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Lüftner D, Schuetz F, Schneeweiss A, Hartkopf A, Bloch W, Decker T, Uleer C, Stötzer O, Foerster F, Schmidt M, Mundhenke C, Tesch H, Jackisch C, Fischer T, Kreuzeder J, Guderian G, Fasching PA. Efficacy and safety of everolimus plus exemestane in patients with hormone receptor-positive, HER-2-negative advanced breast cancer: Results from the open-label, multicentre, non-interventional BRAWO study. Int J Cancer 2024; 155:128-138. [PMID: 38447007 DOI: 10.1002/ijc.34912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 03/08/2024]
Abstract
BRAWO, a real-world study, assessed the efficacy, quality of life (QoL) and safety of EVE + EXE in postmenopausal women with HR+/HER2- advanced breast cancer (ABC) in routine clinical practice. Postmenopausal women with HR+/HER2-ABC with recurrence or progression after a NSAI were included. Primary Observation parameters included the evaluation of the effectiveness of EVE + EXE. A multivariate-analysis using Cox proportional hazard model was built to identify predictors of progression. Overall, 2100 patients were enrolled (August 2012-December 2017); 2074 were evaluable for efficacy and safety analyses. Majority of patients (60.6%) received EVE + EXE as first (28.7%) or second-line (31.9%) therapy. Visceral metastases were present in 54.1% patients. Median progression-free survival (mPFS) reported as 6.6 months (95%CI: 6.3-7.0). Multivariate-analysis in a subset of patients (n = 1837) found higher body mass index (BMI) and non-visceral metastases to be independent predictors of favorable PFS. Patients with a BMI of 20 to <25 had a mPFS of 6.0 (95%CI: 5.4-6.4) and those with a BMI ≥30 had mPFS of 8.5 (95%CI: 6.9-9.9). 41.2% patients achieved stable disease and 7.3% partial response. No major changes were observed QoL; 86.4% patients received stomatitis prophylaxis and 41.4% experienced EVE related AEs of stomatitis, mainly low grade. AEs occurred in 91.2% of patients, of which stomatitis (42.6%) and fatigue (19.8%) were most frequent. The BRAWO study provides real-world evidence of efficacy and safety of EVE + EXE in patients with HR+, HER2- ABC. A high BMI and the absence of visceral metastases were independent predictors of PFS in this cohort of patients.
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Affiliation(s)
- Diana Lüftner
- Medical University of Brandenburg Theodor Fontane, Campus Rüdersdorf and Immanuel Hospital Märkische Schweiz, Buckow, Germany
| | | | - Andreas Schneeweiss
- Division of Gynecologic Oncology, National Center for Tumor Diseases, University Hospital and German Cancer Research Center, Heidelberg, Germany
| | - Andreas Hartkopf
- Department of Women's Health, Universitäts-Frauenklinik Tubingen, Eberhard Karls University, Tubingen, Germany
- Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany
| | | | - Thomas Decker
- Studienzentrum Onkologie Ravensburg, Ravensburg, Germany
| | - Christoph Uleer
- Gyn.-onkologische Gemeinschaftspraxis Hildesheim, Hildesheim, Germany
| | | | | | - Marcus Schmidt
- Department of Obstetrics and Gynecology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | | | - Hans Tesch
- Oncological Practice Bethanien, Frankfurt, Germany
| | | | | | | | | | - Peter A Fasching
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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Moreau-Bachelard C, Robert M, Gourmelon C, Bourbouloux E, Patsouris A, Frenel JS, Campone M. Evaluating everolimus for the treatment of breast cancer. Expert Opin Pharmacother 2023:1-7. [PMID: 37183684 DOI: 10.1080/14656566.2023.2214677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Everolimus is an oral drug that inhibits mTOR with immunosuppressive and antiproliferative characteristics. It is commonly used in association with exemestane in hormone receptor (HR)-positive advanced breast cancer (ABC). AREAS COVERED The current review summarizes the publications relating to everolimus from clinical research in breast cancer. Everolimus showed treatment efficacy and an acceptable safety tolerance with prevention of side effects in Phase II/III studies. BOLERO-2 study showed a progression-free survival improvement in patients with HR-positive ABC previously treated with aromatase inhibitors (AI) and leading to its acceptance in this indication. The absence of a post CDK4/6 inhibitor (CDK4/6i.) study and the arrival of new drugs may raise questions about its current place in the therapeutic strategy. EXPERT OPINION Everolimus is relevant in the management of HR-positive ABC. Because of its efficacy, acceptable tolerability and the absence of drugs that have shown a greater benefit, it remains a second-line treatment option in HR-positive, HER2 negative (score 0) patients without BRCA mutation or visceral crisis and can be discuss with fulvestrant in second line after CDK4-6i. It is likely that within 5 years this treatment will be replaced in second line HR-positive breast cancer by new emerging treatments: drug-conjugated antibodies, tyrosine kinase inhibitors or immunotherapy in combination with chemotherapy.
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Affiliation(s)
| | - Marie Robert
- ICO Centre René Gauducheau, Oncology, Nantes, France
| | | | | | | | | | - Mario Campone
- ICO Centre René Gauducheau, Oncology, Nantes, France
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Moscetti L, Sperduti I, Frassoldati A, Musolino A, Nasso C, Toss A, Omarini C, Dominici M, Piacentini F. Quality of life of therapies for hormone receptor positive advanced/metastatic breast cancer: Regulatory aspects and clinical impact in Europe. Breast 2021; 59:232-238. [PMID: 34304064 PMCID: PMC8327134 DOI: 10.1016/j.breast.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 11/22/2022] Open
Abstract
In recent years, the number of trials incorporating health-related quality of life (HRQoL) data has increased. The impact of HRQoL on regulatory decision making in the European context and on clinical practice is not well established. We conducted an analysis of the role of QoL data extracted from the clinical trials of the drugs approved for hormone receptor positive/HER2-negative advanced/metastatic breast cancer (mBC). The results from the HRQoL were collected and a meta-analysis was performed to evaluate the impact of experimental drugs compared to standard treatments. The results showed a non-detrimental effect in HRQoL from the new treatments. As regards the approval process, from an examination of the European Medicine Agency (EMA) documents, HRQoL was reported nonextensively and contained and discussed in the European assessment reports (EPARs) for eleven trials in the approval process and cited in three cases in the EPARs and summary of medicinal product characteristics (SmPC). An effort should be made by all the stakeholders to increase the visibility of the HRQoL results in order to allow increased consideration in the approval process to make QoL data more easily and visibly available for the clinician and the patients. The evaluation should be reflected in the SmPC in order to increase the amount of information provided to the physician.
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Affiliation(s)
- L Moscetti
- Department of Oncology-Hematology, University Hospital of Modena, Modena, Italy; Gruppo Oncologico Italiano per la Ricerca Clinica (GOIRC), Italy.
| | - I Sperduti
- Department of Bio-Statistics, RCCS Regina Elena National Cancer Institute, Italy
| | - A Frassoldati
- Department of Oncology, Ospedale Sant'Anna di Cona, Ferrara, Italy; Gruppo Oncologico Italiano per la Ricerca Clinica (GOIRC), Italy
| | - A Musolino
- Medical Oncology and Breast Unit, University Hospital of Parma, Department of Medicine and Surgery, University of Parma, Parma, Italy; Gruppo Oncologico Italiano per la Ricerca Clinica (GOIRC), Italy
| | - C Nasso
- Department of Oncology-Hematology, University Hospital of Modena, Modena, Italy; Division of Medical Oncology, Department of Medical and Surgical Sciences for Children & Adults, University Hospital of Modena, Modena, Italy
| | - A Toss
- Department of Oncology-Hematology, University Hospital of Modena, Modena, Italy; Division of Medical Oncology, Department of Medical and Surgical Sciences for Children & Adults, University Hospital of Modena, Modena, Italy
| | - C Omarini
- Department of Oncology-Hematology, University Hospital of Modena, Modena, Italy; Gruppo Oncologico Italiano per la Ricerca Clinica (GOIRC), Italy
| | - M Dominici
- Division of Medical Oncology, Department of Medical and Surgical Sciences for Children & Adults, University Hospital of Modena, Modena, Italy
| | - F Piacentini
- Division of Medical Oncology, Department of Medical and Surgical Sciences for Children & Adults, University Hospital of Modena, Modena, Italy; Gruppo Oncologico Italiano per la Ricerca Clinica (GOIRC), Italy
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Safa H, Tamil M, Spiess PE, Manley B, Pow-Sang J, Gilbert SM, Safa F, Gonzalez BD, Oswald LB, Semaan A, Diab A, Chahoud J. Patient-Reported Outcomes in Clinical Trials Leading to Cancer Immunotherapy Drug Approvals From 2011 to 2018: A Systematic Review. J Natl Cancer Inst 2020; 113:532-542. [PMID: 33146385 DOI: 10.1093/jnci/djaa174] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/23/2020] [Accepted: 10/19/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Patient-reported outcomes (PROs) promote patient centeredness in clinical trials; however, in the field of rapidly emerging and clinically impressive immunotherapy, data on PROs are limited. METHODS We systematically identified all immunotherapy approvals from 2011 through 2018 and assessed the analytic tools and reporting quality of associated PRO reports. For randomized clinical trials (RCTs), we developed a novel 24-point scoring scale: the PRO Endpoints Analysis Score based on 24 criteria derived from the recommendations of the Setting International Standards in Analyzing Patient-Reported Outcomes and Quality of Life Endpoints Data Consortium. RESULTS We assessed 44 trial publications supporting 42 immunotherapy approvals. PROs were published for 21 of the 44 (47.7%) trial publications. Twenty-three trials (52.3%) were RCTs and 21 (47.7%) pertained to single-arm trials. The median time between primary clinical outcomes publications and their corresponding secondary PRO publications was 19 months (interquartile range = 9-29 months). Of the 21 PRO reports, 4 (19.0%) reported a specific hypothesis, and most (85.7%) used descriptive statistics. Three (3 of 21 [14.3%]) studies performed a control for type I error. As for RCTs, 14 of 23 (60.9%) published PRO data, including 13 (56.5%) that published a secondary dedicated manuscript. One-half of these 14 trials scored less than 13 points on the 24-point PRO Endpoints Analysis Score. The mean score was 12.71 (range = 5-17, SD = 3.71), and none met all the recommendations of the Setting International Standards in Analyzing Patient-Reported Outcomes and Quality of Life Endpoints Data Consortium. CONCLUSIONS Suboptimal reporting of PROs occurs regularly in cancer immunotherapy trials. Increased efforts are needed to maximize the value of these data in cancer immunotherapy development and approval.
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Affiliation(s)
- Houssein Safa
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Monica Tamil
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Brandon Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Julio Pow-Sang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Firas Safa
- John W. Deming Department of Medicine, Section of Hematology and Medical Oncology, Tulane University, New Orleans, LA, USA
| | - Brian D Gonzalez
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Laura B Oswald
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Adele Semaan
- Participant Research, Interventions, and Measurements Core, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Adi Diab
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jad Chahoud
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Rugo HS, Diéras V, Gelmon KA, Finn RS, Slamon DJ, Martin M, Neven P, Shparyk Y, Mori A, Lu DR, Bhattacharyya H, Bartlett CHUANG, Iyer S, Johnston S, Ettl J, Harbeck N. Impact of palbociclib plus letrozole on patient-reported health-related quality of life: results from the PALOMA-2 trial. Ann Oncol 2019; 29:888-894. [PMID: 29360932 PMCID: PMC5913649 DOI: 10.1093/annonc/mdy012] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Patient-reported outcomes are integral in benefit-risk assessments of new treatment regimens. The PALOMA-2 study provides the largest body of evidence for patient-reported health-related quality of life (QOL) for patients with metastatic breast cancer (MBC) receiving first-line endocrine-based therapy (palbociclib plus letrozole and letrozole alone). Patients and methods Treatment-naïve postmenopausal women with estrogen receptor-positive (ER+)/human epidermal growth factor receptor 2-negative (HER2-) MBC were randomized 2 : 1 to palbociclib plus letrozole (n = 444) or placebo plus letrozole (n = 222). Patient-reported outcomes were assessed at baseline, day 1 of cycles 2 and 3, and day 1 of every other cycle from cycle 5 using the Functional Assessment of Cancer Therapy (FACT)-Breast and EuroQOL 5 dimensions (EQ-5D) questionnaires. Results As of 26 February 2016, the median duration of follow-up was 23 months. Baseline scores were comparable between the two treatment arms. No significant between-arm differences were observed in change from baseline in FACT-Breast Total, FACT-General Total, or EQ-5D scores. Significantly greater improvement in pain scores was observed in the palbociclib plus letrozole arm (-0.256 versus -0.098; P = 0.0183). In both arms, deterioration of FACT-Breast Total score was significantly delayed in patients without progression versus those with progression and patients with partial or complete response versus those without. No significant difference was observed in FACT-Breast and EQ-5D index scores in patients with and without neutropenia. Conclusions Overall, women with MBC receiving first-line endocrine therapy have a good QOL. The addition of palbociclib to letrozole maintains health-related QOL and improves pain scores in treatment-naïve postmenopausal patients with ER+/HER2- MBC compared with letrozole alone. Significantly greater delay in deterioration of health-related QOL was observed in patients without progression versus those who progressed and in patients with an objective response versus non-responders. ClinicalTrials.gov: NCT01740427 (https://clinicaltrials.gov/ct2/show/NCT01740427).
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Affiliation(s)
- H S Rugo
- Department of Medicine (Hematology/Oncology), University of California San Francisco Comprehensive Cancer Center, San Francisco, USA.
| | - V Diéras
- Department of Medical Oncology, Institut Curie, Paris, France
| | - K A Gelmon
- Department of Medical Oncology, British Columbia Cancer Agency-Vancouver Centre, Vancouver, Canada
| | - R S Finn
- Division of Hematology/Oncology, University of California, Los Angeles, USA
| | - D J Slamon
- Division of Hematology/Oncology, University of California, Los Angeles, USA
| | - M Martin
- Medical Oncology Service, Instituto de Investigación Sanitaria Gregorio Marañón, GEICAM, Universidad Complutense, Madrid, Spain
| | - P Neven
- Department of Oncology, Universitair Ziekenhuis Leuven-Campus Gasthuisberg, Leuven, Belgium
| | - Y Shparyk
- Department of Chemotherapy, Lviv State Oncologic Regional Treatment and Diagnostic Center, Lviv, Ukraine
| | - A Mori
- Global Product Developmen, Clinical, Pfizer s.r.l., Milan, Italy
| | - D R Lu
- Global Product Developmen, Statistics, Pfizer Inc., La Jolla, USA
| | | | | | - S Iyer
- Global Outcomes and Evidence, Pfizer Inc., New York, USA
| | - S Johnston
- Department of Medical Oncology, The Royal Marsden NHS Foundation, London, UK
| | - J Ettl
- Department of Obstetrics and Gynecology, Frauenklinik und Poliklinik Klinikum Rechts der Isar, Technische Universität München, München, Germany
| | - N Harbeck
- Department of Obstetrics and Gynecology, Brustzentrum der Universität München (LMU), München, Germany
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Pe M, Dorme L, Coens C, Basch E, Calvert M, Campbell A, Cleeland C, Cocks K, Collette L, Dirven L, Dueck AC, Devlin N, Flechtner HH, Gotay C, Griebsch I, Groenvold M, King M, Koller M, Malone DC, Martinelli F, Mitchell SA, Musoro JZ, Oliver K, Piault-Louis E, Piccart M, Pimentel FL, Quinten C, Reijneveld JC, Sloan J, Velikova G, Bottomley A; Setting International Standards in Analyzing Patient-Reported Outcomes and Quality of Life Endpoints Data Consortium (SISAQOL). Statistical analysis of patient-reported outcome data in randomised controlled trials of locally advanced and metastatic breast cancer: a systematic review. Lancet Oncol 2018; 19:e459-69. [PMID: 30191850 DOI: 10.1016/S1470-2045(18)30418-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/25/2018] [Accepted: 05/29/2018] [Indexed: 12/25/2022]
Abstract
Although patient-reported outcomes (PROs), such as health-related quality of life, are important endpoints in randomised controlled trials (RCTs), there is little consensus about the analysis, interpretation, and reporting of these data. We did a systematic review to assess the variability, quality, and standards of PRO data analyses in advanced breast cancer RCTs. We searched PubMed for English language articles published in peer-reviewed journals between Jan 1, 2001, and Oct 30, 2017. Eligible articles were those that reported PRO results from RCTs of adult patients with advanced breast cancer receiving anti-cancer treatments with reported sample sizes of at least 50 patients-66 RCTs met the selection criteria. Only eight (12%) RCTs reported a specific PRO research hypothesis. Heterogeneity in the statistical methods used to assess PRO data was observed, with a mixture of longitudinal and cross-sectional techniques. Not all articles addressed the problem of multiple testing. Fewer than half of RCTs (28 [42%]) reported the clinical significance of their findings. 48 (73%) did not report how missing data were handled. Our systematic review shows a need to improve standards in the analysis, interpretation, and reporting of PRO data in cancer RCTs. Lack of standardisation makes it difficult to draw robust conclusions and compare findings across trials. The Setting International Standards in the Analyzing Patient-Reported Outcomes and Quality of Life Data Consortium was set up to address this need and develop recommendations on the analysis of PRO data in RCTs.
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Zhou Z, Tang DH, Xie J, Ayyagari R, Wu E, Niravath PA. Systematic Literature Review of the Impact of Endocrine Monotherapy and in Combination with Targeted Therapy on Quality of Life of Postmenopausal Women with HR+/HER2- Advanced Breast Cancer. Adv Ther 2017; 34:2566-2584. [PMID: 29143928 DOI: 10.1007/s12325-017-0644-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Indexed: 12/22/2022]
Abstract
INTRODUCTION A major treatment goal for advanced breast cancer (ABC) is to maintain or ideally improve patient quality of life (QoL). Given the changing disease landscape, this systematic literature review (SLR) aims to assess the impact of endocrine therapies (ET), including ET monotherapy (ET mono) and ET combined with targeted therapy (ET + TT), on QoL of women with HR+/HER2- ABC. METHODS A SLR was conducted to identify randomized controlled trials (RCTs) meeting the following criteria: (1) included ET mono or ET + TT, (2) reported QoL outcomes, (3) focused on women with HR+/HER2- ABC, and (4) published after 2007 (when standardized HER2 testing became available). The databases searched included MEDLINE, EMBASE, Cochrane Library, and key conference proceedings from 2013 to 2016. QoL outcomes for ET mono, ET + TT, and comparisons between the two were summarized from the identified trials. RESULTS A total of 11 studies (representing 6 RCTs) were identified. The study populations included first-line (5 studies) and ET-failure settings (6 studies). Across settings, global health status (GHS) maintained or deteriorated slightly on these treatments during the trial period. Time to deterioration (TTD) in QoL measured by GHS was analyzed in 6 studies and 4 RCTs. In the first-line setting, reported median TTD in GHS was similar between ET mono and ET + TT (7.2-13.8 months in ET mono; 11.1 months in ET + TT). In the ET-failure setting, ET + TT showed significantly longer TTD vs. ET mono in GHS (median 5.6-8.4 months in ET mono and 8.3-11.7 months in ET + TT) and some additional domains. CONCLUSIONS ET + TT users experienced similar QoL in the first-line and ET-failure setting relative to patients on ET mono. Moreover, ET + TT users experienced better QoL outcomes in some domains in the ET-failure setting relative to ET mono users. FUNDING Novartis.
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Augereau P, Patsouris A, Bourbouloux E, Gourmelon C, Abadie Lacourtoisie S, Berton Rigaud D, Soulié P, Frenel JS, Campone M. Hormonoresistance in advanced breast cancer: a new revolution in endocrine therapy. Ther Adv Med Oncol 2017; 9:335-346. [PMID: 28529550 PMCID: PMC5424863 DOI: 10.1177/1758834017693195] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 01/16/2017] [Indexed: 11/17/2022] Open
Abstract
Endocrine therapy is the mainstay of treatment of estrogen-receptor-positive (ER+) breast cancer with an overall survival benefit. However, some adaptive mechanisms in the tumor emerge leading to the development of a resistance to this therapy. A better characterization of this process is needed to overcome this resistance and to develop new tailored therapies. Mechanisms of resistance to hormone therapy result in activation of transduction signal pathways, including the cell cycle regulation with cyclin D/CDK4/6/Rb pathway. The strategy of combined hormone therapy with targeted agents has shown an improvement of progression-free survival (PFS) in several phase II or III trials, including three different classes of drugs: mTOR inhibitors, PI3K and CDK4/6 inhibitors. A recent phase III trial has shown that fulvestrant combined with a CDK 4/6 inhibitor doubles PFS in aromatase inhibitor-pretreated postmenopausal ER+ breast cancer. Other combinations are ongoing to disrupt the interaction between PI3K/AKT/mTOR and cyclin D/CDK4/6/Rb pathways. Despite these successful strategies, reliable and reproducible biomarkers are needed. Tumor genomics are dynamic over time, and blood-based biomarkers such as circulating tumor DNA represent a major hope to elucidate the adaptive mechanisms of endocrine resistance. The optimal combinations and biomarkers to guide this strategy need to be determined.
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Affiliation(s)
- Paule Augereau
- Department of Medical Oncology, Institut cancerologie de l'ouest site Paul Papin, 15 rue Andre Bocquel 49055 Angers Cedex 02, France
| | - Anne Patsouris
- Department of Medical Oncology, Institut cancerologie de l'ouest site Paul Papin, France
| | - Emmanuelle Bourbouloux
- Department of Medical Oncology, Institut cancerologie de l'ouest site René Gauducheau, Saint Herblain, France
| | - Carole Gourmelon
- Department of Medical Oncology, Institut cancerologie de l'ouest site René Gauducheau, Saint Herblain, France
| | | | - Dominique Berton Rigaud
- Department of Medical Oncology, Institut cancerologie de l'ouest site René Gauducheau, Saint Herblain, France
| | - Patrick Soulié
- Department of Medical Oncology, Institut cancerologie de l'ouest site Paul Papin, France
| | - Jean Sebastien Frenel
- Department of Medical Oncology, Institut cancerologie de l'ouest site René Gauducheau, Saint Herblain, France
| | - Mario Campone
- Department of Medical Oncology, Institut cancerologie de l'ouest site Paul Papin, France Department of Medical Oncology, Institut cancerologie de l'ouest site René Gauducheau, Saint Herblain, France
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Pritchard KI, Chia SK, Simmons C, McLeod D, Paterson A, Provencher L, Rayson D. Enhancing Endocrine Therapy Combination Strategies for the Treatment of Postmenopausal HR+/HER2- Advanced Breast Cancer. Oncologist 2016; 22:12-24. [PMID: 27864574 DOI: 10.1634/theoncologist.2016-0185] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 09/01/2016] [Indexed: 01/16/2023] Open
Abstract
Breast cancer (BC) is the most common malignancy in women worldwide, with approximately two-thirds having hormone receptor-positive (HR+) tumors. New endocrine therapy (ET) strategies include combining ET agents as well as adding inhibitors targeting growth factors, angiogenesis, the mechanistic target of rapamycin, phosphoinositide 3-kinase (PI3K), or cyclin-dependent kinase 4/6 to ET. Level 1 evidence supports use of fulvestrant plus anastrozole or palbociclib plus letrozole as first-line therapy for HR+/HER- advanced BC with special consideration for the former in ET-naïve patients, as well as everolimus plus exemestane or palbociclib plus fulvestrant as second-line therapy with special consideration in select first-line patients. Although the safety profiles of these combinations are generally predictable and manageable, both everolimus and palbociclib are associated with an increased risk of potentially serious or early-onset toxicities requiring individualized a priori adverse event risk stratification, earlier and more rigorous agent-specific monitoring, and patient education. Although each of these combinations improves progression-free survival, none with the exception of anastrazole plus fulvestrant have demonstrated improved overall survival. PI3K catalytic-α mutations assessed from circulating tumor DNA represent the first potentially viable serum biomarker for the selection of ET combinations, and new data demonstrate the feasibility of this minimally invasive technique as an alternative to traditional tissue analysis. Therapeutic ratios of select ET combinations support their use in first- and second-line settings, but optimal sequencing has yet to be determined. THE ONCOLOGIST 2017;22:12-24 IMPLICATIONS FOR PRACTICE: Emerging data show that new endocrine therapy (ET) combinations can improve progression-free and overall survival outcomes in patients with hormone receptor-positive, HER2-negative (HR+/HER-) advanced breast cancer. Level 1 evidence supports consideration of dual ET regimens, particularly in ET-naïve patients, or palbociclib plus letrozole as first-line therapy, as well as the addition of mTOR or CDK4/6 inhibitors to established ET in the second-line setting and in select first-line patients. Some combinations are associated with increased risk of class-specific toxicities that will require individualized risk stratification, earlier and more rigorous agent-specific monitoring, and patient education. Recent data on a noninvasive biomarker assay that predicts response to a phosphoinositide 3-kinase inhibitor demonstrates the feasibility of this minimally invasive technique as an alternative to traditional tissue analysis.
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Affiliation(s)
- Kathleen I Pritchard
- Sunnybrook Odette Cancer Centre and University of Toronto, Toronto, Ontario, Canada
| | - Stephen K Chia
- British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | | | - Deanna McLeod
- Kaleidoscope Strategic, Inc., Toronto, Ontario, Canada
| | | | | | - Daniel Rayson
- Division of Medical Oncology, Dalhousie University, and Atlantic Clinical Cancer Research Unit, Halifax, Nova Scotia, Canada
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Bottomley A, Pe M, Sloan J, Basch E, Bonnetain F, Calvert M, Campbell A, Cleeland C, Cocks K, Collette L, Dueck AC, Devlin N, Flechtner HH, Gotay C, Greimel E, Griebsch I, Groenvold M, Hamel JF, King M, Kluetz PG, Koller M, Malone DC, Martinelli F, Mitchell SA, Moinpour CM, Musoro J, O'Connor D, Oliver K, Piault-Louis E, Piccart M, Pimentel FL, Quinten C, Reijneveld JC, Schürmann C, Smith AW, Soltys KM, Taphoorn MJB, Velikova G, Coens C; Setting International Standards in Analyzing Patient-Reported Outcomes and Quality of Life Endpoints Data (SISAQOL) consortium. Analysing data from patient-reported outcome and quality of life endpoints for cancer clinical trials: a start in setting international standards. Lancet Oncol 2016; 17:e510-4. [PMID: 27769798 DOI: 10.1016/S1470-2045(16)30510-1] [Citation(s) in RCA: 136] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/16/2016] [Accepted: 09/19/2016] [Indexed: 11/22/2022]
Abstract
Measures of health-related quality of life (HRQOL) and other patient-reported outcomes generate important data in cancer randomised trials to assist in assessing the risks and benefits of cancer therapies and fostering patient-centred cancer care. However, the various ways these measures are analysed and interpreted make it difficult to compare results across trials, and hinders the application of research findings to inform publications, product labelling, clinical guidelines, and health policy. To address these problems, the Setting International Standards in Analyzing Patient-Reported Outcomes and Quality of Life Endpoints Data (SISAQOL) initiative has been established. This consortium, directed by the European Organisation for Research and Treatment of Cancer (EORTC), was convened to provide recommendations on how to standardise the analysis of HRQOL and other patient-reported outcomes data in cancer randomised trials. This Personal View discusses the reasons why this project was initiated, the rationale for the planned work, and the expected benefits to cancer research, patient and provider decision making, care delivery, and policy making.
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Turner-Bowker DM, Hao Y, Foley C, Galipeau N, Mazar I, Krohe M, Globe D, Shields AL. The use of patient-reported outcomes in advanced breast cancer clinical trials: a review of the published literature. Curr Med Res Opin 2016; 32:1709-17. [PMID: 27331272 DOI: 10.1080/03007995.2016.1205005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE As a means to measure quantifiable signs, symptoms, and impacts of a disease or its treatment, patient-reported outcome (PRO) instruments can be applied to numerous settings, including use in drug development to support labeling claims. This research summarizes the use of PROs in trials for 16 commonly used regulatory approved treatments for advanced or metastatic breast cancer. METHODS For each treatment (n = 16), a literature search was conducted in MEDLINE, Embase, and PsycINFO. The primary criterion for selection was the report of studies that used PROs to evaluate treatment benefit and/or toxicity in advanced or metastatic breast cancer. From this, a sub-set of articles for each treatment were selected for full-text review where PRO-related information was extracted and summarized. RESULTS The searches yielded 1727 publications. Following abstract review, 1702 were excluded because they failed to meet criteria, or were duplicates or less relevant for PRO information reported. Thus, 25 articles were reviewed in detail for this evaluation. Eleven PRO instruments were identified from these publications. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Core (EORTC QLQ-C30) was utilized the most frequently (n = 13, 52.0%). Most publications reported PROs positioned as secondary endpoints (n = 20, 80.0%); described some of the statistical analyses applied to PRO data (n = 21, 84.0%); and specified PRO results (n = 23, 92.0%). CONCLUSIONS While several of the publications provided some information on how PROs were utilized, many did not describe details for PRO administration, scoring, analyses, and results interpretation. While it is encouraging that PROs are often used in clinical trials for patients with metastatic breast cancer, they are not commonly used to support endpoints that establish the basis for label claims. Because they yield direct insight into the patient experience of a condition, PROs may be used to provide a more comprehensive perspective of the benefits and risks from treatment.
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Affiliation(s)
| | - Yanni Hao
- b Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
| | | | | | | | | | - Denise Globe
- b Novartis Pharmaceuticals Corporation , East Hanover , NJ , USA
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12
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Steelman LS, Martelli AM, Cocco L, Libra M, Nicoletti F, Abrams SL, McCubrey JA. The therapeutic potential of mTOR inhibitors in breast cancer. Br J Clin Pharmacol 2016; 82:1189-1212. [PMID: 27059645 DOI: 10.1111/bcp.12958] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/29/2016] [Accepted: 03/31/2016] [Indexed: 12/16/2022] Open
Abstract
Rapamycin and modified rapamycins (rapalogs) have been used to prevent allograft rejection after organ transplant for over 15 years. The mechanistic target of rapamycin (mTOR) has been determined to be a key component of the mTORC1 complex which consists of the serine/threonine kinase TOR and at least five other proteins which are involved in regulating its activity. Some of the best characterized substrates of mTORC1 are proteins which are key kinases involved in the regulation of cell growth (e.g., p70S6K) and protein translation (e.g., 4E-BP1). These proteins may in some cases serve as indicators to sensitivity to rapamycin-related therapies. Dysregulation of mTORC1 activity frequently occurs due to mutations at, or amplifications of, upstream growth factor receptors (e.g., human epidermal growth factor receptor-2, HER2) as well as kinases (e.g., PI3K) and phosphatases (e.g., PTEN) critical in the regulation of cell growth. More recently, it has been shown that certain rapalogs may enhance the effectiveness of hormonal-based therapies for breast cancer patients who have become resistant to endocrine therapy. The combined treatment of certain rapalogs (e.g., everolimus) and aromatase inhibitors (e.g., exemestane) has been approved by the United States Food and Drug Administration (US FDA) and other drug regulatory agencies to treat estrogen receptor positive (ER+) breast cancer patients who have become resistant to hormonal-based therapies and have progressed. This review will summarize recent basic and clinical research in the area and evaluate potential novel therapeutic approaches.
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Affiliation(s)
- Linda S Steelman
- Department of Microbiology and Immunology, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Alberto M Martelli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Lucio Cocco
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Massimo Libra
- Department of Biomedical and Biotechnological Sciences, Laboratory of Translational Oncology & Functional Genomics, Section of Pathology & Oncology, University of Catania, Catania, Italy
| | - Ferdinando Nicoletti
- Department of Biomedical and Biotechnological Sciences, Laboratory of Translational Oncology & Functional Genomics, Section of Pathology & Oncology, University of Catania, Catania, Italy
| | - Stephen L Abrams
- Department of Microbiology and Immunology, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - James A McCubrey
- Department of Microbiology and Immunology, Brody School of Medicine at East Carolina University, Greenville, NC, USA.
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13
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Li N, Hao Y, Xie J, Lin PL, Koo V, Ohashi E, Wu EQ. Everolimus-Based Therapy versus Chemotherapy among Patients with HR+/HER2- Metastatic Breast Cancer: Comparative Effectiveness from a Chart Review Study. Int J Breast Cancer 2015; 2015:240750. [PMID: 26078883 DOI: 10.1155/2015/240750] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/23/2015] [Accepted: 04/24/2015] [Indexed: 11/17/2022] Open
Abstract
Objective. To compare the real-world effectiveness of everolimus-based therapy and chemotherapy in postmenopausal women with hormone-receptor-positive/human-epidermal-growth-factor-receptor-2-negative (HR+/HER2−) metastatic breast cancer (mBC). Methods. This retrospective chart review examined a nationwide sample of postmenopausal HR+/HER2− mBC women in community-based oncology practices. Patients received everolimus-based therapy or chemotherapy for mBC between 07/01/2012 and 04/15/2013, after failure of a non-steroidal aromatase inhibitor. Overall survival (OS), progression-free survival (PFS), and time on treatment (TOT) were compared using Kaplan-Meier analysis and Cox proportional hazards models adjusting for line of therapy and baseline characteristics. Results. 234 and 137 patients received everolimus-based therapy and chemotherapy. Patients treated with everolimus-based therapy tended to have less aggressive mBC than patients treated with chemotherapy. Multivariate-adjusted Cox models showed that everolimus-based therapy was associated with significantly longer OS [hazard ratio (HR) = 0.37, 95% confidence interval (CI): 0.22–0.63], PFS (HR = 0.70, 95% CI = 0.50–0.97), and TOT (HR = 0.34, 95% CI: 0.25–0.45) than chemotherapy. Adjusted comparative effectiveness results were generally consistent across lines of therapy. Conclusion. In this retrospective chart review of postmenopausal HR+/HER2− mBC patients, treatment with everolimus-based therapy was associated with longer OS, PFS, and TOT than chemotherapy.
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14
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Generali D, Venturini S, Rognoni C, Ciani O, Pusztai L, Loi S, Jerusalem G, Bottini A, Tarricone R. A network meta-analysis of everolimus plus exemestane versus chemotherapy in the first- and second-line treatment of estrogen receptor-positive metastatic breast cancer. Breast Cancer Res Treat 2015; 152:95-117. [PMID: 26044370 DOI: 10.1007/s10549-015-3453-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 05/28/2015] [Indexed: 01/09/2023]
Abstract
The goal of this study was to compare the efficacy and toxicity of chemotherapy to exemestane plus everolimus (EXE/EVE) through a network meta-analysis (NMA) of randomized controlled trials. NMA methods extend standard pairwise meta-analysis to allow simultaneous comparison of multiple treatments while maintaining randomization of individual studies. The method enables "direct" evidence (i.e., evidence from studies directly comparing two interventions) and "indirect" evidence (i.e., evidence from studies that do not compare the two interventions directly) to be pooled under the assumption of evidence consistency. We used NMA to evaluate progression-free survival (PFS) and time to progression (TTP) curves in 34 studies, and response rate (RR) and the hazard ratios (HRs) of the PFS/TTP in 36 studies. A number needed to treat (NNT) analysis was also performed as well as descriptive comparison of reported toxicities. The NMA for PFS/TTP curves and for HR shows EXE/EVE is more efficacious than capecitabine plus sunitinib, CMF, megestrol acetate and tamoxifen, with an average of related-PFS/TTP difference ranging from about 10 months for capecitabine plus sunitinib to more than 6 months for tamoxifen. The NMA for overall RR shows that EXE/EVE provides a better RR than bevacizumab plus capecitabine, capecitabine, capecitabine plus sorafenib, capecitabine plus sunitinib, CMF, gemcitabine plus epirubicin plus paclitaxel, EVE plus tamoxifen, EXE, FEC, megestrol acetate, mitoxantrone, and tamoxifen. Finally, the NMA for NNT shows that EXE/EVE is more beneficial as compared to BMF, capecitabine, capecitabine plus sunitinib, CMF, FEC, megestrol acetate, mitoxantrone, and tamoxifen. The combination of EXE/EVE as first- or second-line therapy for ER+ve/HER2-ve metastatic breast cancer is more efficacious than several chemotherapy regimens that were reported in the literature. Toxicities also favored EXE/EVE in most instances.
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Affiliation(s)
- Daniele Generali
- U.O. di Patologia Mammaria-Breast Cancer Unit, U.S. Terapia Molecolare e Farmacogenomica, AO-Istituti Ospitalieri di Cremona, Viale Concordia 1, 26100, Cremona, Italy.
| | - Sergio Venturini
- Centre for Research on Health and Social Care Management (CeRGAS), Bocconi University, Via Roentgen 1, Milan, Italy
| | - Carla Rognoni
- Centre for Research on Health and Social Care Management (CeRGAS), Bocconi University, Via Roentgen 1, Milan, Italy
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management (CeRGAS), Bocconi University, Via Roentgen 1, Milan, Italy
| | - Lajos Pusztai
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, United States
| | - Sherene Loi
- Translational Breast Cancer Genomics and Therapeutics Lab, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - Guy Jerusalem
- Centre Hospitalier Universitaire du Sart Tilman Liege and Liege University, Liège, Belgium
| | - Alberto Bottini
- U.O. di Patologia Mammaria-Breast Cancer Unit, U.S. Terapia Molecolare e Farmacogenomica, AO-Istituti Ospitalieri di Cremona, Viale Concordia 1, 26100, Cremona, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CeRGAS), Bocconi University, Via Roentgen 1, Milan, Italy.,Department of Policy Analysis and Public Management, Bocconi University, Via Roentgen 1, Milan, Italy
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Hortobagyi GN. Everolimus plus exemestane for the treatment of advanced breast cancer: a review of subanalyses from BOLERO-2. Neoplasia 2015; 17:279-88. [PMID: 25810012 PMCID: PMC4372651 DOI: 10.1016/j.neo.2015.01.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/19/2015] [Accepted: 01/23/2015] [Indexed: 02/07/2023]
Abstract
Hormone receptor-positive breast cancer is typically managed with endocrine therapies. However, resistance to endocrine therapy results in disease progression in a large proportion of breast cancers. Through the understanding of the mechanisms of endocrine resistance, identification of implicated pathways and targets has led to the development of novel agents targeting these pathways. Phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin (PI3K/AKT/mTOR) pathway aberrations are common in breast cancer, with increased PI3K/AKT/mTOR signaling associated with resistance to endocrine and human epidermal growth factor receptor 2 (HER2)-targeted therapies. The mTOR inhibitor everolimus, in combination with exemestane, has been approved for patients with advanced hormone receptor-positive/HER2-negative breast cancer who progress on prior nonsteroidal aromatase inhibitor therapy based on results reported in the Breast Cancer Trials of Oral Everolimus-2 (BOLERO-2) study. This review will summarize the overall findings from BOLERO-2 and will consider available subanalyses by age, Asian origin, visceral or bone metastases, and prior therapy, with the aim of identifying populations most likely to benefit from everolimus therapy. The review will also summarize safety findings and their management and the effects of everolimus on quality of life.
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Key Words
- ae, adverse event
- bsap, bone-specific alkaline phosphatase
- cbr, clinical benefit rate
- cr, complete response
- ctx, c-terminal cross-linking telopeptide of type 1 collagen
- her2, human epidermal growth factor receptor 2
- hr, hazard ratio
- nip, noninfectious pneumonitis
- orr, objective response rate
- pi3k/akt/mtor, phosphoinositide 3-kinase/protein kinase b/mammalian target of rapamycin
- pfs, progression-free survival
- p1np, amino-terminal propeptide of type 1 collagen
- pr, partial response
- qol, quality of life
- tdd, time to definitive deterioration
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Affiliation(s)
- Gabriel N Hortobagyi
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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16
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Abstract
Endocrine therapy is an important treatment option for women with hormone receptor-positive (HR+) advanced breast cancer (ABC), yet many tumors are either intrinsically resistant or develop resistance to these therapies. Treatment of patients with ABC presenting with visceral metastases, which is associated with a poor prognosis, is also problematic. There is an unmet need for effective treatments for this patient population. Although chemotherapy is commonly perceived to be more effective than endocrine therapy in managing visceral metastases, patients who are not in visceral crisis might benefit from endocrine therapy, avoiding chemotherapy-associated toxicities that might affect quality of life. To improve outcomes, several targeted therapies are being investigated in combination with endocrine therapy for patients with endocrine-resistant, HR+ ABC. Although available data have considered patients with HR+ ABC as a whole, there are promising data from a prespecified analysis of a Phase III study of everolimus (Afinitor(®)), a mammalian target of rapamycin (mTOR) inhibitor, in combination with exemestane (Aromasin(®)) in patients with visceral disease progressing after nonsteroidal aromatase inhibitor therapy. In this review, challenges and treatment options for management of HR+ ABC with visceral disease, including consideration of therapeutic approaches undergoing clinical investigation, will be assessed.
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17
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Jerusalem G, Bachelot T, Barrios C, Neven P, Di Leo A, Janni W, de Boer R. A new era of improving progression-free survival with dual blockade in postmenopausal HR(+), HER2(-) advanced breast cancer. Cancer Treat Rev 2014; 41:94-104. [PMID: 25575443 DOI: 10.1016/j.ctrv.2014.12.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/17/2014] [Accepted: 12/19/2014] [Indexed: 01/05/2023]
Abstract
Disease progression despite existing endocrine therapies remains a major challenge to the effective management of hormone-receptor-positive (HR(+)), human epidermal growth factor receptor-2-negative (HER2(-)), advanced breast cancer. Recent advances in elucidating the molecular mechanisms of disease progression have identified the existence of adaptive "cross-talk" between the estrogen receptor (ER) and various growth factor receptor and intracellular signaling pathways, allowing breast cancer cells to escape the inhibitory effects of endocrine therapy. These findings provide the clinical rationale for enhancing or extending endocrine sensitivity by combining endocrine therapy with a targeted agent against a compensatory pathway. In BOLERO-2, adding the mTOR inhibitor everolimus to endocrine therapy significantly improved progression-free survival (PFS) in patients with HR(+) advanced breast cancer previously treated with nonsteroidal aromatase inhibitor therapy. Notably, PFS benefits were comparable in subgroup analyses of first- and later-line settings. These results contrast with those of the large first-line HORIZON study, wherein adding the mTOR inhibitor temsirolimus to endocrine therapy did not improve PFS. Therefore, it is unclear whether a targeted agent should only be combined with endocrine therapy to restore endocrine sensitivity or whether it may also prevent or delay resistance in hormone-sensitive advanced breast cancer. Numerous additional targeted agents are currently being evaluated in combination with endocrine therapies, including PI3K, cyclin-dependent kinase 4/6, SRC, and histone deacetylase inhibitors. Appropriate patient selection based on prior treatment history will become increasingly important in maximizing the incremental benefit derived from these new agents combined with existing endocrine therapies in HR(+) advanced breast cancer.
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Affiliation(s)
- Guy Jerusalem
- Centre Hospitalier Universitaire du Sart Tilman Liège and Liège University, Domaine Universitaire du Sart Tilman, B35, 4000 Liège, Belgium.
| | - Thomas Bachelot
- Centre de Recherche en Cancérologie de Lyon, Inserm U1052 CNRS 5286, Centre Léon Bérard, 28 rue Laënnec, 69373 LYON cedex 08, Lyon, France.
| | - Carlos Barrios
- PUCRS School of Medicine, Padre Chagas 66, 203, Porto Alegre, RS 90 570 080, Brazil.
| | | | - Angelo Di Leo
- Hospital of Prato, Istituto Toscani Tumori, Prato, Italy.
| | - Wolfgang Janni
- Women's Hospital, University of Ulm, Prittwitzstr. 43, D-89075 Ulm, Germany.
| | - Richard de Boer
- Royal Melbourne Hospital, Grattan St., Parkville, Melbourne 3050, Australia.
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Brufsky AM. Managing postmenopausal women with hormone receptor-positive advanced breast cancer who progress on endocrine therapies with inhibitors of the PI3K pathway. Breast J 2014; 20:347-57. [PMID: 24861776 DOI: 10.1111/tbj.12278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Although endocrine therapies that interfere with estrogen receptor (ER)-mediated signaling have revolutionized the management of postmenopausal women with hormone receptor-positive (HR+) breast cancer (BC), long-term management of these patients is suboptimal because of the eventual emergence of endocrine resistance. Intense research has elucidated a number of targets that act downstream or upstream of the ER, as well as those that crosstalk with the ER; however, clinical validation of inhibiting specific targets to overcome endocrine resistance has been lacking. The phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) pathway has been implicated to mediate endocrine resistance, and a number of novel agents that target this pathway are in early- and late-stage clinical trials. Recently, everolimus, an inhibitor of mTOR, a critical component of the PI3K/AKT/mTOR pathway, in combination with endocrine therapy, was shown to prolong progression-free survival with a manageable adverse-event profile in postmenopausal patients with HR+ BC. Bolstered by the safety and efficacy observed with concomitant inhibition of the ER and the PI3K/mTOR pathway and the validation of dual inhibition approach in managing postmenopausal patients with HR+ BC, a number of novel agents that inhibit PI3K (pan-PI3K inhibitors) or PI3K and mTOR (dual PI3K/mTOR) are being evaluated in clinical trials. Thus, mTOR inhibitors have provided the much-needed ammunition to oncologists who manage postmenopausal women with BC and have paved the way for the development of novel therapies that target the PI3K/mTOR pathway. Use of these novel therapies in managing postmenopausal women with BC, in combination with endocrine therapies, is expected to improve overall outcomes by overcoming endocrine resistance.
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Affiliation(s)
- Adam M Brufsky
- Magee-Women's Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Gilabert M, Launay S, Gonçalves A. [Exemestane-everolimus in HER2-negative, hormonal receptor-positive, post-menopausal metastatic breast cancer with resistance to non-steroidal aromatase inhibitor: a new option]. Bull Cancer 2014; 101:325-33. [PMID: 24691195 DOI: 10.1684/bdc.2014.1910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Phosphatidylinositol-3-kinase (PI3K)/Akt/mammalian target of rapamycin (mTOR) pathway is commonly deregulated in breast cancer and has been involved in resistance to endocrine therapy. In the BOLERO-2 study, the addition of everolimus, a selective inhibitor of mTOR protein, to exemestane was associated with a significant improvement in progression-free survival, compared to exemestane plus placebo, in patients with hormone receptor-positive, HER2-negative metastatic breast cancer, and resistant to non-steroidal aromatase inhibitor therapy. However, adverse events and treatment stops were more often observed with the combination therapy, suggesting the need for a careful benefit/risk evaluation before initiating this new combination. This review aims at synthesizing the biological basis of the everolimus-exemestane association, presenting the main validated and ongoing therapeutic trials, interests and limits, as well as the multiple potential therapeutic perspectives.
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