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Schlam I, Tarantino P, Tolaney SM. Overcoming Resistance to HER2-Directed Therapies in Breast Cancer. Cancers (Basel) 2022; 14:3996. [PMID: 36010990 PMCID: PMC9406173 DOI: 10.3390/cancers14163996] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Simple Summary Breast cancer is the most common cancer in women in the United States. Around 15% of all breast cancers overexpress the HER2 protein. These HER2-positive tumors have been associated with aggressive behavior if left untreated. Drugs targeting HER2 have greatly improved the outcomes of patients with HER2-positive tumors in the last decades. Despite these improvements, many patients with early breast cancer have recurrences, and many with advanced disease experience progression of disease on HER2-targeted drugs, suggesting that patients can develop resistance to these medications. In this review, we summarize several mechanisms of resistance to HER2-targeted treatments. Understanding how the tumors grow despite these therapies could allow us to develop better treatment strategies to continue to improve patient outcomes. Abstract Human epidermal growth factor receptor 2 (HER2)-positive breast cancer accounts for around 15% of all breast cancers and was historically associated with a worse prognosis compared with other breast cancer subtypes. With the development of HER2-directed therapies, the outcomes of patients with HER2-positive disease have improved dramatically; however, many patients present with de novo or acquired resistance to these therapies, which leads to early recurrences or progression of advanced disease. In this narrative review, we discuss the mechanisms of resistance to different HER2-targeted therapies, including monoclonal antibodies, small tyrosine kinase inhibitors, and antibody-drug conjugates. We review mechanisms such as impaired binding to HER2, incomplete receptor inhibition, increased signaling from other receptors, cross-talk with estrogen receptors, and PIK3CA pathway activation. We also discuss the role of the tumor immune microenvironment and HER2-heterogeneity, and the unique mechanisms of resistance to novel antibody-drug conjugates. A better understanding of these mechanisms and the potential strategies to overcome them will allow us to continue improving outcomes for patients with breast cancer.
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Chia SK, Ellard SL, Mates M, Welch S, Mihalcioiu C, Miller WH, Gelmon K, Lohrisch C, Kumar V, Taylor S, Hagerman L, Goodwin R, Wang T, Sakashita S, Tsao MS, Eisenhauer E, Bradbury P. A phase-I study of lapatinib in combination with foretinib, a c-MET, AXL and vascular endothelial growth factor receptor inhibitor, in human epidermal growth factor receptor 2 (HER-2)-positive metastatic breast cancer. Breast Cancer Res 2017; 19:54. [PMID: 28464908 PMCID: PMC5414192 DOI: 10.1186/s13058-017-0836-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 03/16/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The mechanisms of resistance to anti-human epidermal growth factor receptor 2 (HER 2) therapies are unclear but may include the tyrosine-protein kinase Met (c-Met), vascular endothelial growth factor (VEGF) and AXL pathways. Foretinib is an inhibitor of c-Met, VEGF receptor 2 (VEGFR-2), platelet-derived growth factor receptor beta (PDGFRB), AXL, Fms-like tyrosine kinase 3 (FLT3), angiopoiten receptor (TIE-2), RET and RON kinases. This phase Ib study sought to establish the associated toxicities, pharmacokinetics (PK) and recommended phase II doses (RP2D) of foretinib and lapatinib in a cohort of HER-2-positive patients with metastatic breast cancer (MBC). METHODS Women with HER-2 positive MBC, Performance status (PS 0-2), and no limit on number of prior chemotherapies or lines of anti-HER-2 therapies were enrolled. A 3 + 3 dose escalation design was utilized. Four dose levels were intended with starting doses of foretinib 30 mg and lapatinib 750 mg orally once a day (OD) on a 4-weekly cycle. Assessment of c-MET status from the primary archival tissue was performed. RESULTS We enrolled 19 patients, all evaluable for toxicity assessment and for response evaluation. Median age was 60 years (34-86 years), 95% were PS 0-1, 53% were estrogen receptor-positive and 95% had at least one prior anti-HER-2-based regimen. The fourth dose level was reached (foretinib 45 mg/lapatinib 1250 mg) with dose-limiting toxicities of grade-3 diarrhea and fatigue. There was only one grade-4 non-hematological toxicity across all dose levels. There were no PK interactions between the agents. A median of two cycles was delivered across the dose levels (range 1-20) with associated progression-free survival of 3.2 months (95% CI 1.61-4.34 months). By immunohistochemical assessment with a specified cutoff, none of the 17 samples tested were classified as positive for c-Met. CONCLUSIONS The RP2D of the combined foretinib and lapatinib is 45 mg and 1000 mg PO OD, respectively. Limited activity was seen with this combination in a predominantly unselected cohort of HER-2-positive patients with MBC.
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Affiliation(s)
- Stephen K. Chia
- 0000 0001 0702 3000grid.248762.dMedical Oncology, British Columbia Cancer Agency (BCCA), Vancouver, BC Canada
| | - Susan L. Ellard
- 0000 0001 0702 3000grid.248762.dMedical Oncology, BCCA, Kelowna, BC Canada
| | - Mihaela Mates
- 0000 0004 0633 727Xgrid.415354.2Queen’s University and Cancer Centre of South Eastern Ontario at Kingston General Hospital, Kingston, ON Canada
| | - Stephen Welch
- 0000 0000 9132 1600grid.412745.1London Regional Cancer Program, London, ON Canada
| | - Catalin Mihalcioiu
- 0000 0004 1936 8649grid.14709.3bJewish General Hospital and Rossy Cancer Network, McGill University, Montreal, QC Canada
| | - Wilson H. Miller
- 0000 0004 1936 8649grid.14709.3bJewish General Hospital and Rossy Cancer Network, McGill University, Montreal, QC Canada
| | - Karen Gelmon
- 0000 0001 0702 3000grid.248762.dMedical Oncology, British Columbia Cancer Agency (BCCA), Vancouver, BC Canada
| | - Caroline Lohrisch
- 0000 0001 0702 3000grid.248762.dMedical Oncology, British Columbia Cancer Agency (BCCA), Vancouver, BC Canada
| | - Vikaash Kumar
- 0000 0004 0633 727Xgrid.415354.2Queen’s University and Cancer Centre of South Eastern Ontario at Kingston General Hospital, Kingston, ON Canada
| | - Sara Taylor
- 0000 0001 0702 3000grid.248762.dMedical Oncology, BCCA, Kelowna, BC Canada
| | | | - Rachel Goodwin
- 0000 0000 9606 5108grid.412687.eThe Ottawa Hospital Cancer Centre, Ottawa, ON Canada
| | - Tao Wang
- 0000 0001 2157 2938grid.17063.33Princess Margaret Cancer Centre and University Health Network, University of Toronto, Toronto, ON Canada
| | - Shingo Sakashita
- 0000 0001 2157 2938grid.17063.33Princess Margaret Cancer Centre and University Health Network, University of Toronto, Toronto, ON Canada
| | - Ming S. Tsao
- 0000 0001 2157 2938grid.17063.33Princess Margaret Cancer Centre and University Health Network, University of Toronto, Toronto, ON Canada
| | - Elizabeth Eisenhauer
- 0000 0004 0633 727Xgrid.415354.2Queen’s University and Cancer Centre of South Eastern Ontario at Kingston General Hospital, Kingston, ON Canada
| | - Penelope Bradbury
- 0000 0001 2157 2938grid.17063.33Princess Margaret Cancer Centre and University Health Network, University of Toronto, Toronto, ON Canada
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Rantalainen M, Klevebring D, Lindberg J, Ivansson E, Rosin G, Kis L, Celebioglu F, Fredriksson I, Czene K, Frisell J, Hartman J, Bergh J, Grönberg H. Sequencing-based breast cancer diagnostics as an alternative to routine biomarkers. Sci Rep 2016; 6:38037. [PMID: 27901097 PMCID: PMC5128815 DOI: 10.1038/srep38037] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 10/25/2016] [Indexed: 12/20/2022] Open
Abstract
Sequencing-based breast cancer diagnostics have the potential to replace routine biomarkers and provide molecular characterization that enable personalized precision medicine. Here we investigate the concordance between sequencing-based and routine diagnostic biomarkers and to what extent tumor sequencing contributes clinically actionable information. We applied DNA- and RNA-sequencing to characterize tumors from 307 breast cancer patients with replication in up to 739 patients. We developed models to predict status of routine biomarkers (ER, HER2,Ki-67, histological grade) from sequencing data. Non-routine biomarkers, including mutations in BRCA1, BRCA2 and ERBB2(HER2), and additional clinically actionable somatic alterations were also investigated. Concordance with routine diagnostic biomarkers was high for ER status (AUC = 0.95;AUC(replication) = 0.97) and HER2 status (AUC = 0.97;AUC(replication) = 0.92). The transcriptomic grade model enabled classification of histological grade 1 and histological grade 3 tumors with high accuracy (AUC = 0.98;AUC(replication) = 0.94). Clinically actionable mutations in BRCA1, BRCA2 and ERBB2(HER2) were detected in 5.5% of patients, while 53% had genomic alterations matching ongoing or concluded breast cancer studies. Sequencing-based molecular profiling can be applied as an alternative to histopathology to determine ER and HER2 status, in addition to providing improved tumor grading and clinically actionable mutations and molecular subtypes. Our results suggest that sequencing-based breast cancer diagnostics in a near future can replace routine biomarkers.
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Affiliation(s)
- Mattias Rantalainen
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Daniel Klevebring
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Johan Lindberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Emma Ivansson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Gustaf Rosin
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Lorand Kis
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Pathology and Cytology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
| | - Fuat Celebioglu
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Irma Fredriksson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Breast- and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jan Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Breast- and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Hartman
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Pathology and Cytology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Bergh
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Pathology and Cytology, Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Grönberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Baselga J, Lewis Phillips GD, Verma S, Ro J, Huober J, Guardino AE, Samant MK, Olsen S, de Haas SL, Pegram MD. Relationship between Tumor Biomarkers and Efficacy in EMILIA, a Phase III Study of Trastuzumab Emtansine in HER2-Positive Metastatic Breast Cancer. Clin Cancer Res 2016; 22:3755-63. [PMID: 26920887 DOI: 10.1158/1078-0432.ccr-15-2499] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 01/27/2016] [Indexed: 01/05/2023]
Abstract
PURPOSE HER2-positive breast cancer is heterogeneous. Some tumors express mutations, like activating PIK3CA mutations or reduced PTEN expression, that negatively correlate with response to HER2-targeted therapies. In this exploratory analysis, we investigated whether the efficacy of trastuzumab emtansine (T-DM1), an antibody-drug conjugate comprised of the cytotoxic agent DM1 linked to the HER2-targeted antibody trastuzumab, was correlated with the expression of specific biomarkers in the phase III EMILIA study. EXPERIMENTAL DESIGN Tumors were evaluated for HER2 (n = 866), EGFR (n = 832), and HER3 (n = 860) mRNA expression by quantitative reverse transcriptase PCR; for PTEN protein expression (n = 271) by IHC; and for PIK3CA mutations (n = 259) using a mutation detection kit. Survival outcomes were analyzed by biomarker subgroups. T-DM1 was also tested on cell lines and in breast cancer xenograft models containing PIK3CA mutations. RESULTS Longer progression-free survival (PFS) and overall survival (OS) were observed with T-DM1 compared with capecitabine plus lapatinib in all biomarker subgroups. PIK3CA mutations were associated with shorter median PFS (mutant vs. wild type: 4.3 vs. 6.4 months) and OS (17.3 vs. 27.8 months) in capecitabine plus lapatinib-treated patients, but not in T-DM1-treated patients (PFS, 10.9 vs. 9.8 months; OS, not reached in mutant or wild type). T-DM1 showed potent activity in cell lines and xenograft models with PIK3CA mutations. CONCLUSIONS Although other standard HER2-directed therapies are less effective in tumors with PI3KCA mutations, T-DM1 appears to be effective in both PI3KCA-mutated and wild-type tumors. Clin Cancer Res; 22(15); 3755-63. ©2016 AACR.
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Affiliation(s)
- José Baselga
- Memorial Sloan Kettering Cancer Center, New York, New York.
| | | | - Sunil Verma
- Sunnybrook Odette Cancer Centre, Toronto, Canada
| | | | - Jens Huober
- Breast Center, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | | | - Steve Olsen
- Genentech, Inc., South San Francisco, California
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Abstract
The PI3K/AKT pathway is the focus of several targeted therapeutic agents for a variety of malignancies. In ERBB2-amplified breast cancer, the hyperactivation of this signaling cascade is associated with resistance to ERBB2-targeted therapy. This can occur through gain-of-function alterations or compensatory mechanisms that enter into play upon pharmacological pressure. The strong rationale in combining anti-ERBB2 agents with PI3K/AKT inhibitors, together with the identification of genomic alterations conferring sensitivity to targeted inhibition, are guiding the design of clinical studies aimed at preventing the emergence of drug resistance and achieving more durable response. In the present review, we describe the involvement of this pathway in breast cancer pathogenesis, with an emphasis on AKT kinases, and provide insight into currently available targeted agents for the treatment of ERBB2-amplified breast cancer. Finally, we provide preliminary data on a novel AKT3 mutation detected in the context of resistance to anti-ERBB2 therapy as an example of genomics-based approaches towards uncovering novel actionable targets in this setting.
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Affiliation(s)
- F Javier Carmona
- Memorial Sloan Kettering Cancer Center (MSKCC), Human Oncology and Pathogenesis Program (HOPP), NY, USA
| | - Filippo Montemurro
- Unit of Investigative Clinical Oncology, Institute for Cancer Research and Treatment, Candiolo, Italy
| | | | - Valentina Rossi
- Medical Oncology, Ospedale Civile di Saluzzo, Saluzzo, Italy
| | - Chandra Verma
- Bioinformatics Institute (A*STAR), #07-01 Matrix, 30 Biopolis Street #07-01, 138671, Singapore; Department of Biological Sciences, National University of Singapore, 14 Science Drive 4, 117543, Singapore; School of Biological Sciences, Nanyang Technological University, 60 Nanyang Drive, 637551, Singapore
| | - José Baselga
- Memorial Sloan Kettering Cancer Center (MSKCC), Human Oncology and Pathogenesis Program (HOPP), NY, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box 20, New York, NY 10065, USA
| | - Maurizio Scaltriti
- Memorial Sloan Kettering Cancer Center (MSKCC), Human Oncology and Pathogenesis Program (HOPP), NY, USA.
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Goel S, Tolaney S. Optimizing the Management of Metastatic HER2-Positive Breast Cancer. Curr Breast Cancer Rep 2015; 7:190-202. [DOI: 10.1007/s12609-015-0191-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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