with low accessibility.

Survival Among Patients With ERBB2-Positive Metastatic Breast Cancer and Central Nervous System Disease

Importance

Approximately one-third of patients with ERBB2 (formerly HER2 or HER2/neu)-positive (ERBB2+) metastatic breast cancer (MBC) develop brain metastasis. It is unclear whether patients with disease limited to the central nervous system (CNS) have different outcomes and causes of death compared with those with concomitant extracranial metastasis.

Objective

To assess overall survival (OS) and CNS-related mortality among patients with ERBB2+ breast cancer and a diagnosis of CNS disease by disease distribution (CNS only vs CNS plus extracranial metastasis).

Design, Setting, and Participants

This single-center, retrospective cohort study included patients with ERBB2+ MBC and CNS disease, including parenchymal brain metastasis, leptomeningeal disease (LMD), or dural metastasis, who were treated between August 2010 and April 2022 at Memorial Sloan Kettering Cancer Center. Data were analyzed between December 2023 and August 2024.

Main Outcomes and Measures

Overall survival, estimated with the Kaplan-Meier method, and CNS-related mortality with cumulative incidence.

Results

The cohort included 274 patients (272 [99.3%] female). The median age was 53.7 years (range, 28.7-87.4 years); 125 patients (45.6%) presented with de novo MBC. At CNS metastasis diagnosis, 73 (26.6%) presented with CNS-only disease. There was a median follow-up of 3.7 years (range, 0.2-12.0 years) from CNS disease diagnosis among those alive at the end of follow-up. Both OS and CNS-related death were significantly correlated with the pattern of presentation: OS was shortest among patients with LMD (1.24 years; 95% CI, 0.89-2.08 years) followed by those with extracranial metastasis (2.16 years; 95% CI, 1.87-2.58 years) and was longest among patients with parenchymal or dural CNS disease only (3.57 years; 95% CI, 2.10-5.63 years) (P = .001). Of 192 patients (70.1%) who died, 106 (55.2%) died of a CNS-related cause. The group with CNS-only disease remained at high risk of death from CNS causes, with a 3-year CNS-related death rate of 33.98% (95% CI, 22.84%-45.43%) and a 3-year death rate from other causes of 6.07% (95% CI, 1.93%-13.69%). On multivariable modeling for CNS-related death, LMD (hazard ratio, 1.87; 95% CI, 1.19-2.93; P = .007) and treatment with whole-brain radiotherapy (hazard ratio, 1.71; 95% CI, 1.13-2.58; P = .01) were associated with CNS-related death.

Conclusions and Relevance

In this cohort study, 55.2% of deaths among patients with ERBB2+ breast cancer and brain metastasis were due to CNS-related causes, with the greatest risk among patients with LMD. CNS-only presentation was associated with improved survival but a higher rate of CNS-related death, supporting an approach of aggressive local therapy for select patients.

An Attribution of Value Framework for Combination Treatments

OBJECTIVES

The use of cost-effectiveness methods to support policy decisions has become well established, but difficulties can arise when evaluating a new treatment that is indicated to be used in combination with an established backbone treatment. If the latter has been priced close to the decision maker's willingness-to-pay threshold, this may mean that there is no headroom for the new treatment to demonstrate value, at any price, even if the combination is clinically effective. Without a mechanism for attributing value to component treatments within a combination therapy, the health system risks generating negative funding decisions for combinations of proven clinical benefit to patients. The aim of this work was to define a value attribution methodology, which could be used to allocate value between the components of any combination treatment.

METHODS

The framework is grounded in the standard decision rules of cost-effectiveness analysis and provides solutions according to key features of the problem: perfect/imperfect information about component treatment monotherapy effects and balanced/unbalanced market power between their manufacturers.

RESULTS

The share of incremental value varies depending on whether there is perfect/imperfect information and balance/imbalance of market power, with some scenarios requiring the manufacturers to negotiate a share of the incremental value within a range defined by the framework.

CONCLUSIONS

It is possible to define a framework that is independent of price and focuses on benefits expressed as quality-adjusted life-year gains (and/or quality-adjusted life-year equivalents for cost savings), a standard metric used by many health technology assessment agencies to evaluate novel treatments.

Combined pyrotinib and fulvestrant for hormone receptor-positive and HER2-positive metastatic breast cancer: A multicenter, single-arm, phase II trial

This multicenter, single-arm, phase II clinical trial (NCT04034589) evaluated the efficacy and safety of pyrotinib combined with fulvestrant in patients with HR-positive/HER2-positive metastatic breast cancer who had experienced trastuzumab treatment failure. A total of 46 patients were enrolled, receiving pyrotinib orally once daily and fulvestrant intramuscularly on days 1 and 15 of cycle 1, followed by monthly doses on day 1. The primary endpoint was progression-free survival (PFS), while secondary endpoints included overall survival (OS), objective response rate (ORR), disease control rate (DCR), and safety. The median PFS was 18.2 months (95% CI, 11.9-31.1) overall, 19.5 months (95% CI, 10.6-NA) for those receiving the combination as first-line therapy, and 18.4 months (95% CI, 16.7-NA) for patients with brain metastases. Median OS was not reached, with a 3-year OS rate of 75.2% (95% CI, 62.8-90.2%). The ORR was 32.5%, and the DCR was 97.5%. Responses were observed in patients with low tumor mutation burden and ZNF217 mutation. Importantly, no grade 4 or higher treatment-related adverse events or deaths were reported, indicating a favorable safety profile. In conclusion, the combination of pyrotinib and fulvestrant demonstrated promising antitumor activity and acceptable safety in HR-positive/HER2-positive metastatic breast cancer patients.

Expert consensus on the prevention of brain metastases in patients with HER2-positive breast cancer

BACKGROUND

Patients with HER2-positive breast cancer have a significant risk of developing brain metastases (BrM), which have detrimental effects on survival outcomes and quality of life. Although there are several systemic treatment options available that may delay the appearance of BrM and secondary progression of previously treated BrM, there are still substantial unmet needs for this patient population and primary prevention remains elusive.

METHODS

A group of experts created consensus statements, through a modified Delphi process, to bridge the gap between current unmet needs, available evidence, and international guidelines.

RESULTS

The steering committee reviewed all relevant literature and formed research questions to be answered by the subsequent consensus statements. In total, 61 contributors provided feedback on the consensus statements, with 34 statements reaching agreement out of the 55 statements that were voted on altogether. Statements with consensus aimed to define BrM primary and secondary prevention, screening procedures, assessment of symptoms, treatment efficacy, and preventing the occurrence and progression of BrM, while acknowledging the possibilities and limitations in daily clinical practice. Some statements did not reach agreement for a variety of reasons, mostly due to lack of evidence.

CONCLUSIONS

The consensus statements outlined in this publication provide a point of reference for daily clinical practice and can act as recommendations for clinical trial procedures and future guidelines.

A Novel Effective Models for Identifying BRCA Patients and Optimizing Clinical Treatments

OBJECTIVE

This study aimed to develop an effective model that identifies high-risk breast cancer (BRCA) patients and optimizes clinical treatments.

METHODS

This study includes five public datasets, TCGA-BRCA as the training dataset and other cohorts as the validation datasets. Machine learning algorithms for finding key tumor-associated immune gene pairs (TAIGPs). These TAIGPs were used to construct tumor-associated immune gene pair index (TAIGPI) by multivariate analysis and further validated on the validation datasets. In addition, the differences in clinical prognosis, biological characteristics, and treatment benefits between high and low TAIGPI groups were further analyzed.

RESULTS

The TAIGPI was established by 36 TAIGPs. Better clinical outcomes in the low TAIGPI patients, with consistent results, were also obtained in the validation datasets. The study showed that patients in the low TAIGPI group had a high infiltration of immune cells and low proliferative activity of tumor cells. In contrast, patients in the high TAIGPI group exhibited low infiltration of immune cells and high proliferative activity of tumor cells. In addition, patients in the low TAIGPI group are more likely to benefit from chemotherapy, adjuvant chemotherapy, or immunotherapy.

CONCLUSIONS

The TAIGPI can be an effective predictive strategy for the clinical prognosis of breast cancer patients, providing new insights into personalized treatment options for breast cancer patients.

PARP Pioneers: Using BRCA1/2 Mutation-targeted Inhibition to Revolutionize Breast Cancer Treatment

Breast cancer stands on the second position in the world in being common and women happen to have it with high rate of about five-folds around the world. The causes of occurrence can matter with different humans be it external factors or the internal genetic ones. Breast cancer is primarily driven by mutations in the BRCA1 and BRCA2 susceptibility genes. These BC susceptibility genes encode proteins critical for DNA homologous recombination repair (HRR). Poly (ADP ribose) polymerases (PARP) are the essential enzymes involved in the repairing of the damaged DNA. So the inhibition of these inhibitors can be considered as the promising strategy for targeting cancers with defective damage in the deoxyribonucleic acid. Olaparib and talazoparib are PARP inhibitors (PARPi) are being employed for the monotherapies in case of the deleterious germline HER2-negative and BRCA-mutated breast cancer. The potency of PARP for trapping on DNA and causes cytotoxicity may have difference in the safety and efficacy with the PARPi. The PARPi have been found its place in the all different types of breast cancers and have shown potential benefits. The purpose of this review is to provide an update on the oral poly (ADP-ribose) polymerase (PARP) inhibitors for the improvement in the treatment and management of breast cancer.

Expert recommendations on treatment sequencing and challenging clinical scenarios in human epidermal growth factor receptor 2-positive (HER2-positive) metastatic breast cancer

Human epidermal growth factor receptor 2 (HER2) overexpression and/or ERBB2 gene amplification occurs in approximately 15-20% of breast cancers and is associated with poor prognosis. While the introduction of HER2-targeted therapies has significantly improved survival in patients with HER2-positive metastatic breast cancer, the incidence of brain metastases has increased due to patients living longer. Current recommendations sequence treatments by line of therapy, as well as by the status of brain metastases in patients with HER2-positive breast cancer. However, in the third-line treatment setting and beyond, there is a lack of clarity of the preferred choice of therapy. In clinical practice, clinicians may also encounter challenging scenarios where the optimal therapeutic approach has not been defined by clinical studies, so there is a need for clarity in such situations. Two consensus meetings of expert oncologists (12 from Europe and one from Canada) were convened to discuss these scenarios. We subsequently developed this article to present an overview of current treatment recommendations for HER2-positive metastatic breast cancer and give practical guidance on addressing challenging scenarios in a real-world setting. Based on our clinical experience, we provide a unanimous consensus concerning the treatment of elderly patients as well as those with brain-only metastases, leptomeningeal disease, oligometastatic disease, central nervous system oligo-progressive disease or ERBB2-mutant disease. We also discuss how to combine HER2-targeted therapy with endocrine therapy in patients with HER2-positive/hormone-receptor-positive disease, considerations for potential discontinuation of HER2-targeted therapy in patients with long-term remission and how to treat patients whose metastatic biopsy no longer confirms their HER2-positive status.

HER2-Positive Breast Cancer Treatment and Resistance

HER2-positive (+) breast cancer is an aggressive disease with poor prognosis, a narrative that changed drastically with the advent and approval of trastuzumab, the first humanized monoclonal antibody targeting HER2. In addition to another monoclonal antibody, more classes of HER2-targeted agents, including tyrosine kinase inhibitors, and antibody-drug conjugates were developed in the years that followed. While these potent therapies have substantially improved the outcome of patients with HER2+ breast cancer, resistance has prevailed as a clinical challenge ever since the arrival of targeted agents. Efforts to develop new treatment regimens to treat/overcome resistance is futile without a primary understanding of the mechanistic underpinnings of resistance. Resistance could be attributed to mechanisms that are either specific to the tumor epithelial cells or those that emerge through changes in the tumor microenvironment. Reactivation of the HER receptor layer due to incomplete blockade of the HER receptor layer or due to alterations in the HER receptors is one of the major mechanisms. In other instances, resistance may occur due to deregulations in key downstream signaling such as the PI3K/AKT or RAS/MEK/ERK pathways or due to the emergence of compensatory pathways such as ER, other RTKs, or metabolic pathways. Potent new targeted agents and approaches to target key actionable drivers of resistance have already been identified, many of which are in early clinical development or under preclinical evaluation. Ongoing and future translational research will continue to uncover additional therapeutic vulnerabilities, as well as new targeted agents and approaches to treat and/or overcome anti-HER2 treatment resistance.

Attrition between lines of therapy and real-world outcomes of patients with HER2-positive metastatic breast cancer in Europe: a cohort study leveraging electronic medical records

PURPOSE

To characterize real-world attrition rates across first-line (1L) to third-line (3L) therapies in patients with HER2-positive (HER2 +) metastatic breast cancer (mBC) receiving routine care in seven hospital systems across Europe (France, Germany, Italy, Spain, and the UK).

METHODS

This retrospective, observational, multi-country, cohort study collected electronic medical record data from women aged ≥ 18 years diagnosed with HER2 + mBC from 2017-2021. The primary endpoint was attrition rate (the proportion of patients receiving a line of therapy [LOT] with no further evidence of subsequent LOTs). Key additional endpoints included treatment patterns, real-world time to treatment discontinuation (TTD), and time to next treatment (TTNT).

RESULTS

29.6% (95% confidence interval [CI] 25.0-34.6) and 34.2% (95% CI 27.5-41.5) of treated patients with HER2 + mBC had no further evidence of treatment beyond 1L and second-line (2L) therapy, respectively. Attrition was primarily owing to death, move to end-of-life palliative care, loss to follow up, and "other" reasons. Treatment patterns were generally aligned with clinical guidelines. Decreases in TTD (12.1 months [95% CI 10.4-14.5] for 1L, 8.9 months [95% CI 7.3-11.9] for 2L, 6.4 months [95% CI 5.2-8.9] for 3L) and TTNT (15.4 months [95% CI 13.6-20.6] for 1L, 13.5 months [95% CI 10.8-19.4] for 2L) were observed with each subsequent LOT.

CONCLUSION

Results unveil a large proportion of patients who do not benefit from state-of-the-art subsequent LOT, and suggest diminishing effectiveness with each subsequent LOT.

Envisioning Clinical Management of Breast Cancer: a Comprehensive Review

BACKGROUND

Background: Coming to the edge of disease manufacturing in the twenty-- first-century, breast cancer occupies a terrifying scenario in the globe, especially in adult women. Its curiosity endeavours remarkable advances made during the past decennaries for cancer treatment and diagnosis.

OBJECTIVE

It accounts for the fifth leading cause of transience, killing approximately 570,000 people per annum. To reduce the prognosis of clinical oncological development with the application of a new chemical entity, some of the critical challenges, like active pharmaceutical ingredients with high chemical resistance, extreme side effects, and high treatment costs are some of the limitations in the curbing aspects of breast melanoma.

METHODS

In cancer research, hence, the development of drugs that are safe, efficient, and cost-effective remains a 'Holy Grail' that may be considered as a boon to target the malignant tissues with novel therapeutics devices.

RESULTS

Through the findings on overcoming the drawbacks of traditional methods, researchers have given special attention to cancer-preventive and theranostic approaches based on some novel drug delivery systems.

CONCLUSION

The present study forecasts the wide-ranging modern applications, and on developing some novel liposomal drug delivery therapy against breast cancer.

Non-Coding RNAs in Breast Cancer: Diagnostic and Therapeutic Implications

Breast cancer (BC) is one of the most prevalent forms of cancer globally, and has recently become the leading cause of cancer-related mortality in women. BC is a heterogeneous disease comprising various histopathological and molecular subtypes with differing levels of malignancy, and each patient has an individual prognosis. Etiology and pathogenesis are complex and involve a considerable number of genetic alterations and dozens of alterations in non-coding RNA expression. Non-coding RNAs are part of an abundant family of single-stranded RNA molecules acting as key regulators in DNA replication, mRNA processing and translation, cell differentiation, growth, and overall genomic stability. In the context of breast cancer, non-coding RNAs are involved in cell cycle control and tumor cell migration and invasion, as well as treatment resistance. Alterations in non-coding RNA expression may contribute to the development and progression of breast cancer, making them promising biomarkers and targets for novel therapeutic approaches. Currently, the use of non-coding RNAs has not yet been applied to routine practice; however, their potential has been very well studied. The present review is a literature overview of current knowledge and its objective is to delineate the function of diverse classes of non-coding RNAs in breast cancer, with a particular emphasis on their potential utility as diagnostic and prognostic markers or as therapeutic targets and tools.

Clinico-pathological predictors of radiologic complete response to first-line anti-HER2 therapy in metastatic breast cancer

This study aimed to identify the clinico-pathological variables predictive of radiologic complete response (rCR) to first-line anti-HER2 therapy in patients with HER2-positive metastatic breast cancer. Patients were selected from the database of the GIM14 study and classified according to the best radiologic response obtained to first-line anti-HER2 therapy and upon time-to-treatment-discontinuation (TTD). A total of 545 patients were included in the analysis. Eighty patients experienced a rCR to first-line anti-HER2 therapy with a TTD > 3 months and HER2 Immunohistochemistry score 3+, presence of non-visceral metastases and 1 metastatic site were significantly associated with higher odds of obtaining a CR. Of the 80 patients achieving a rCR, 56 experienced a CR with a TTD > 18 months, with anti-HER2 therapy being the only variable significantly associated with a higher probability of achieving such sustained CR.

The diabetic myocardial transcriptome reveals Erbb3 and Hspa2 as a novel biomarkers of incident heart failure

AIMS

Diabetes mellitus (DM) increases heart failure incidence and worsens prognosis, but its molecular basis is poorly defined in humans. We aimed to define the diabetic myocardial transcriptome and validate hits in their circulating protein form to define disease mechanisms and biomarkers.

METHODS AND RESULTS

RNA-sequencing data from the Genotype-Tissue Expression (GTEx) project was used to define differentially expressed genes (DEGs) in right atrial (RA) and left ventricular (LV) myocardium from people with vs. without DM (type 1 or 2). DEGs were validated as plasma proteins in the UK Biobank cohort, searching for directionally concordant differential expression. Validated plasma proteins were characterized in UK Biobank participants, irrespective of diabetes status, using cardiac magnetic resonance imaging, incident heart failure, and cardiovascular mortality. We found 32 and 32 DEGs associated with DM in the RA and LV, respectively, with no overlap between these. Plasma proteomic data were available for 12, with ERBB3, NRXN3, and HSPA2 (all LV hits) exhibiting directional concordance. Irrespective of DM status, lower circulating ERBB3 and higher HSPA2 were associated with impaired LV contractility and higher LV mass. Participants in the lowest quartile of circulating ERBB3 or highest quartile of circulating HSPA2 had increased incident heart failure and cardiovascular death vs. all other quartiles.

CONCLUSION

DM is characterized by lower Erbb3 and higher Hspa2 expression in the myocardium, with directionally concordant differences in their plasma protein concentration. These are associated with LV dysfunction, incident heart failure, and cardiovascular mortality.

Apatinib and trastuzumab-based chemotherapy for heavily treated primary trastuzumab-resistant metastatic breast cancer

BACKGROUND

The low incidence and poor prognosis primary trastuzumab resistance (PTR) in HER2-positive breast cancer has limited research into possible treatments. Thus, it remains unclear whether this group of patients could benefit from nontargeting HER2 antiangiogenic therapy.

PATIENTS AND METHODS

We collected the medical data for HER2-positive patients with PTR who received apatinib 250 mg and trastuzumab-based chemotherapy (ATBC) between March 18, 2017, and March 31, 2022. All patients had progressed on ≥2 anti-HER2 treatments, including trastuzumab and small molecular tyrosine kinase inhibitors. We evaluated tumor response and safety profiles to ATBC over a median follow-up time of 34.5 months.

RESULTS

A total of 198 consecutively HER2-positive metastatic breast cancer patients were reviewed; 20 were PTR and received ATBC. The clinical benefit rate of the total cohort was 55.0%. No patient showed a complete response. The median PFS and overall survival (OS) of the entire cohort was 5.7 months (95% CI 2.9-8.5) and 24.6 months (95% CI 6.9-42.4), respectively. The estimated 2-year survival rate was 46.7% (95% CI 38.4-81.6%). The most common nonhematologic adverse events were hypertension (70.0%), hand-foot skin reaction (55.0%), proteinuria (40.0%), and cardiovascular decrease of LVEF (20.0%). No new toxicities were observed.

CONCLUSION

ATBC had favorable effects for PTR breast cancer patients in later line treatment. The toxicity of the triple-combination regimen was tolerable; thus, further research should focus on identifying PTR patients who could benefit from ATBC.

Updates in Treatment of HER2-positive Metastatic Breast Cancer

OPINION STATEMENT

The therapeutic landscape for HER2-positive metastatic breast cancer has exploded in the last two decades following the initial advent of trastuzumab, a monoclonal antibody. While the first line treatment has remained a combination of dual HER2 blockade with taxane chemotherapy, we now have several exciting options in the second line and beyond. The introduction of antibody-drug conjugates, in specific trastuzumab deruxtecan, has resulted in the best progression-free survival among patients with this subtype of breast cancer. Given the excellent outcomes of these drugs, clinical trials are now evaluating the role of ADCs in the front-line setting in previously untreated patients. In addition, there are also clinical trials evaluating the role of other targets in patients with HER2-positive cancers, including PI3KCA mutations, PD-L1 and CDK4/6. Given the predilection for brain metastases in this population, there is enthusiasm to identify the optimal combination of effective treatments. Tucatinib, capecitabine, and trastuzumab combination represent one such promising strategy. With the increasing longevity of these patients, important clinical questions include optimal treatment sequencing, the role of de-escalation of treatment in excellent responders, and the associated financial toxicity. Despite the aggressive nature of this subtype of breast cancer, the outcomes continue to improve for these patients with the evolving treatments.

Assessing the real-world effectiveness of 8 major metastatic breast cancer drugs using target trial emulation

BACKGROUND

Demonstration of trial emulation ability to benchmark randomised controlled trials (RCTs) from real-world data (RWD) is required to increase confidence in the use of routinely collected data for decision making in oncology.

METHODS

To assess the frequency with which emulation findings align with RCTs regarding effect size on overall survival (OS) in metastatic breast cancer (MBC), 8 of 13 pre-selected pivotal RCTs in MBC were emulated using data from 32,598 patients enrolled in the French ESME-MBC cohort between January 1, 2008 and December 31, 2021. Adjustment methods and confounders were selected a priori for each emulation; stabilized weight was the reference method to mitigate confounding. Concordance in OS hazard ratios with associated 95 % confidence intervals between RCTs and emulations were assessed used predefined metrics based on statistical significance, estimates, and standardized differences.

RESULTS

The effect sizes were consistent with RCT results in 7 out of the 8 emulations; 4 emulations achieved full statistical significance agreement; 5 emulations had a point estimate included in the RCT CI (estimate agreement); 6 emulations reported no significant differences between RCT and emulation (standardized difference agreement). Discrepancies related to residual confounders and significant shifts in prescription practices post-drug approval may arise in some cases.

CONCLUSION

Target trial emulation from RWD combined with appropriate adjustment can provide conclusions similar to RCTs in MBC. In oncology, this methodology offers opportunities for confirming the impact on long-term survival, for expanding indications in patients excluded from RCTs and for comparative effectiveness in single-arm trials using external control arms.

Mechanism of miRNAs and miRNA-mRNA Regulatory Networks in Modulating Drug Resistance in HER2-Positive Breast Cancer: An Integrative Bioinformatics Approach

BACKGROUND

HER2-positive breast cancer is an aggressive subtype where innate/acquired resistance to targeted drugs remains a challenge. This study aims to uncover the underlying mechanisms of HER2 drug resistance through miRNA analysis and target identification.

METHODS

MiRNA datasets were systematically retrieved from the GEO database, and differential expression analysis was conducted for both miRNA and mRNA datasets. Functional analyses were also conducted to validate the identified miRNAs and assess their clinical relevance.

RESULTS

We identified 113 differentially expressed miRNAs (DEMs) and 923 target genes. Validation was performed using external mRNA datasets, and intersection with significant genes identified 110 overlapping genes associated with HER2 drug resistance. Further analyses included functional enrichment, construction of a protein-protein interaction (PPI) network, identification of key hub genes such as BCL2, FOS, and CXCR4, and assessment of clinical relevance through survival analysis and immunohistochemistry (IHC) assessments.

CONCLUSIONS

This integrative approach unveils a complex landscape of HER2 drug resistance in breast cancer, identifying crucial miRNAs, target genes, and significant pathways. The findings offer novel insights into the mechanisms governing drug resistance and highlight the potential for enhancing therapeutic strategies. Future studies are necessary for experimental validation to further explore the complex mechanisms involved.

Phase I/Ib Trial of Inavolisib Plus Palbociclib and Endocrine Therapy for PIK3CA-Mutated, Hormone Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Advanced or Metastatic Breast Cancer

PURPOSE

To investigate the safety, tolerability, pharmacokinetics (PK), and preliminary antitumor activity of inavolisib, a potent and selective small-molecule inhibitor of p110α that promotes the degradation of mutated p110α, in combination with palbociclib and endocrine therapy (ET), in a phase I/Ib study in patients with PIK3CA-mutated, hormone receptor-positive/human epidermal growth factor receptor 2-negative locally advanced/metastatic breast cancer (ClinicalTrials.gov identifier: NCT03006172).

METHODS

Women ≥18 years of age received inavolisib, palbociclib, and letrozole (Inavo + Palbo + Letro arm) or fulvestrant (Inavo + Palbo + Fulv arm) until unacceptable toxicity or disease progression. The primary objective was to evaluate safety or tolerability.

RESULTS

Fifty-three patients were included, 33 in the Inavo + Palbo + Letro arm and 20 in the Inavo + Palbo + Fulv arm. Median duration of inavolisib treatment was 15.7 and 20.8 months (cutoff: March 27, 2023), respectively. Treatment-related adverse events (TRAEs) occurred in all patients; the most frequent were stomatitis, hyperglycemia, and diarrhea; grade ≥3 any TRAE rates were 87.9% and 85.0%; 6.1% and 10.0% discontinued any treatment due to TRAEs in the Inavo + Palbo + Letro and Inavo + Palbo + Fulv arms, respectively. No PK drug-drug interactions (DDIs) were observed among the study treatments when administered. Confirmed objective response rates were 52.0% and 40.0% in patients with measurable disease, and median progression-free survival was 23.3 and 35.0 months in the Inavo + Palbo + Letro and Inavo + Palbo + Fulv arms, respectively. Available paired pre- and on-treatment tumor tissue and circulating tumor DNA analyses confirmed the effects of study treatment on pharmacodynamic and pathophysiologic biomarkers of response.

CONCLUSION

Inavolisib plus palbociclib and ET demonstrated a manageable safety profile, lack of DDIs, and promising preliminary antitumor activity.

DLL4-targeted CAR-T therapy sensitizes neoadjuvant chemotherapy via eliminating cancer stem cells and reshaping immune microenvironment in HER2+ breast cancer

BACKGROUND

Neoadjuvant therapy with trastuzumab, pertuzumab and paclitaxel (THP) has significantly improved the prognosis of patients with human epidermal growth factor receptor 2 (HER2)+ breast cancer (BC). However, there remains a subset of non-responsive patients. Thus, this study sought to identify key regulators of THP neoadjuvant therapy resistance and potential targets to sensitize sensitivity.

METHODS

The Cancer Genome Atlas database, Gene Expression Omnibus and membrane protein database were used to identify the key regulator of THP neoadjuvant resistance. The biological functions and mechanisms of delta-like 4 proteins (DLL4) in THP therapy resistance were investigated in vitro and in vivo using the bioinformatic analysis, multiplex immunofluorescence, flow cytometry, sphere formation assays and chromatin immunoprecipitation, etc. Furthermore, DLL4-targeted chimeric antigen receptor (CAR)-T cells were established to sensitize THP therapy.

RESULTS

DLL4 was identified as a key target in THP neoadjuvant therapy resistance for HER2+ BC. Mechanistically, DLL4+ tumor cells exhibited enhanced stemness and resistance to the THP neoadjuvant chemotherapy. Additionally, soluble DLL4 can split away from tumor cells and diffuse into the stroma, where it can activate the Notch signaling pathway in neutrophils, inducing the formation and release of neutrophil extracellular traps (NETs) by regulating the transcription of MPO, PDIA4 and ELANE. This led to the exclusion of lymphocyte infiltration, thereby enhancing therapy resistance. What is more, we designed a DLL4-targeted CAR-T to eliminate DLL4+ tumor cells and reverse the resistant status.

CONCLUSIONS

Our study revealed novel functions of DLL4 in cell stemness and immune infiltration, including NET formation and T cell exclusion, which collectively contributed to THP neoadjuvant therapy resistance in HER2+ BC. Furthermore, we provided a CAR-T-based therapy to sensitize the THP neoadjuvant therapy.

Targeting HER2 in solid tumors: Unveiling the structure and novel epitopes

Human epidermal growth factor receptor-2 (HER2) is overexpressed in various solid tumor types, acting as an established therapeutic target. Over the last three decades, the fast-paced development of diverse HER2-targeted agents, notably marked by the introduction of the antibody-drug conjugate (ADC), yielding substantial improvements in survival rates. However, resistance to anti-HER2 treatments continues to pose formidable challenges. The complex structure and dynamic dimerization properties of HER2 create significant hurdles in the development of novel targeted therapeutics. In this review, we synthesize the latest insights into the structural intricacies of HER2 and present an unprecedented overview of the epitope characteristics of HER2-targeted antibodies and their derivatives. Furthermore, we delve into the correlation between anti-HER2 antibody binding epitopes and their respective functions, with a particular focus on their efficacy against resistant tumors. In addition, we highlight the potential of emerging anti-HER2 agents that target specific sites or non-overlapping epitopes, poised to transform the therapeutic landscape for HER2-positive tumors in the foreseeable future.

Dual HER2 inhibition: mechanisms of synergy, patient selection, and resistance

HER2-targeted therapies for patients with HER2+ breast cancer are rapidly evolving, offering a range of more complex and personalized treatment options. Currently, an array of anti-HER2 monoclonal antibodies, tyrosine kinase inhibitors and antibody-drug conjugates are administered, sometimes alongside chemotherapy or endocrine therapy, both in curative and palliative contexts. However, the heterogeneous nature of HER2+ breast cancer demands a deeper understanding of disease biology and its role in responsiveness to novel HER2-targeted agents, as well as non-HER2-targeted therapies, in order to optimize patient outcomes. In this Review, we revisit the mechanisms of action of HER2-targeted agents, examine the evidence supporting the use of dual HER2 blockade in patients with HER2-amplified tumours, and explore the role of biomarkers in guiding future treatment strategies. We also discuss potential implications for the future treatment of patients with HER2+ breast cancer.

Guidance for Canadian Breast Cancer Practice: National Consensus Recommendations for the Systemic Treatment of Patients with HER2+ Breast Cancer in Both the Early and Metastatic Setting

Human epidermal growth factor receptor 2-positive (HER2+) breast cancer is an aggressive subtype of breast cancer associated with a poor prognosis when sub-optimally treated. Recent advances include new and effective targeted therapies that have significantly improved outcomes for patients. Despite these advances, there are significant gaps across Canada, underscoring the need for evidence-based consensus guidance to inform treatment decisions. Addressing these gaps is crucial to ensuring that effective therapies are integrated into clinical practice, so as to improve the lives of patients affected by this aggressive form of breast cancer. The Research Excellence, Active Leadership (REAL) Canadian Breast Cancer Alliance is a standing nucleus committee of clinical-academic oncologists across Canada and Breast Cancer Canada, a patient organization. The mandate of this group is to provide evidence-based guidance on best practices in the management of patients with breast cancer. These consensus recommendations were developed using a modified Delphi process with up to three rounds of anonymous voting. Consensus was defined a priori as ≥75% of voters agreeing with the recommendation as written. There are 9 recommendations in the early setting; 7 recommendations in the metastatic setting; and 10 recommendations for patients with brain metastases.

Expression of c-erb-B2 oncoprotein as a neoantigen strategy to repurpose anti-neu antibody therapy in a model of melanoma

In this study, we tested a novel approach of "repurposing" a biomarker typically associated with breast cancer for use in melanoma. HER2/neu is a well characterized biomarker in breast cancer for which effective anti-HER2/neu therapies are readily available. We constructed a lentivirus encoding c-erb-B2, an animal (rat) homolog to HER2/neu. This was used to transfect B16 melanoma in vitro for use in an orthotopic preclinical mouse model, which resulted in expression of rat c-erb-B2 as a neoantigen target for anti-c-erb-B2 monoclonal antibody (7.16.4). The c-erb-B2-expressing melanoma was designated B16/neu. 7.16.4 produced statistically significant in vivo anti-tumor responses against B16/neu. This effect was mediated by NK-cell antibody-dependent cell-mediated cytotoxicity. To further model human melanoma (which expresses < 5% HER2/neu), our c-erb-B2 encoding lentivirus was used to inoculate naïve (wild-type) B16 tumors in vivo, resulting in successful c-erb-B2 expression. When combined with 7.16.4, anti-tumor responses were again demonstrated where approximately 40% of mice treated with c-erb-B2 lentivirus and 7.16.4 achieved complete clinical response and long-term survival. For the first time, we demonstrated a novel strategy to repurpose c-erb-B2 as a neoantigen target for melanoma. Our findings are particularly significant in the contemporary setting where newer anti-HER2/neu antibody-drug therapies have shown increased efficacy.

Outcome of patients with solid malignancies considered for intensive care unit admission: a single-center prospective cohort study

PURPOSE

To identify the predictors and outcomes of ICU triage decisions in patients with solid malignancies (SM) and to investigate the usefulness of the National Early Warning Score (NEWS) and quick Sequential Organ Failure Assessment (qSOFA) score at triage.

METHODS

All patients with SM for whom ICU admission was requested between July 2019 and December 2021 in a French university-affiliated hospital were included prospectively.

RESULTS

Of the 6262 patients considered for ICU admission, 410 (6.5%) had SM (age, 66 [58-73] years; metastases, 60.1%; and performance status 0-2, 81%). Of these 410 patients, 176 (42.9%) were admitted to the ICU, including 141 (80.1%) subsequently discharged alive. Breast cancer, hemoptysis, and pneumothorax were associated with ICU admission; whereas older age, performance status 3-4, metastatic disease, and request at night were associated with denial of ICU admission. The NEWS, and the qSOFA score in patients with suspected infection, determined at triage performed poorly for predicting hospital mortality (area under the receiver operating characteristics curve, 0.52 and 0.62, respectively). Performance status 3-4 was independently associated with higher 6-month mortality and first-line anticancer treatment with lower 6-month mortality. Hospital mortality was 33.3% in patients admitted to the ICU after refusal of the first request.

CONCLUSION

Patients with SM were frequently denied ICU admission despite excellent in-ICU survival. Poor performance status was associated with ICU admission denial and higher 6-month mortality, but none of the other reasons for denying ICU admission predicted 6-month mortality. Physiological scores had limited usefulness in this setting.

A 14-year retrospective of HER2 + metastatic breast cancer treatment at one comprehensive cancer center: Impact of the trastuzumab/pertuzumab and trastuzumab-emtansine sequence versus trastuzumab on overall survival

Introduction: Monoclonal antibodies represent a significant improvement in the treatment of the HER2 + metastatic cancer, which is associated with a worse prognosis. The objective of this study was to compare overall survival (OS) data in patients treated with trastuzumab + pertuzumab followed by trastuzumab-emtansine (T-DM1) in the second line of metastatic treatment (Arm A) versus patients treated with trastuzumab alone (Arm B). Progression-free survival (PFS) in first-line metastatic patients was also compared in both arms. Methods: This single-center retrospective study included patients from February 2008 to August 2022. OS and PFS of both arms were described and estimated using the Kaplan-Meier method. Data were extracted from electronic medical records and CHIMIO prescribing software. Results: The total duration of metastatic treatment of the 82 patients was significantly longer in the arm A (43.2 ± 28 months vs 33.6 ± 28.9 months), as was the median time to death (59 vs 52 months). The OS data showed a significant reduction in the risk of death in the arm A (Hazard Ratio = 0.59; 95% Confidence Interval [0.37-0.94]; p = 0.02). No difference was shown for PFS. Conclusion: The trastuzumab/pertuzumab/T-DM1 combination showed a significant improvement in OS. Our results are in line with the CLEOPATRA and EMILIA studies, but long-term responders in the arm A may have impacted our results. The absence of difference in term of PFS in first metastatic line may be explained by a selection bias, as patients in the arm A potentially have more aggressive forms.

A randomized phase 2 study of HLX22 plus trastuzumab biosimilar HLX02 and XELOX as first-line therapy for HER2-positive advanced gastric cancer

BACKGROUND

Gastric cancer is the fifth most common cancer and the fourth most common cause of cancer death worldwide, yet the prognosis of advanced disease remains poor.

METHODS

This was a randomized, double-blinded, phase 2 trial (ClinicalTrials.gov: NCT04908813). Patients with locally advanced/metastatic HER2-positive gastric/gastroesophageal junction cancer and no prior systemic antitumor therapy were randomized 1:1:1 to 25 mg/kg HLX22 (a novel anti-HER2 antibody) + HLX02 (trastuzumab biosimilar) + oxaliplatin and capecitabine (XELOX) (group A), 15 mg/kg HLX22 + HLX02 + XELOX (group B), or placebo + HLX02 + XELOX (group C) in 3-week cycles. Primary endpoints were progression-free survival (PFS) and objective response rate (ORR) assessed by independent radiological review committee (IRRC).

FINDINGS

Between November 29, 2021, and June 6, 2022, 82 patients were screened; 53 were randomized to group A (n = 18), B (n = 17), and C (n = 18). With 14.3 months of median follow-up, IRRC-assessed median PFS was prolonged with the addition of HLX22 (A vs. C, 15.1 vs. 8.2 months, hazard ratio [HR] 0.5 [95% confidence interval (CI) 0.17-1.27]; B vs. C, not reached vs. 8.2 months, HR 0.1 [95% CI 0.04-0.52]). Confirmed ORR was comparable among groups (A vs. B vs. C, 77.8% vs. 82.4% vs. 88.9%). Treatment-related adverse events (TRAEs) were observed in 18 (100%), 16 (94.1%), and 17 (94.4%) patients, respectively. One (5.6%) patient in group C reported a grade 5 TRAE.

CONCLUSIONS

Adding HLX22 to HLX02 and XELOX prolonged PFS and enhanced antitumor response in the first-line treatment of HER2-positive gastric cancer, with manageable safety.

FUNDING

Shanghai Henlius Biotech, Inc.