Abstract GS1-07: Results from a phase III randomized, placebo-controlled clinical trial evaluating adjuvant endocrine therapy +/- 1 year of everolimus in patients with high-risk hormone receptor-positive, HER2-negative breast cancer: SWOG S1207

BACKGROUND: Abnormalities of the PI3kinase/AKT/mTOR signaling network are common in breast cancer (BC) and are associated with endocrine resistance. Everolimus, an mTOR-inhibitor increased PFS when combined with endocrine therapy (ET) in the metastatic setting and is thought to revert endocrine resistance. S1207 is a phase III randomized, placebo-controlled trial evaluating the role of everolimus in combination with ET in the adjuvant setting among patients with high-risk hormone receptor-positive, HER2-negative BC (NCT01674140). METHODS: Eligible patients were >18 years of age with histologically confirmed invasive hormone receptor-positive and HER2-negative high-risk BC. Four risk groups were defined as: 1) > 2cm node-negative disease (or pN1mi), and either an Oncotype DX® Recurrence Score (RS) > 25 or MammaPrint® high-risk category (MP high); 2) 1-3 positive nodes and either RS >25, MP high or a pathological grade 3 tumor; 3) >4 positive lymph nodes. Patients treated with neoadjuvant chemotherapy were eligible if: 4) after surgery had >1 lymph node involvement. Patients were randomized 1:1 to physician’s choice adjuvant ET in combination with one year of everolimus (10 mg PO daily) or ET plus placebo stratified by risk group. The primary endpoint was invasive disease-free survival (IDFS) evaluated by a stratified log-rank test. Secondary endpoints included overall survival (OS) and safety. The hazard ratio (HR) for treatment efficacy was estimated using Cox regression with stratification by risk groups. Subset analyses included preplanned evaluation within risk group and exploratory analyses of menopausal status and age. RESULTS: 1,939 patients were randomized between September 2013 and May 2019, of them 1,792 were eligible and included in the analysis (896 per arm). Primary reason for ineligibility was timing after chemotherapy/radiation or not high risk. Median age was 54 years (22-85) and 32% were premenopausal. With a median follow-up of 50.5 months, there were 389 IDFS events as of May 2022 (data cutoff). 5-year IDFS was 74.8% among patients treated with everolimus and 73.9% among patients treated with placebo, HR=0.93 (95% CI 0.76-1.14). However, the proportional hazards assumption was violated (p=0.02) suggesting differential treatment effect over time. The HR during the one year of treatment was 0.72 (95% CI 0.47-1.10) while after one year it was 1.00 (95% CI 0.80-1.26). The 5-year OS was 87.6% in the everolimus arm and 85.5% in the placebo arm, HR=0.98 (95% CI 0.75-1.28). Analysis by risk group did not show higher everolimus benefit as risk increased. No difference in IDFS or OS was seen among postmenopausal patients (IDFS HR=1.08 [95% CI 0.85-1.36], OS HR=1.19 [95% CI 0.87-1.61]). Among premenopausal patients, everolimus was associated with improved IDFS (HR=0.63 [95% CI 0.43-0.93]) and OS (HR=0.48 [95% CI 0.26-0.88]). Treatment completion of randomized therapy was lower in the everolimus arm compared to placebo (47.9% v 72.7%). Grade 3 and 4 toxicities were noted in 6.5% and 0.5% of patients in the placebo arm and in 31.2% and 3.7% in the everolimus arm respectively. CONCLUSIONS: Addition of one year of adjuvant everolimus to standard adjuvant ET did not improve IDFS or OS and was associated with low completion rate and increased AEs. Among premenopausal patients there was a benefit in IDFS and OS that is hypothesis generating. Future translational studies will evaluate potential predictors of everolimus benefit and drug toxicity.

Citation Format: Marianna Chavez, Jieling Miao, Lajos Pusztai, Matthew P. Goetz, Priya Rastogi, Patricia A. Ganz, Eleftherios (Terry) Mamounas, Soonmyung Paik, Hanna Bandos, Wajeeha Razaq, Anne O’Dea, Virginia Kaklamani, Andrea L.M. Silber, Lisa E. Flaum, Eleni Andreopolu, Joseph Baar, Albert G. Wendt, Jennifer F. Carney, Priyanka Sharma, Julie R. Gralow, Danika L. Lew, William E. Barlow, Gabriel N. Hortobagyi. Results from a phase III randomized, placebo-controlled clinical trial evaluating adjuvant endocrine therapy +/- 1 year of everolimus in patients with high-risk hormone receptor-positive, HER2-negative breast cancer: SWOG S1207 [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr GS1-07.

Abstract PD12-08: PD12-08 Randomized trial of exercise and nutrition on pathological complete response among women with breast cancer receiving neoadjuvant chemotherapy: the Lifestyle, Exercise and Nutrition Early after Diagnosis (LEANer) Study

Background: Neoadjuvant chemotherapy is available to women with locally advanced breast cancer where chemotherapy is given prior to surgery. By examining resected tissue following neoadjuvant chemotherapy pathological complete response (pCR) can be determined. pCR is a favorable prognostic factor associated with longer survival compared to residual disease after neoadjuvant chemotherapy. Physical activity and diet may improve some side effects during treatment, but less is known about their effect on chemotherapy completion and more specifically on pCR in the neoadjuvant setting. Utilizing data from a randomized trial of diet and physical activity with a primary endpoint of chemotherapy completion in women with newly diagnosed breast cancer initiating chemotherapy, we evaluated the effect of a lifestyle intervention on pCR among the subset of women in the trial who received neoadjuvant chemotherapy. Methods: The Lifestyle, Exercise and Nutrition Early after Diagnosis (LEANer) Study enrolled 173 women with Stage I-III breast cancer who were randomized to usual care (n = 86) or a yearlong, 16-session, in-person or telephone-administered diet and physical activity intervention (n = 87) delivered by registered dietitians. Among study participants, 73 women received neoadjuvant chemotherapy and of these, 72 (98.6%) had complete follow-up pCR data (intervention = 40; usual care = 32). pCR, dates, doses and reason for dose-adjustments/delays of chemotherapy were abstracted from electronic medical records and confirmed with treating oncologists. A Chi-square test was used to examine the effect of the intervention versus usual care on pCR. Results: The 72 women receiving neoadjuvant chemotherapy with complete follow-up pCR data in LEANer were 49.4±11.6 years old, had a body mass index of 30.0+6.7 kg/m2, and 37.0% and 49.3% had stage I or II breast cancer, respectively. Just over half (52.1%) of women had ER/PR positive cancers and 32.9% of tumors were HER2 positive, with no statistically significant differences in tumor type by study arm. 92.7% of the women randomized to intervention adhered to all of the counseling sessions during their neoadjuvant chemotherapy and had statistically significant improvements in mean physical activity (161 minute increase versus 40 minute increase, p-value = < 0.001) and fiber intake (0.21 gram/day increase versus -5.17 g/day decrease, p-value = 0.020), as well as median fruit and vegetable intake (0.6 serving/day increase versus -0.5 serving/day decrease, p-value = 0.041) compared to usual care. There was a benefit of the intervention on pCR compared to usual care (52.5% with pCR in the intervention arm versus 28.1% with pCR in the usual care arm, p-value = 0.037). The intervention effect on pCR did not appear to be impacted by chemotherapy completion (relative dose intensity of 92% in intervention versus 90% in usual care) or chemotherapy dose delays as these were similar in the two study arms. In mediation analyses, results suggested that the changes in physical activity mediated, at least partially, the intervention effect on pCR. Conclusions: A primarily telephone-based diet and physical activity intervention led to improved pCR compared to usual care among the subset of women with breast cancer in the LEANer Study who received neoadjuvant chemotherapy. As pCR is an important prognostic factor for breast cancer, additional lifestyle interventions focusing on the neoadjuvant treatment setting with pCR as the primary outcome are necessary to confirm the potential benefits of lifestyle changes on pCR.

Citation Format: Leah Ferrucci, Tara B. Sanft, Maura Harrigan, Brenda Cartmel, Fangyong Li, Michelle Zupa, Courtney McGowan, Leah Puklin, Thai Hien Nguyen, Anna M. Tanasijevic, Marian L. Neuhouser, Dawn Hershman, Karen Basen-Engquist, Beth Jones, Tish Knobf, Anees B. Chagpar, Andrea L.M. Silber, Jennifer A. Ligibel, Melinda L. Irwin. PD12-08 Randomized trial of exercise and nutrition on pathological complete response among women with breast cancer receiving neoadjuvant chemotherapy: the Lifestyle, Exercise and Nutrition Early after Diagnosis (LEANer) Study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD12-08.

Abstract P1-04-12: Systemic immune response to a Phase I/II trial of Durvalumab concomitant with neoadjuvant chemotherapy in early stage TNBC

Background Peripheral blood cells and secreted products are important regulators of the systemic immune response. Circulating cytokines have been shown to predict severity of immune-related toxicity in melanoma patients that received combination anti-PD-1-based immunotherapy. In this study, we evaluated 38 serum cytokines and the peripheral blood t cell receptor (TCR) immune repertoire of 66 patients with TNBC for associations with pCR, treatment phase (PRE; POST), and immune related treatment emergent adverse events (TEAEs). Methods Serum and peripheral blood buffy coats were collected at pre-treatment (week 0) and at post-treatment (~ week 24). MILLIPLEX MAP Human Cytokine/Chemokine Magnetic Bead Panel was run in duplicate and read on the Luminex platform. Genomic DNA was isolated using QIAGEN Kits per manufacturer’s instructions. TCR immune repertoire profiling was performed using the Immunoseq at Adaptive Biotechnologies. Statistical analysis was performed in R. P-values < 0.05 for serum cytokines and P-values < 0.05 for TCR were considered significant. Results Pielou’s diversity index showed no difference between patient groups for TCR (P>0.319). Baseline samples had increased sCD40L, EGF, and IL-10 in patients with RD compared to pCR (P< 0.05). Baseline samples had decreased FGF2 and IFN gamma in patients with immune related TEAEs compared to those with no immune related TEAEs (P< 0.05). Comparison of Pre- vs Post-treatment revealed that EGF, MIP1 alpha, IL-1 alpha, IL-8, and MDC were increased in patients with pCR compared to those with RD. Comparison of Pre- vs. Post- also revealed increased levels of cytokines (EGF, IL-7, IFN gamma, GM-CSF) in samples in patients with immune related TEAEs (P< 0.05) compared to those patients without immune-related TEAEs. It also revealed that there was an increase in a subset of cytokines (IL-7, IL-4, MCP3, and IL-1 alpha) in patients that presented with serious immune related TEAEs (P< 0.05) compared to those patients without serious immune-related TEAEs. Conclusions There are subsets of circulating inflammatory cytokines that may be associated with treatment emergent adverse events in patients with TNBC treated with Durvalumab concomitant with standard of care chemotherapy.

Citation Format: Kim Blenman, Michal Marczyk, Julia Foldi, Vignesh Gunasekharan, Andrea L.M. Silber, Lajos Pusztai. Systemic immune response to a Phase I/II trial of Durvalumab concomitant with neoadjuvant chemotherapy in early stage TNBC [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-04-12.

Bidirectional Text Messaging to Monitor Endocrine Therapy Adherence and Patient-Reported Outcomes in Breast Cancer

Introduction

Up to 40% of patients with breast cancer may not adhere to adjuvant endocrine therapy. Therapy-related adverse effects (AEs) are important contributors to nonadherence. We developed a bidirectional text-message application, BETA-Text, that simultaneously tracks adherence, records symptoms, and alerts the clinical team.

Patients and Methods

We piloted our intervention in 100 patients. The intervention consisted of text messages to which patients responded for 3 months: daily, evaluating adherence; weekly, evaluating medication-related AEs; and monthly, regarding barriers to adherence. Concerning responses prompted a telephone call from a clinic nurse. The primary objective was to assess patient acceptance of this intervention using self-reported surveys. To compare participants with the general population at our institution, we assessed 100 consecutively treated patients as historical controls using medical record review.

Results

We approached 141 consecutive patients, 100 (71%) of whom agreed to participate and 89 of whom completed the intervention. A majority of patients reported that the intervention was easy to use (98%) and helpful in taking their medication (96%). Four patients discontinued therapy before 3 months, and 93% of patients who continued therapy took ≥ 80% of their medication. The frequency of AEs reported by participants via text was higher than that reported in clinical trials: hot flashes (72%), arthralgias (53%), and vaginal symptoms (35%). Approximately 39% of patients reported one or more severe AE that prompted an alert to the provider team to call the patient.

Conclusion

A daily bidirectional text-messaging system can monitor adherence and identify AEs and other barriers to adherence in real time without inconveniencing patients. AEs of endocrine therapy, as detected using this texting approach, are more prevalent than reported in clinical trials.

Abstract P5-11-03: Development of an interactive text messaging tool to improve adherence with adjuvant endocrine therapy: Breast cancer endocrine therapy adherence (BETA) pilot study

Introduction: Approximately 75% of stage I-III breast cancers are hormone receptor (HR) positive for which the standard of care is 5-10 years of adjuvant endocrine therapy, which has been shown to reduce recurrences and improve survival. Unfortunately, up to 40% of patients may not take the prescribed medication daily or may discontinue it early. Mobile health technology provides an opportunity to develop new innovative tools to identify women who are not taking medication as prescribed, to understand their barriers for adherence and to facilitate communication with providers to improve adherence.

Methods: The objective of the BETA study was to develop a new bi-directional text messaging application that simultaneously assesses patient adherence to endocrine therapy and provides direct communication to the provider team. Our primary endpoint was to assess feasibility of the application and the secondary endpoints included adherence, side effects and their severity, and quality of life (QOL). The intervention consisted of 3 types of text messages to which patients responded: 1) daily, evaluating adherence, 2) weekly, evaluating medication-related side effects and their severity, and 3) monthly, evaluating barriers to taking the medication. After 3 months of participation, patients completed surveys assessing the tolerability and financial burden of the intervention and adherence to medication. Patients were eligible if they had stage I-III, HR-positive breast cancer, owned a cell phone, and were initiating endocrine therapy. Target enrollment is 100 patients. For comparison, 100 consecutive patients meeting the above criteria were identified retrospectively as historical controls; adherence was assessed via chart review.

Results: Between November 2014 and May 2015, 62 patients (mean age 53.5 years) were enrolled and 25 had completed the study. Of those approached, 66% participated. Of those who completed the study, the application was found to be helpful by 63%; specifically, 76% felt the intervention was a reminder to take the medication, 96% felt it was easy to use, and 71% wanted to continue receiving text messages after the study ended. On average, patients spent 12 minutes with the application per week, 0% felt it took up too much time, and only 1 patient incurred text messaging fees. No patients withdrew from the study and only 1 patient did not adhere to treatment (as defined by ≥ 80% adherence). None of the enrolled patients discontinued endocrine therapy, compared to 9% of historical controls. Side effects were common: hot flashes/night sweats (61% of patients), joint aches/pains (56%), and vaginal symptoms (29%) were reported. Severe side effects (reported by 29% of patients) prompted a return phone call to the patient. The study is ongoing and final results will be available by December 2015.

Conclusion: We developed a new bi-directional text messaging intervention to assess adherence to endocrine therapy that provides real-time feedback to providers. Patients found the application helpful, easy to use, and not time consuming. Our tool is scalable for large population-based trials.

Citation Format: Epstein LN, Jhaveri AP, Han G, Abu-Khalaf MM, Hofstatter EW, Sanft TB, DiGiovanna MP, Silber AL, Adelson KB, Chung GG, Pusztai L, Gross CP, Mougalian SS. Development of an interactive text messaging tool to improve adherence with adjuvant endocrine therapy: Breast cancer endocrine therapy adherence (BETA) pilot study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-11-03.

Detection bias and relation of benign breast disease to breast cancer

The relation between benign breast disease and breast cancer was investigated in a case-control study of postmenopausal patients selected either by diagnostic procedure sampling (mammography 150 cases and controls, breast biopsy 107 cases and controls) or by conventional sampling procedures (257 controls to match total number of cases). For mammography patients, the odds ratio for association between benign breast disease and breast cancer was 0.9; for biopsy patients the odds ratio was 0.8; but by use of conventional methods, the odds ratio was elevated to a "causal" and statistically significant 2.6. When patients were classified according to cancer stage, benign breast disease was present in 56/147 patients with localised cancer compared with 24/107 patients with non-localised cancer (odds ratio 2.3). Evidence that benign breast disease is a risk factor for breast cancer may therefore be misleading if choice of control groups makes no provision for bias produced by inequalities in detection of disease.

Transient asymptomatic hydrothorax in pregnancy at term

Two cases of transient asymptomatic hydrothorax during pregnancy are reported. In both cases the effusions resolved completely within a week of the termination of pregnancy. No apparent pathologic explanation could be found for this finding.