Drug monitoring detects under- and overdosing in patients receiving 5-fluorouracil-containing chemotherapy-results of a prospective, multicenter German observational study

INTRODUCTION

Body surface area (BSA)-based dosing of 5-fluorouracil (5-FU) results in marked inter-individual variability in drug levels, whereas determination of plasma 5-FU concentration and area under the curve (AUC) is a more precise dosing method but has not been integrated into clinical routine. We conducted a multicenter, prospective study to study 5-FU AUC distributions and assess clinical factors predicting therapeutic dosing in patients receiving BSA-dosed 5-FU.

METHODS

Between June 2017 and January 2018, a total of 434 patients receiving continuous, infusional BSA-dosed 5-FU from 37 sites in Germany were included. Plasma 5-FU concentration and AUC were measured in venous blood samples at steady state. The primary objective was to determine 5-FU AUC distributions in relation to the target range, which is defined as 20-30 mg × h/l. The second objective was to explore clinical parameters that correlate with achievement of 5-FU AUC target range.

RESULTS

The primary tumor was mainly located in the gastrointestinal tract (96.3%), with colorectal cancer being the most common (71.2%) tumor entity. 5-FU was administered as monotherapy (8.1%) or as part of FOLFOX (33.2%), FOLFIRI (26.3%), or other regimens (12.4%). Treatment setting was adjuvant (31.3%) or metastatic (64.5%). The median AUC was 16 mg × h/l. Only 20.3% of patients received 5-FU treatment within the target range, whereas the majority of patients (60.6%) were underdosed and 19.1% of patients were overdosed. In the univariate logistic regression, treatment setting was the only clinical parameter that significantly correlated with achievement of the target range. Patients treated in the metastatic setting had a 2.1 (95% confidence interval 1.186-3.776, P = 0.011) higher odds to reach the target range compared with patients treated in the adjuvant setting.

CONCLUSIONS

The majority of patients received suboptimal doses of 5-FU using BSA dosing. Therapeutic drug monitoring of 5-FU is an option for optimized individualized cancer therapy and should be integrated into the clinical practice.

A randomised phase II study investigating durvalumab in addition to an anthracycline taxane-based neoadjuvant therapy in early triple-negative breast cancer: clinical results and biomarker analysis of GeparNuevo study

BACKGROUND

Combining immune-checkpoint inhibitors with chemotherapy yielded an increased response rates in patients with metastatic triple-negative breast cancer (TNBC). Therefore, we evaluated the addition of durvalumab to standard neoadjuvant chemotherapy (NACT) in primary TNBC.

PATIENTS AND METHODS

GeparNuevo is a randomised phase II double-blind placebo-controlled study randomising patients with TNBC to durvalumab or placebo given every 4 weeks in addition to nab-paclitaxel followed by standard EC. In the window-phase durvalumab/placebo alone was given 2 weeks before start of nab-paclitaxel. Randomisation was stratified by stromal tumour-infiltrating lymphocyte (sTILs). Patients with primary cT1b-cT4a-d disease, centrally confirmed TNBC and sTILs were included. Primary objective was pathological complete response (pCR) (ypT0 ypN0).

RESULTS

A total of 174 patients were randomised, 117 participated in the window-phase. Median age was 49.5 years (range 23-76); 47 patients (27%) were younger than 40 years; 113 (65%) had stage ≥IIA disease, 25 (14%) high sTILs, 138 of 158 (87%) were PD-L1-positive. pCR rate with durvalumab was 53.4% (95% CI 42.5% to 61.4%) versus placebo 44.2% (95% CI 33.5% to 55.3%; unadjusted continuity corrected χ2P = 0.287), corresponding to OR = 1.45 (95% CI 0.80-2.63, unadjusted Wald P = 0.224). Durvalumab effect was seen only in the window cohort (pCR 61.0% versus 41.4%, OR = 2.22, 95% CI 1.06-4.64, P = 0.035; interaction P = 0.048). In both arms, significantly increased pCR (P < 0.01) were observed with higher sTILs. There was a trend for increased pCR rates in PD-L1-positive tumours, which was significant for PD-L1-tumour cell in durvalumab (P = 0.045) and for PD-L1-immune cell in placebo arm (P = 0.040). The most common immune-related adverse events were thyroid dysfunction any grade in 47%.

CONCLUSIONS

Our results suggest that the addition of durvalumab to anthracycline-/taxane-based NACT increases pCR rate particularly in patients treated with durvalumab alone before start of chemotherapy.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT02685059.

Influence of patient and tumor characteristics on early therapy persistence with letrozole in postmenopausal women with early breast cancer: results of the prospective Evaluate-TM study with 3941 patients

Background

Patients' compliance and persistence with endocrine treatment has a significant effect on the prognosis in early breast cancer (EBC). The purpose of this analysis was to identify possible reasons for non-persistence, defined as premature cessation of therapy, on the basis of patient and tumor characteristics in individuals receiving adjuvant treatment with letrozole.

Patients and methods

The EvAluate-TM study is a prospective, multicenter, noninterventional study in which treatment with the aromatase inhibitor letrozole was evaluated in postmenopausal women with hormone receptor-positive EBC in the early therapy phase. Treatment persistence was evaluated at two pre-specified study visits after 6 and 12 months. As a measure of early therapy persistence the time from the start to the end of treatment (TTEOT) was analyzed. Cox regression analyses were carried out to identify patient characteristics and tumor characteristics predicting TTEOT.

Results

Out of the total population of 3941 patients with EBC, 540 (13.7%) events involving treatment cessation unrelated to disease progression were observed. This was due to drug-related toxicity in the majority of cases (73.5%). Persistence rates were 92.2%, 86.9%, and 86.3% after 6, 12, and 15 months, respectively. The main factors influencing premature treatment discontinuation were older age [hazard ratio (HR) 1.02/year], comorbidities (HR 1.06 per comorbidity), low body mass index, and lower tumor grade (HR 0.85 per grade unit).

Conclusion

These results support the view that older, multimorbid patients with low tumor grade and low body mass index are at the greatest risk for treatment discontinuation and might benefit from compliance and support programs.

Abstract OT1-11-02: PRAEGNANT - Real world evidence, translational research, big and smart data: A prospective academic translational research network for the optimization of the oncological health care quality in the adjuvant and advanced/ metastatic setting (NCT02338167)

Background

During the last decades the treatment of advanced breast cancer (ABC) patients has improved due to a variety of new treatment strategies. Nevertheless, many ABC patients are faced with limited prognosis, and their treatment remains a challenge. New targeted therapies complement the well-established treatment options for ABC (CDK4/6 inhibition, anti-endocrine, chemotherapy, antibody based and bone related therapies), leading to improved treatment regimens tailored to the needs of special patient sub-populations.

SPECIFIC AIMS/TRIAL DESIGN

The PRAEGNANT network study is conducted as an academic, prospective registry and diagnostic translational study, accompanied by biomaterial collection. The pilot phase in more than 60 centers aims at including 3500 ABC patients. The primary objective is to discover biomarkers, which predict progression free survival (PFS). Secondary objectives include overall survival (OS), breast cancer specific survival, objective response rate, patient reported outcomes (PRO), description of therapies used in the metastatic setting, therapy adherence, health economics for patients with ABC, incidence of (serious) adverse events and big data/ machine learning algorithms. The exploratory objectives comprise correlations of gene alterations and their influence on OS, PFS, side effects and PRO. Exploratory biomarkers are assessed at baseline and at every change of therapy. These biomarkers include gene expression profiling of the primary tumor and corresponding metastasis, somatic mutations (measured in the tumor and in circulating tumor DNA), germline genetic variations, epigenetic changes and miRNA variations. Furthermore, plasma and serum markers are assessed. If actionable molecular alterations are detected patients are informed and recruited into suitable studies if available.

ELIGIBILITY CRITERIA:

Any adult patient (&gt;18 years) with the diagnosis of ABC and who is willing and able to sign the informed consent can be enrolled.

STATISTICAL METHODS/TARGET ACCRUAL:

The PRAEGNANT study as a prospective real world registry and diagnostic translational study aims to identify biomarkers in ABC patients, which may predict PFS. Target accrual for the pilot phase is 3500 patients. Each patient will be documented for up to 36 months with an estimated median PFS for all patients of 11 months across all treatment lines.

Citation Format: Müller V, Huober J, Volz B, Overkamp F, Kolberg H-C, Hadji P, Haeberle L, Ettl J, Hartkopf AD, Lux MP, Lüftner DI, Wallwiener M, Taran F-A, Beckmann MW, Belleville E, Wimberger P, Hielscher C, Geberth M, Lermann J, Abenhardt A, Kurbacher C, Wuerstlein R, Thomssen C, Untch M, Janni W, Fehm TN, Brucker SY, Wallwiener D, Schneeweiss A, Fasching PA, Tesch H. PRAEGNANT - Real world evidence, translational research, big and smart data: A prospective academic translational research network for the optimization of the oncological health care quality in the adjuvant and advanced/ metastatic setting (NCT02338167) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-11-02.

Abstract P6-17-21: Matching the critical function of the biosimilar ABP 980 and trastuzumab: Totality of evidence and scientific justification for extrapolation across trastuzumab indications

Background

Approval of biosimilars is based on the totality of evidence (TOE) supporting clinical equivalence between the proposed biosimilar and the reference product (RP). TOE comprises comprehensive studies designed to evaluate structural, functional, pharmacokinetic (PK), and clinical similarity. TOE provides scientific justification for possible extrapolation across indications that share a common mechanism of action. ABP 980 has been shown to be biosimilar to trastuzumab using robust analytical and functional assessments. Results from phase 1 and phase 3 studies have shown PK and clinical similarity to trastuzumab. Here, we extend the similarity assessment using multiple orthogonal assays for the primary mechanism of action.

Methods

Multiple lots of ABP 980, trastuzumab (US) and trastuzumab (EU) were compared in the biological activity assessment. In addition to the primary assessment, we conducted additional characterization assays assessing human epidermal growth factor receptor 2 (HER2) cell binding, inhibition of HER2 signaling, inhibition of HER2 ligand-independent proliferation in gastric cancer cells, and a synergy study conducted with docetaxel chemotherapy in gastric cancer cells. HER2 cell-based binding assays were performed using SKBR-3 target cells and a competitive inhibition format. Inhibition of AKT phosphorylation was assessed by comparing the effect of test samples on basal pAkt in the BT-474 breast cancer line. Inhibition of HER2 ligand-independent proliferation was assessed using the gastric cell line NCI-N87 and specificity of inhibition was evaluated using MCF-7 cells that do not have amplified HER2 expression. The synergy study was conducted using NCI-N87 gastric cancer cells and docetaxel using the Combinatorix™ method.

Results

Relative cell binding to HER2 was similar (ABP 980, 93%-112%; trastuzumab [EU], 98%-109%; trastuzumab [US], 96%-102%). Synergy scores (mean ± SD) with docetaxel (in NCI-N87 cells) for ABP 980, trastuzumab (US) and trastuzumab (EU), respectively, were 16.1 ± 1.4, 16.4 ± 1.8, and 15.8 ± 1.3. Functionally, ABP 980 and trastuzumab similarly inhibited HER2 ligand-independent proliferation in NCI-N87 gastric cancer cells, exhibited specificity against MCF7 non-amplified HER2 expressing breast cancer cells, and showed similar inhibition of pAkt phosphorylation in BT-474 breast cancer cells.

Conclusions

In this study, we show similar activity between ABP 980 and trastuzumab RP, either alone or in combination with docetaxel, in both breast cancer and gastric cancer cell lines. Our results add to the TOE supporting the biosimilarity of ABP 980 and trastuzumab, and the justification for extrapolation across its approved indications.

Citation Format: Kolberg H-C, Colleoni MA, Tomasevic Z, Ponomarova O, McBride HJ, Tesch H, Hanes V. Matching the critical function of the biosimilar ABP 980 and trastuzumab: Totality of evidence and scientific justification for extrapolation across trastuzumab indications [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-21.

Abstract P6-17-37: Therapy landscape of patients with metastatic, HER2 positive breast cancer - Data from the real world breast cancer registry PRAEGNANT (NCT02338167)

Purpose:

This analysis describes comprehensive real-world data concerning the use of anti-HER2 therapies in HER2 positive metastatic breast cancer (MBC). Specifically, it describes the therapy patterns of treatments with trastuzumab (TZM), pertuzumab+trastuzumab (PTZ/TZM), lapatinib (LAP) and trastuzumab emtansine (T-DM1).

Methods:

The PRAEGNANT study is a real-time, real-world registry for patients with MBC. Patients can be registered for PRAEGNANT at any time during the course of their metastatic disease and are followed up until death. All therapy lines are documented. This analysis presents the utilization of anti-HER2 therapies as well as therapy sequences.

Results:

Of 1936 patients within PRAEGNANT at the time of database closure 451 were HER2 positive (23.3%). Within the analysis set (417 patients after an unilateral breast cancer diagnosis), of which 53% were included in PRAEGNANT in the 1stline setting, 241 were treated with TZM (58%), 237 with PTZ (57%), 85 with LAP (20%) and 125 with T-DM1 (30%) during the course of their therapies. The sequence PTZ/TZMàT-DM1 was given to 51 patients (12%). Worse ECOG, negative hormone receptor status, and visceral or brain metastases were associated with a more frequent use of this therapy sequence. Most patients received T-DM1 after a therapy with pertuzumab.

Conclusions:

Both novel therapies (PTZ/TZM and T-DM1) are utilized in a high proportion of HER2 positive breast cancer patients. As most patients receive T-DM1 after pertuzumab real world data might help to understand whether this sequence has similar efficacy like in the approval study.

Citation Format: Lux MP, Hartkopf AD, Huober J, Volz B, Taran F-A, Overkamp F, Hadji P, Tesch H, Haeberle L, Ettl J, Lueftner DI, Wallwiener M, Müller V, Beckmann MW, Belleville E, Wimberger P, Hielscher C, Geberth M, Lermann J, Abenhardt W, Kurbacher C, Wuerstlein R, Thomssen C, Untch M, Fasching PA, Janni W, Fehm TN, Wallwiener D, Brucker SY, Schneeweiss A, Kolberg H-C. Therapy landscape of patients with metastatic, HER2 positive breast cancer - Data from the real world breast cancer registry PRAEGNANT (NCT02338167) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-37.

Abstract P6-17-22: Progression free survival (PFS) and overall survival (OS) of patients treated with trastuzumab emtansine (T-DM1) after previous treatment with pertuzumab in patients with advanced breast cancer (NCT02338167)

Background

Studies leading to the approval of trastuzumab emtansine (T-DM1) have been conducted without pertuzumab as previous therapy. Therefore data about patient characteristics and the efficacy of T-DM1 after a treatment with pertuzumab is scarce. Aim of this study was to analyze a real world patient cohort of advanced breast cancer (aBC) patients, who were treated with T-DM1 after a treatment containing pertuzumab in the metastatic setting with regard to patient characteristics and progression free survival (PFS).

Methods

The PRAEGNANT metastatic breast cancer registry (NCT02338167) is a prospective registry for metastatic breast cancer patients with focus on molecular biomarkers. Patients of all therapy lines with any kind of treatment are eligible for this registry. Collected data comprises all relevant patient and tumor characteristics, therapies, adverse events, quality of life, patient reported outcomes, response and survival (PFS/OS). Here we report on the patient characteristics and PFS data for HER2 positive patients treated with T-DM1 after a treatment with pertuzumab. Patients had to be included before or at the beginning of the T-DM1 therapy.

Results

A total of 58 patients could be identified, who were suitable for the analysis. Of those 34 were treated in the second line, 14 in the third line and 10 in the fourth line or higher. Most of the pertuzumab therapies before T-DM1 were conducted in first line (n=46; 79.3%). Median PFS for all patients was 4.8 months (95% CI: 3.0-7.8 months). Median PFS for patients treated in the 3rdline and 4thline or higher was 4.2 months(95%CI: 2.3 - NA) and 4.0 months (95%CI: 1.8-N.A.), respectively. In patients treated 2ndline with T-DM1 PFS was 7.7 months (95%CI: 2.8 – 12.2).

Conclusion

T-DM1 is effective as 2ndand further line therapy following pretreatment with pertuzumab. Overall PFS was about 5 months with 7.7 months as 2nd-line therapy. The PFS in higher therapy lines might be shorter. As the sample size of this real world cohort was rather low and analyses have to be considered exploratory, this data need to be confirmed in studies with a larger sample size.

Citation Format: Schneeweiss A, Lux MP, Hartkopf AD, Volz B, Kolberg H-C, Hadji P, Tesch H, Haeberle L, Ettl J, Lüftner DI, Wallwiener M, Müller V, Beckmann MW, Belleville E, Wimberger P, Hielscher C, Geberth M, Lermann J, Abenhardt W, Kurbacher C, Wuerstlein R, Thomssen C, Untch M, Overkamp F, Huober J, Taran F-A, Janni W, Wallwiener D, Brucker SY, Fasching PA, Fehm TN. Progression free survival (PFS) and overall survival (OS) of patients treated with trastuzumab emtansine (T-DM1) after previous treatment with pertuzumab in patients with advanced breast cancer (NCT02338167) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-22.

Abstract GS5-03: Lifestyle Intervention and Effect on Disease-free Survival in Early Breast Cancer Pts: Interim Analysis from the Randomized SUCCESS C Study

Background:

Recent trials have provided evidence that obesity and a low level of physical activity are not only associated with a higher risk of developing breast cancer, but also with an increased risk for recurrence and reduced survival in breast cancer patients (pts). The SUCCESS C study is the first randomized Phase III trial to evaluate the effect of an intensive lifestyle intervention program, focusing on both physical activity and healthy diet following adjuvant chemotherapy on disease-free survival in women with early breast cancer.

Methods:

SUCCESS C is a German multicenter, 2×2 factorial design, randomized phase III study comparing disease-free survival (DFS) in pts with HER2-negative early breast cancer treated with either 3 cycles of epirubicine, fluorouracil, cyclophosphamide chemotherapy followed by 3 cycles of docetaxel (FEC-D) or 6 cycles of docetaxel-cyclophosphamide (DC). The second randomization compares DFS in pts with a body mass index (BMI) of 24—40 kg/m2 receiving either a telephone-based individualized lifestyle intervention (LI) program aiming at moderate weight loss for 2 years (LI arm) or general recommendations for a healthy lifestyle alone (non-LI arm). DFS according to lifestyle intervention was analyzed using both univariable cox regressions and multivariable cox regressions adjusted for age (years, continuous), BMI (kg/m2, continuous), menopausal status (premenopausal, postmenopausal), tumor size (pT1, pT2, pT3/pT4), nodal stage (pN0, pN1, pN2, pN3), hormone receptor status (positive, negative), grading (G1, G2, G3), histological type (ductal, lobular, other) and chemotherapy randomization (FEC-D, DC). Median follow-up was 64.2 months.

Results:

Overall, 2292 of the 3643 pts recruited for the SUCCESS C study were randomized for the lifestyle intervention program (1146 pts in both the non-LI arm and the LI arm). The Intention-to-treat analysis revealed no difference in DFS between the two treatment arms (LI vs. non-LI) in univariable analysis (hazard ratio [HR] 0.99, 95% confidence interval [CI] 0.76 — 1.28, p = 0.922) and in adjusted multivariable cox regression (HR 0.91, 95% CI 0.70 — 1.18, p = 0.48). At the 2-year follow up, pts in the LI arm lost on average 1.0 kg weight compared to the start of the LI program, while pts in the non-LI arm gained on average 0.95 kg (p &lt; 0.001). Overall, 1477 pts completed the 2-year LI program (non-LI arm: 80.7%, 925 of 1146 pts; LI arm: 48.2%, 552 of 1146 pts; p &lt; 0.001). Pts that completed the 2-year LI program had a significant better DFS than non-completers (HR 0.35, 95% CI 0.27 — 0.45, p &lt; 0.001). Among completers, pts in the LI arm had a significantly better DFS than pts in the non-LI arm both in univariable analysis (HR 0.53, 95% CI 0.35 — 0.82, p = 0.004) and in adjusted multivariable cox regression (HR 0.51, 95% CI 0.33 — 0.78, p = 0.002).

Conclusions:

This explorative and non-planned interim analysis indicates that the completion of a systematic telephone life style intervention program may positively impact patient outcome in early breast cancer.

Citation Format: Janni W, Rack BK, Friedl TW, Müller V, Lorenz R, Rezai M, Tesch H, Heinrich G, Andergassen U, Harbeck N, Schochter F, De Gregorio A, Tzschaschel M, Huober J, Hepp P, Fehm TN, Schneeweiss A, Lichtenegger W, Blohmer J, Hauner D, Beckmann MW, Häberle L, Fasching PA, Hauner H. Lifestyle Intervention and Effect on Disease-free Survival in Early Breast Cancer Pts: Interim Analysis from the Randomized SUCCESS C Study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS5-03.

Abstract P6-18-08: Everolimus + exemestane for HR+ advanced breast cancer in routine clinical practice- Final results from the non-interventional trial, BRAWO

Background: In the pivotal BOLERO-2 trial, everolimus (EVE) + exemestane (EXE) more than doubled the median progression-free survival (PFS) vs EXE alone in hormone receptor positive (HR+), human epidermal growth factor-receptor 2-negative (HER2-) advanced breast cancer (ABC) recurring/progressing on/after prior non-steroidal aromatase inhibitors (NSAIs). BRAWO is a German non-interventional study conducted in patients (pts) with HR+, HER2–ABC receiving EVE + EXE, according to Summary of Product Characteristics (SmPC), in routine clinical practice. Here we report the final PFS and safety results.

Methods: This multicenter study documented 2100 pts between October 2012 and December 2017 across 341 sites in Germany. 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 used in routine care for the entire pt group.

Results: In the final analysis, out of the 2100 documented pts, 2074 were included in the full analysis set. The median time since the primary diagnosis was 7.1 years and the median time from first sign of relapse (local recurrence or distant metastases) was 2.1 years. At baseline, 54.1% of pts presented with visceral metastases and 50.1% had an ECOG performance status of 0. Approximately, 63% of pts started with EVE 10 mg (median duration of exposure: 5.1 months; 95% CI, 4.6-5.4), while 34.1% started with EVE 5 mg (median duration of exposure: 4.6 months; 95% CI, 4.1-5.2).

The distribution of treatment lines was as follows: first line, 28.7% (n=595); second line, 31.9% (n=662); third line, 18.1% (n=376); fourth line, 10.7% (n=221) and, fifth line and later, 10.6% (n=220). Treatment was discontinued by 55.7% of pts (n=1170) due to progressive disease and 26% of pts (n=546) due to adverse events. The Kaplan-Meier estimate of the median PFS was 6.6 months (95% CI, 6.2-7.0). The best overall responses, based on clinical routine, were complete response, 0.8% (n=17), partial response, 7.4% (n=150), and stable disease, 41.3% (n=842). The general safety profile was consistent with the previously reported safety findings. The most common adverse events were stomatitis (any grade: 42.6%, grade 3: 3.8%, grade 4: &lt;0.1%) and fatigue (any grade: 19.8%, grade 3: 1.5%).

Conclusions: Data from BRAWO support EVE + EXE as a suitable treatment option with a reasonable safety profile for HR+, HER2− ABC recurring or progressing on/after prior NSAIs.

Citation Format: Lüftner D, Schuetz F, Schneeweiss A, Grischke E-M, Bloch W, Decker T, Uleer C, Salat C, Förster F, Schmidt M, Mundhenke C, Tesch H, Jackisch C, Fischer T, Guderian G, Hanson S, Fasching P. Everolimus + exemestane for HR+ advanced breast cancer in routine clinical practice- Final results from the non-interventional trial, BRAWO [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-08.

Abstract P2-08-10: Similarities between low hormone receptor positive and hormone receptor negative breast cancer: An analysis of 4366 patients from multicenter clinical trials

Background:

Currently, patients with breast cancer (BC) with hormone receptor (HR) immunohistochemical expression between 1-9% are eligible to receive endocrine therapy. However, recent data suggest that these tumors express a basal-like molecular phenotype associated with triple negative BC (TNBC) rather than luminal phenotype associated with HR positive BC. Here, we aimed to determine the differences between strong HR positive, low HR positive and negative HR BC, in regard to responsiveness to neoadjuvant chemotherapy (NACT) and disease free survival (DFS) in large cohorts from GBG clinical trials.

Methods:

In this retrospective analysis of data from women with BC treated in the neoadjuvant GeparQuinto (n=2572), GeparSixto (n=588) and GeparSepto (n=1206) clinical trials, we compared patients with three HR phenotypes: low positive (ER and/or PR= 1-9%), strong positive (ER or PR= 10-100%), and negative (ER and PR= &lt;1%), regarding pathological complete response (pCR, ypT0 ypN0) and DFS. A logistic regression model for endpoint pCR was performed on pooled data from all trials. Cox regression was used to model DFS for patients participating in GeparQuinto and GeparSixto trial, including 71 with low HR positive phenotype. The models were adjusted by age, tumor and nodal status, grading, Her2 status, histological type, stromal and tumor infiltrating lymphocytes and clinical trial. The survival model was additionally adjusted by pCR after NACT.

Results:

Patients median age was 49 years, the majority had clinical tumor stage 2 (54.1%), negative nodal status (54.7%), and Her2 negative tumors (72.4%). 85.1% of women had BC classified as no special histological type. The pCR rate across the studies was 26.2%. 145 (3.4%) patients had low HR positive, 2417 (57.3%) strong HR positive and 1658 (39.3%) HR negative tumors. After NACT, 16.3% of patients with strong HR positive BC achieved a pCR, while among those with HR negative and low HR positive tumors, pCR rates were 40.2% and 37.9%, respectively (p&lt;0.001). In the adjusted logistic regression model, there was no statistically significant difference between low HR positive and HR negative tumors (OR: 1.34, 95%-CI: (0.84-2.13), p=0.222). But strong HR positive tumors had a significantly lower chance of achieving a pCR compared to low HR positives (OR 0.48, 95%-CI: 0.30-0.76, p=0.002). Patients with strong HR positive BC had a better DFS than patients with low HR positive tumors (hazard ratio 0.35, 95%-CI: 0.18-0.70, p=0.003). DFS was not significantly different between patients with HR negative and low HR positive tumors (hazard ratio 0.74, 95%-CI: 0.38-1.43, p=0.370).

Conclusions:

Similarly to patients with negative HR tumors, patients with low HR positive tumors have a better responsiveness to NACT and worse survival rates, compared to patients with strongly HR positive BC. We suggest that studies on treatment options for basal-like/TNBC, should also consider including patients with low HR positive tumors.

Citation Format: Villegas SL, Lederer B, Untch M, Holms F, Ulmer H-U, Diebold K, Fasching PA, Weber K, Schmitt WD, Tesch H, Rezai M, Marmé F, Sinn B, Hackmann J, Schneeweiss A, Tannapfel A, Nekljudova V, Denkert C, Loibl S. Similarities between low hormone receptor positive and hormone receptor negative breast cancer: An analysis of 4366 patients from multicenter clinical trials [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-10.

Abstract P2-08-01: Factors predicting relapse in early breast cancer patients with a pathological complete response after neoadjuvant therapy – Results of a pooled analysis based on the GBG meta-database

Background

Even though patients with a pCR following neoadjuvant chemotherapy have an excellent prognosis still some of these patients will eventually relapse. A better identification of pts with an increased risk of relapse despite a pCR would be helpful to select these patients for additional post-neoadjuvant treatment strategies. Thus, the rationale of this retrospective analysis was to identify factors predicting relapse despite a pCR.

Methods

This pooled retrospective analysis based on the GBG meta-database includes the neoadjuvant trials GeparTrio, GeparQuattro, GeparQuinto, GeparSixto and GeparSepto. In these trials 2188 (27%) of 7933 pts had a pCR according to ypT0/ypTis ypN0 Definition and were included. The primary endpoint was disease-free survival (DFS), secondary endpoints were distant DFS (DDFS) and overall survival (OS). A multivariate Cox proportional hazards model was used to report hazard ratios with 95% confidence interval (CI). The two-sided significance level was set to α=0.05. Endpoints were analysed for all pts and in subgroups defined by intrinsic subtypes. The potential risk factors intrinsic subtype (HER2 negative/hormone receptor (HR) positive, triple negative, HER2 positive/HR positive, HER2 positive/HR negative), histological tumor type (lobular vs other), grade (G1/G2 vs G3), KI67 (≤20% vs higher), initial cT and cN stadium (cT1 vs cT2 vs cT3/4; cN0 vs cN+), age (≤40 vs 41-59 vs ≥60), BMI (&lt; 25 vs 25-29 vs ≥ 30), planned number of cycles of chemotherapy (≤6 vs &gt; 6), menopausal status (pre- vs postmenopausal) and clinical response after 2-4 cycles (SD vs PR vs CR vs PD) were included as covariates in multivariate Cox regression models as well as study identification.

Results

From 2188 evaluable patients DFS, DDFS and OS events were observed in 290/197/130 pts respectively; the median follow-up over all studies was 59 months. In multivariate analysis including study and all potential risk factors DFS was significantly different with regard to the initial cN status (cN+ vs cN0, hazard ratio (HR) 1.70; 95% CI [1.2, 2.4], p=0.002). Of borderline significance was histological type (non-lobular vs lobular, HR 0.52 95% CI [0.3, 1.1]; p=0.076) and initial tumor stage (cT3/4 vs cT1, HR 1.61 95% CI [1.0, 2.7]; p=0.064). In terms of DDFS significant differences were seen for the initial cN status (cN+ vs cN0, HR 2.34; 95% CI [1.5, 3.6], p&lt;0.001) and initial tumor stage (cT3/4 vs cT1, HR 1.83 95% CI [1.0, 3.3]; p=0.044); histological type was again close to significance (non-lobular vs lobular, HR 0.46 95% CI [0.2, 1.1]; p=0.067). Multivariate analysis showed significantly worse OS with initial cT3/4 tumors (cT3/4 vs cT1, HR 2.48 95%CI [1.1, 5.7]; p=0.030), and the lobular type (non-lobular vs lobular, HR 0.35 95% CI [0.1, 0.9]; p=0.026) and a trend for worse OS in pts with cN+ (cN+ vs cN0, HR 1.67 95% CI [1.0, 2.9]; p=0.067).

Conclusions

Initial tumor load before start of neoadjuvant chemotherapy (tumor stage and nodal status) and lobular subtype were predictors of long term outcome after a pCR following neoadjuvant chemotherapy. Intrinsic subtype, KI67, grade and planned number of cycles were not predictive for a relapse.

Citation Format: Huober J, Schneeweiss A, Blohmer J-U, Denkert C, Tesch H, Hanusch CA, Salat C, Rhiem K, Rezai M, Solbach C, Fasching PA, Jackisch C, Mehta K, Nekljudova V, Seither F, von Minckwitz G, Loibl S, Untch M. Factors predicting relapse in early breast cancer patients with a pathological complete response after neoadjuvant therapy – Results of a pooled analysis based on the GBG meta-database [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-01.

German Adjuvant Intergroup Node-positive Study (GAIN): a phase III trial comparing two dose-dense regimens (iddEPC versus ddEC-PwX) in high-risk early breast cancer patients

Background

Dose-dense (dd) regimens are one of the preferred options for the adjuvant treatment of breast cancer patients with intermediate to high risk. The German Adjuvant Intergroup Node-positive trial aimed at optimizing intense dd (idd) strategies by evaluating drug combinations and the addition of capecitabine.

Patients and methods

Women (aged 18 years and biologically <65 years) with histologically involved axillary lymph nodes were randomly assigned to receive three courses each of epirubicin (E) 150 mg/m2, paclitaxel (P) 225 mg/m2 and cyclophosphamide (C) 2500 mg/m2 (reduced to 2000 mg/m2 after recruitment of 1200 patients) q2w intravenously (i.v.) (iddEPC-regimen) or ddEC (E 112.5 mg/m2 + C 600 mg/m2, i.v. q2w for 4 cycles) followed by paclitaxel weekly (Pw 67.5 mg/m2 i.v. q8d for 10 weeks) plus capecitabine (X 2000 mg/m2 p.o. days 1-14, q22 for 4 cycles) (ddEC-PwX-regimen). Further randomization assigned patients to ibandronate for 2 years versus observation and to pegfilgrastim day 2 versus 4.

Results

From June 2004 to August 2008, 2994 patients were randomized to either iddEPC (N = 1498), or ddEC-PwX (N = 1496) and started treatment. Median age was 50 years; pN1 (37.8%), pN2 (35.3%); pN3 (26.9%); 46.4% were G3 tumors; 76.9% hormone receptor-positive and 22% HER2-positive. After a median follow-up of 74 months, 645 events and 383 deaths were recorded. Hematological adverse events grades 3-4 were more common with iddEPC (P < 0.001), nonhematological with ddEC-PwX (P = 0.04), even if the toxicity profile of the two regimens was different. At 5 years, estimated disease-free survival rates for ddEC-PwX and iddEPC were 81.7% [95% confidence interval (CI) 79.5-83.6] versus 80.2% (95% CI 78.0-82.2). Hazard ratio (HR)=0.95 (95% CI 0.81-1.11, log-rank P = 0.49). Five-year overall survival rates were 89.4% for ddEC-PwX (95% CI 87.7-91.0) and 89.0% for iddEPC (95% CI 87.2-90.6), HR = 0.85 (95% CI 0.69-1.04, log-rank P = 0.10).

Conclusion

Adding capecitabine to ddEC-Pw did not improve outcome in comparison to iddEPC but increased toxicity and should not be recommended for further use.

Influence of side-effects on early therapy persistence with letrozole in post-menopausal patients with early breast cancer: Results of the prospective EvAluate-TM study

BACKGROUND

Endocrine treatment (ET) with an aromatase inhibitor (AI) is the treatment of choice in post-menopausal patients with hormone receptor-positive early breast cancer (EBC). However, adverse events (AEs) often lead to treatment discontinuation. This analysis aimed to identify side-effects that lead to patients failing to persist with letrozole treatment.

PATIENTS AND METHODS

Post-menopausal hormone receptor-positive EBC patients starting ET with letrozole were enroled in EvAluate-TM, a non-interventional study. Information regarding treatment compliance and persistence was gathered in months 6 and 12. Persistence was defined as the time from 30 d after the start to the end of treatment. The influence on persistence of musculoskeletal syndrome, menopausal disorder, sleep disorder and other AEs within the first 30 d was analysed using Cox regression analyses.

RESULTS

Among 3887 patients analysed, the persistence rate after 12 months was >85%. In all, 568 patients (14.6%) discontinued the treatment, 358 of whom (63.0%) did so only because of side-effects. The main AEs influencing persistence were musculoskeletal symptoms (hazard ratio [HR] 2.55; 95% confidence interval [CI], 1.90-3.42), sleep disorders (HR 1.95; 95% CI, 1.41-2.70) and other AEs (HR 2.03; 95% CI, 1.51-2.73). Menopausal disorder was not associated with non-persistence (HR 1.17; 95% CI, 0.74-1.84).

CONCLUSIONS

These results suggest that side-effects of AIs such as musculoskeletal syndrome and sleep disorder lead to ET discontinuation within the first treatment year in significant numbers of EBC patients. Compliance programmes adapted for subgroups that are at risk for early non-persistence might help to ensure the recommended therapy duration.

CLINICAL TRIALS NUMBER

CFEM345DDE19.

Abstract P3-11-07: Factors associated with first line chemotherapy use in patients with hormone receptor positive, HER2 negative metastatic breast cancer – data from the PRAEGNANT breast cancer registry

Background

For breast cancer patients with metastases which are not life threatening national and international guidelines recommend the exhaustion of all antihormonal therapeutic options before recommending chemotherapy. In Germany up to now only everolimus was an additional option to overcome endocrine resistance. CDK4/6 inhibitors recently became available in Germany (Nov 2011). Aim of this analysis was the identification of predictors for a decision against an antihormonal treatment.

Methods

The PRAEGNANT metastatic breast cancer registry (NCT02338167) is a prospective registry for metastatic breast cancer patients. Besides biomarker research the description of real-world treatment data was one of the main study aims. This analysis was restricted to first line metastatic patients who were hormone receptor (HR) positive and HER2 negative. First, predictors were identified with a multiple logistic regression model. Then patients, who received chemo or not ,were compared with regard to overall survival using Cox regression analysis with the predictors for chemotherapy from above and additionally chemo status (yes/no)

Results

A total of 389 HR-positive and HER2-negative patients with detailed treatment information were included during the 1st line therapy into PRAEGNANT. Of those 173 (44.5%) received a chemotherapy, 190 an antihormone therapy (AHT) (48.8%), and 26 (6.7%) everolimus+AHT. In the multiple logistic regression model, older patients, lower graded tumors, bone only disease and previous adjuvant chemotherapy were associated with a lower rate of first line chemotherapies. BMI and number of concomitant diseases had no influence on the choice of first line metastatic therapy. In patients with visceral metastases 58.1% were treated with a 1st line chemo, while in patients with brain metastases or bone only metastases these numbers were 55.6% and 26.9%. Grading had an influence with patients having a G1, G2 and G3 tumor receiving 1st line chemo in 28.0%, 38.4% and 63.2% of the cases respectively. Patients who received chemo seemed to have a worse overall survival than patients who did not receive chemo (adjusted HR 1.58; 95% CI, 0.89 to 2.18). However, this result was not signifcant (p = 0.12). Overall survival was primarily influenced by ECOG and location of metastasis

Conclusion

The usage of chemotherapy can be predicted with age, metastasis pattern, grading and previous use of chemotherapy. However, we could not show that patients benefited from chemotherapy. On contrary, there was a tendency that patients treated with chemotherapy had poorer overall survival. Further studies with larger sample sizes are needed to confirm this claim.

Citation Format: Huober J, Fasching PA, Taran F-A, Volz B, Overkamp F, Kolberg HC, Hadji P, Tesch H, Haeberle L, Ettl J, Hartkopf AD, Lux MP, Lueftner D, Wallwiener M, Mueller V, Beckmann MW, Belleville E, Wimberger P, Hielscher C, Geberth M, Fersis N, Abenhardt W, Kurbacher C, Wuerstlein R, Thomssen C, Untch M, Janni W, Wallwiener D, Brucker SY, Schneeweiss A, Fehm TN. Factors associated with first line chemotherapy use in patients with hormone receptor positive, HER2 negative metastatic breast cancer – data from the PRAEGNANT breast cancer registry [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-11-07.

Abstract P1-07-20: Developing prognostic indicators of poor outcomes in PRAEGNANT metastatic breast cancer cohort

Background: Despite novel, targeted therapies, metastatic breast cancer patients have an extremely unfavourable prognosis. Prognostic and predictive factors for patients with advanced breast cancer are not well understood. Molecular assessment of the patient and the tumor in the metastatic situation is not routinely performed despite advances in molecular precision medicine indicating great benefit to this patient group. Here we present early findings from the first 142 patients of a prospective molecular breast cancer registry with completed transcriptomic profiling.

Methods: The PRAEGNANT study proctocol (NCT02338767) is a molecular registry designed to provide an infrastructure for the real-time comprehensive analysis of tumor and patient molecular characteristics under study conditions. Formalin fixed paraffin embedded tumors have been used from this registry to identify molecular, transcriptomic predictors for overall survival (OS).

Known clinical correlates for OS (e.g. hormone-receptor status, age at diagnosis, and BMI) were analyzed by Cox proportional hazard ratios, and compared to transcriptomic markers of outcomes. Transcriptomes for all patient tumors were sequenced on the Illumina sequencing platform, and analyzed by RSEM to estimate transcripts per million (TPM) values for each gene isoform. Log-TPM values were used in established (PAM50) and novel (hierarchical clustering) expression-based subtyping of tumor samples. Expression-based subtypes were demonstrated to be strong prognostic indicators by Cox analysis. A Lasso regression machine learning algorithm was used to develop an expression-based predictive model of OS.

Results: Hormone receptor positivity (HR=0.7, p&lt;0.006) and TNBC status (HR=1.4, p&lt;0.01) were significantly associated with outcomes. PAM50 subtypes were also strong indicators of outcomes (e.g. Basal disease compared to Luminal-A subtype has HR=1.4, p&lt;0.017). A novel expression-based high-risk cluster in this cohort was more indicative of poor prognosis than clinical variates or Basal-type, with a HR=2.7 (p&lt;0.009) when compared to Luminal-A subtype. An expression-based survival prediction model achieved a concordance-index of 0.65 in an unseen validation cohort. Patients predicted as having the shortest survival times were in the high-risk cluster.

Conclusions: Here we demonstrate using molecular profiling to develop prognostic signatures that out-perform standard clinical correlates of poor outcomes, even in a small subset of the total cohort. As the PRAEGNANT cohort expands these prognostic tools will continue to improve and supplement physician knowledge to improve patient outcomes.

Citation Format: Szeto C, Benz S, Nguyen A, Rübner M, Wallwiener D, Tesch H, Hadji P, Fehm TN, Janni W, Overkamp F, Lueftner D, Lux MP, Wallwiener M, Beckmann MW, Huebner H, Ettl J, Hartkopf AD, Mueller V, Taran FA, Belleville E, Schneeweiss A, Soon-Shiong P, Rabizadeh S, Fasching PA. Developing prognostic indicators of poor outcomes in PRAEGNANT metastatic breast cancer cohort [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-20.

Abstract P1-17-01: Development of brain metastases in breast cancer patients treated in the neoadjuvant trials Geparquinto and Geparsixto

Background: The incidence of brain metastases (BM) in breast cancer patients is rising and has become a major clinical challenge. So far, the incidence of BM after modern neoadjuvant treatment is not clear.

Materials and Methods: In Geparquinto, patients with untreated HER2-positive breast cancer (n=615) received either lapatinib or trastuzumab, patients with HER2 negative breast cancer (n=1925) received bevacizumab in addition to an anthracycline and taxane-containing regimen and those not responding paclitaxel and everolimus (n=32). In Geparsixto, patients with HER2-positive tumors (n=273) received trastuzumab and lapatinib and patients with triple-negative tumors (n=315) received bevacizumab in addition to chemotherapy. We analyzed clinical factors associated with the occurrence of BM as first site of metastatic relapse after neoadjuvant treatment in both trials (n=3160).

Results: After a median follow-up of 61 months, 108 (3%) of a total of 3160 patients developed BM as first site of recurrence and 411 (13%) patients had distant metastases outside the brain. Brain metastases as first site of recurrence occurred later than other metastases (3--year-relapse free-rate 96.7% for patients who developed BM and 89.5% for patients who developed metastases outside the brain). Regarding subtypes of the primary tumor, 1% of luminal A (11/954), 2% of luminal B (7/381), 4% of HER2 positive (34/809) and 6% of triple-negative patients (56/1008) developed BM as first site of recurrence. In multivariate analysis, risk factors for the development of BM were larger tumor size (cT3-4; HR 1.9, 95%-CI 1.3-2.8, p=0.0022), node positive disease (HR 2.8, 95% CI 1.8-4.4, p&lt;0.0001), no pCR after neoadjuvant chemotherapy (HR 2.7, 95% CI 1.6-4.7, p=0.0003) and HER2 positive (HR 3.8, 95% CI 1.9-7.8, p=0.0002) or triple-negative subtype (HR 8.1, 95% CI 4.2 – 15.8, p&lt; 0.0001). Breast cancer subtype remained the most relevant risk factor for BM. Patients who developed BM were more often HER2 positive or triple-negative tumors compared with patients who developed metastases outside the brain (HER2 positive subtype 32 vs. 19%, triple-negative subtype 52 vs. 40%, p&lt; 0.001).

Conclusion: Especially patients with HER2-positive and triple negative tumors are at risk of developing BM despite active systemic treatment. A better understanding of the underlying mechanisms is required in order to develop potential preventive strategies.

Citation Format: Witzel ID, Laakmann E, Fasching PA, Rezai M, Schem C, Solbach C, Tesch H, Klare P, Schneeweiss A, Zahm D, Blohmer J, Ingold-Heppner B, Huober J, Hanusch C, Jackisch C, Reinisch M, Untch M, von Minckwitz G, Müller V, Loibl S. Development of brain metastases in breast cancer patients treated in the neoadjuvant trials Geparquinto and Geparsixto [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-17-01.

Abstract P6-15-01: Withdrawn

This abstract was withdrawn by the authors.

Abstract P5-21-09: Overall survival of metastatic breast cancer patients – data from the PRAEGNANT breast cancer registry

Background

Breast Cancer registries can help to understand how patient groups are treated outside clinical trials and what outcome is to expected for specific patient groups and therapy lines, which are not included into clinical trials. Here we present overall survival data according to therapy lines, patient and tumor characteristics.

Methods

The PRAEGNANT metastatic breast cancer registry (NCT02338167) is a prospective registry for breast cancer patients with focus on molecular biomarkers. Patients of all therapy lines with any kind of treatment are eligible for this registry. Collected data comprises therapies, adverse events, quality of life and other patient reported outcomes. Here we report on the comparison of overall survival data for different patient groups. For that analysis was restricted to patients included in the first therapy line for subgroup comparisons. Only for the analysis of the effect of therapy line on overall survival the complete dataset was used.

Results

A total of 1854 patients took part in this analysis. Of those 1016 were included first line, and 340, 213 and 285 patients 2nd line, 3rd lin4 and 4th line or higher respectively. A total of 339 deaths were observed. Two year survival rates (2Y-OS) for these groups were 75%, 65%, 57% and 36% (p(log-rank)&lt;0.001). All further analyses were done only for the subset of first line treated patients with a total of 127 events. HER2 positive patients had the highest 2Y-OS rate of 84% and TNBC had the worst with 60% (see figure 1). Absolute numbers of deaths for TNBC, luminal A like, luminal B like and HER2 posives were 21, 48, 25, and 21. According to metastastic pattern the following survival rates were seen: brain (48%), other locations (69%), visceral (78%) and bone only (81%). ECOG was another factor that had a large influence on OS with ECOG 0: 83%, ECOG 1: 67% and EGOG 2+: 63% 2Y-OS. Age, BMI, number of concomitant diseases, and primary metastatic status did not have an influence on 2Y-OS.

Conclusion

This breast registry included patients over all therapy lines however mainly during the 1st line of therapy. Simple patient and tumor characteristics can classify patients into patients with differently favourable prognosis. Patients with HER2 positive disease had the best overall survival, while TNBC and luminal B like patients had the worst prognosis. As most of the patients were luminal A like 43% of all deaths occured within the group of luminal A like patients, which will need further focus for therapy development in the future.

Citation Format: Taran F-A, Fasching PA, Volz B, Huober J, Overkamp F, Kolberg HC, Hadji P, Tesch H, Haeberle L, Ettl J, Lux MP, Hartkopf AD, Lueftner D, Wallwiener M, Müller V, Beckmann MW, Belleville E, Wimberger P, Hielscher C, Geberth M, Fersis N, Abenhardt W, Kurbacher C, Wuerstlein R, Thomssen C, Untch M, Janni W, Fehm TN, Wallwiener D, Brucker SY, Schneeweiss A. Overall survival of metastatic breast cancer patients – data from the PRAEGNANT breast cancer registry [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-09.

Abstract P6-11-10: Impact of disease progression on health-related quality of life in patients with metastatic breast cancer in the PRAEGNANT breast cancer registry

Background: Improved progression-free survival is considered as treatment goal for patients with metastatic breast cancer (MBC) since it is assumed to delay or prevent deterioration of quality of life.Aim of our analysis was to examine the influence of disease progression on health-related quality of life (HRQoL).

Methods: The PRAEGNANT study comprises a real-life registry for patients with MBC. HRQoL was assessed with the EORTC-QLQ-C30 Version 3.0 questionnaire at study entry and every 3 months thereafter. The primary endpoint was minimally important deterioration (MID) in global HRQoL score by ≥ five points between baseline and any follow-up assessment. A logistic regression model was built with MID (yes/no) at a follow-up timepoint as outcome variable and several covariates as predictors.

Results: In total, 329 patients were included in this analysis, with disease progression in 63 patients. Concerning the primary study aim, progression status predicted MID of global HRQoL status in addition to the other covariates. The adjusted odds ratio for the effect of progression status on MID was 2.22 (95% CI: 1.04 – 4.73). Comparisons of mean differences of QoL domains/scales yielded no differences.

Conclusions: We provide evidence that disease progression in patients with metastatic breast cancer in a real-world registry has a significant negative impact on HRQoL as measured by MID of HRQoL. This study emphasizes the relevance of avoiding progression and prolonging PFS to maintain QoL.

Citation Format: Wallwiener M, Nabieva N, Haeberle L, Taran FA, Hartkopf AD, Volz B, Overkamp F, Brandl AL, Kolberg H-C, Hadji P, Tesch H, Ettl J, Lux MP, Lueftner D, Belleville E, Fasching PA, Janni W, Beckmann MW, Wimberger P, Hielscher C, Fehm T, Brucker SY, Wallwiener D, Schneeweiss A, Mueller V. Impact of disease progression on health-related quality of life in patients with metastatic breast cancer in the PRAEGNANT breast cancer registry [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-11-10.

Genetic Breast Cancer Susceptibility Variants and Prognosis in the Prospectively Randomized SUCCESS A Study

Large-scale genotyping studies have identified over 70 single nucleotide polymorphisms (SNPs) associated with breast cancer (BC) risk. However, knowledge regarding genetic risk factors associated with the prognosis is limited. The aim of this study was therefore to investigate the prognostic effect of nine known breast cancer risk SNPs. BC patients (n = 1687) randomly sampled in an adjuvant, randomized phase III trial (SUCCESS A study) were genotyped for nine BC risk SNPs: rs17468277 (CASP8) , rs2981582 (FGFR2) , rs13281615(8q24), rs3817198 (LSP1) , rs889312 (MAP3K1) , rs3803662 (TOX3) , rs13387042(2q35), rs4973768 (SLC4A7) , rs6504950 (COX11) . Cox proportional hazards models were used to test the SNPs' association with overall survival (OS) and progression-free survival (PFS). Additional analyses were carried out for molecular subgroups. rs3817198 in LSP1 (lymphocyte-specific protein 1) was the only SNP that significantly influenced OS (p = 0.01) and PFS (p < 0.01) in the likelihood ratio test comparing the genetic survival model with the clinical survival model. In the molecular subgroups, triple-negative patients with two minor alleles in rs3817198 had a much better prognosis relative to OS (adjusted HR 0.03; 95% CI 0.002 - 0.279) and PFS (HR 0.09; 95% CI 0.02 - 0.36) than patients with the common alleles. The same effect on PFS was shown for patients with luminal A tumors (HR 0.19; 95% CI 0.05 - 0.84), whereas patients with luminal B tumors had a poorer PFS with two minor alleles (HR 2.13; 95% CI 1.02 - 4.40). The variant in rs3817198 has a prognostic effect particularly in the subgroup of patients with triple-negative BC, suggesting a possible link with immunomodulation and BC.

Abstract P5-16-01: A randomised phase III trial comparing two dose-dense, dose-intensified approaches (ETC and PM(Cb)) for neoadjuvant treatment of patients with high-risk early breast cancer (GeparOcto)

This abstract was withdrawn by the authors.

Abstract P2-05-02: Active surveillance with a combination of tumor marker CA27.29 and detection of circulating tumor cells two year after primary diagnosis strongly predicts subsequent prognosis

Introduction

The prognosis of patients with early breast cancer is commonly estimated by prognostic factors obtained at the time of the initial diagnosis. However, patients and physicians alike are seeking for factors evaluating the prognosis years thereafter during follow-up. The identification of a patient group with an unfavourable prognosis could lead to secondary treatment intervention, potentially improving outcome. Aim of the study was to assess the added prognostic value of circulating tumor cells (CTCs) and CA27.29 beyond established predictors.

Materials and Methods

Patients of the phase III SUCCESS-A study were included into this analysis (n=1005). SUCCESS-A is a chemotherapy study for high risk patients with a comprehensive translational research program, which included the determination of CTCs and CA27.29 two years after the initial diagnosis. A Cox regression model with disease-free survival (DFS) as outcome and well-established predictors (age, BMI, pT, pN, histology, grading, ER, PR, Her2neu) was compared with an extended Cox model with the well-established predictors and additionally CTC (&gt;0 versus 0) two years after randomization, and CA27.29 (in U/mL) measured after chemotherapy and again two years after randomization using a likelihood ratio test. In case of significance, the extended model was applied to predict for each patient the risk of disease recurrence within the next 12 months (0 to 100%). Cross-validated AUC, sensitivity and specificity values were determined to assess clinical usefulness of risk prediction.

Results

The markers CA27.29 and CTC were both significantly associated with subsequent prognosis (p &lt; 0.000001). The detection of CTCs increased the risk of subsequent DFS events (HR=2.14, 95%CI: 1.31-3.48), while CA27.29 after two years increased the risk for DFS events with a HR of 1.12 per U/mL increase (95%CI: 1.09-1.15). The combination of the two markers significantly empowered the prognostic relevance, with a HR of 6.64 for patients with CTCs and an elevated CA27.29 by 10 U/mL compared to patients without CTCs and without CA27.29 elevation. The mean risk of disease recurrence in the third year after randomization was 2.38%. Discrimination of patients with and without disease recurrence based on risk prediction from the extended Cox model (AUC: 0.80) was better than discrimination based on the clinical model without the markers CTC and CA27.29 (AUC: 0.64). Sensitivity with regard to decision thresholds 1%, 2%, 3%, and 4% predicted risk was 0.89, 0.77, 0.65, and 0.55, respectively. The corresponding specificity was 0.42, 0.69, 0.81, and 0.88.

Discussion

Both CTCs and CA29.27 values determined 2 years after primary diagnosis are clinically relevant predictors of subsequent prognosis for those patients. This study extends evidence for active surveillance of breast cancer survivors. Identifying a group of women with a high recurrence risk after two years could be the basis for the development of secondary adjuvant treatment.

Citation Format: Janni W, Rack B, Häberle L, Friedl TWP, Tesch H, Lorenz R, Jäger B, Fehm T, Müller V, Schneeweiß A, Lichtenegger W, Blohmer J, Beckmann MW, Scholz C, Pantel K, Trapp E, Fasching PA. Active surveillance with a combination of tumor marker CA27.29 and detection of circulating tumor cells two year after primary diagnosis strongly predicts subsequent prognosis [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-05-02.

Abstract OT2-01-04: SOLAR-1: A phase III study of alpelisib and fulvestrant in men and postmenopausal women with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–) advanced breast cancer (BC) progressing on or after aromatase inhibitor (AI) therapy

Background: The phosphatidylinositol 3-kinase (PI3K)/mammalian target of rapamycin (mTOR) pathway is often dysregulated in HR+ BC and is associated with resistance to endocrine therapy (ET). Alpelisib (BYL719; PI3Kα-specific inhibitor) and fulvestrant showed signs of antitumor activity in patients (pts) with estrogen receptor-positive (ER+), HER2– advanced BC (phase I), especially in PIK3CA-altered tumors (Janku et al. SABCS 2014, PD5-5).

Methods: SOLAR-1 (NCT02437318) is a phase III, randomized, double-blind study in men and postmenopausal women with HR+, HER2– advanced BC. Pts are assigned to 1 of 2 cohorts based on PIK3CA tumor status (mutant vs non-mutant), and randomized 1:1 to oral alpelisib/placebo (300 mg once daily) and intramuscular fulvestrant (500 mg on Day 1 and 15 of Cycle 1; Day 1 of Cycles ≥2 [28-day cycles]) until disease progression or discontinuation. Randomization is stratified by presence of liver and/or lung metastases and prior CDK4/6 inhibitor therapy. Key inclusion criteria: recurrence or progression on or after AI therapy, ≥1 measurable lesion (RECIST v1.1) or predominantly lytic bone lesion, and ECOG performance status ≤1. Key exclusion criteria: symptomatic visceral disease or disease burden precluding ET, acute pancreatitis ≤1 year prior to screening or history of chronic pancreatitis, and prior therapy with fulvestrant, chemotherapy (except [neo]adjuvant), or PI3K/AKT/mTOR inhibitors.

The primary and key secondary endpoints are progression-free survival (PFS; RECIST v1.1; local assessment) and overall survival (OS), respectively, in the PIK3CA-mutant cohort. Other secondary endpoints include PFS and OS in the PIK3CA non-mutant cohort, PFS (Blinded Independent Central Review; RECIST v1.1), the association between PFS and baseline PIK3CA status in circulating tumor DNA, overall response rate, clinical benefit rate, safety, and pharmacokinetics. The primary endpoint will be analyzed by a stratified log-rank test at one-sided 2% level of significance.

Recruitment of the planned 560 pts is ongoing.

Citation Format: Andre F, Kaufman B, Juric D, Ciruelos EM, Iwata H, Mayer IA, Rugo HS, Conte P, Liobl S, Rubovszky G, Inoue K, Tesch H, Lu Y-S, Ryvo L, Longin A-S, Mills D, Wilke C, Germa C, Campone M. SOLAR-1: A phase III study of alpelisib and fulvestrant in men and postmenopausal women with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–) advanced breast cancer (BC) progressing on or after aromatase inhibitor (AI) therapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-01-04.

Abstract P1-01-03: Dynamics of circulating tumor cells during the course of chemotherapy and prognostic relevance across molecular subtypes in high-risk early breast cancer patients – Results from the adjuvant SUCCESS A trial

Background: The presence of circulating tumor cells (CTCs) before chemotherapy is known to be associated with reduced disease free survival (DFS) and overall survival (OS) in early breast cancer (EBC). In addition, recent findings suggest that CTCs persisting after adjuvant chemotherapy indicate poor prognosis. In an explorative analysis of the SUCCESS A trial, we evaluated the prognostic relevance of changes in CTC counts during the course of adjuvant chemotherapy across molecular subtypes to assess whether the prognostic role of persisting CTCs varies according to tumor biology.

Methods: The SUCCESS A trial is a phase III study, where patients with high-risk EBC (stage pN1-3 or pT2-4 or grade 3 or age ≤ 35 or hormone-receptor negative) were randomized to adjuvant chemotherapy with 3 cycles of epirubicin-fluorouracil-cyclophosphamide followed by either 3 cycles of docetaxel or 3 cycles of gemcitabine-docetaxel. CTC enumeration was performed before and after chemotherapy using the FDA-approved CellSearch® System (Janssen Diagnostics, LLC), and CTC positivity was defined as ≥ 1 CTC in 23 ml blood. Molecular subtypes were defined as luminal A like (hormone-receptor positive, grading 1 or 2), luminal B like (hormone-receptor positive, grading 3), triple-negative or HER2-positive. Patient outcome in terms of DFS and OS was analyzed using univariate log-rank tests and Cox regression models (median follow-up time 65.2 months).

Results: Data on both molecular subtypes and CTC status before and after chemotherapy were available for 1485 (39.6%) of 3754 patients randomized. This cohort contained 577 (38.9%) luminal A like, 236 (15.9%) luminal B like, 379 (25.5%) HER2-positive and 293 (19.7%) triple negative tumors. Overall, 917 (61.8%) patients were CTC negative before and after chemotherapy (neg/neg), 260 (17.5%) patients had a negative CTC status before and a positive CTC status after chemotherapy (neg/pos), 229 (15.4%) patients converted from positive to negative CTC status (pos/neg), and 79 (5.3%) patients were positive for CTCs at both time points (pos/pos). There were significant differences in DFS and OS among these four groups in patients with luminal A like tumors (log rank test, both p &lt; 0.003) and patients with luminal B like tumors (log rank test, both p &lt; 0.001). In both patients with luminal A like or luminal B like tumors, persistently CTC positive patients had the worst outcome (relative to persistently CTC-negative patients) in terms of DFS and OS. In contrast to luminal-like tumors, no significant differences with regard to DFS or OS were found among the four groups (neg/neg, neg/pos, pos/neg, pos/pos) in patients with HER2-positive or triple-negative tumors (log rank test, all p &gt; 0.13).

Conclusion: The presence of CTCs both before and after adjuvant chemotherapy was associated with poor survival in luminal A like and luminal B like tumors, but not in HER2-positive or triple-negative tumors. Further research is needed to evaluate the effect of chemotherapy on CTC prevalence in different molecular subtypes of EBC.

Citation Format: Tzschaschel MLJ, Rack B, Andergassen U, Friedl TWP, Schneeweiss A, Mueller V, Tanja F, Pantel K, Gade J, Lorenz R, Rezai M, Tesch H, Soeling U, Polasik A, Alunni-Fabbroni M, Trapp EK, Mahner S, Schindlbeck C, Lichtenegger W, Beckmann MW, Fasching PA, Janni W. Dynamics of circulating tumor cells during the course of chemotherapy and prognostic relevance across molecular subtypes in high-risk early breast cancer patients – Results from the adjuvant SUCCESS A trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-01-03.

Abstract P2-11-04: Efficacy and safety of darbepoetin alfa or epoetin beta in 2994 high risk early breast cancer patients participating in the German adjuvant intergroup node-positive study (GAIN)

Background

Reduced quality of life during chemotherapy is often due to fatigue and dyspnea caused by chemotherapy-induced anemia. In breast cancer patients the incidence is estimated to be above 50% and rising during the course of treatment resulting as well in therapy delays. Despite red blood cell transfusion the administration of erythrocyte stimulating factors (ESF) serves as a treatment option. In comparison with conventional chemotherapy intense dose dense regimens have proven to be beneficial in high-risk breast cancer patients, but higher incidences of anemia have been reported. In the GAIN trial two dose dense regimens were evaluated and patients received either Darbepoetin alfa or Epoetin beta. The aim of this subanalysis was to analyse the efficacy and safety of the application of two different ESF during adjuvant chemotherapy for primary node positive breast cancer.

Methods

Patients were randomly assigned to receive three courses each of epirubicin (E), paclitaxel (T), cyclophosphamide (C) all given at 2-week intervals i.v. (idd ETC-regimen) or ddEC followed by paclitaxel weekly (Tw) plus capecitabine (X)(EC-TX-regimen).All patients received either primary prophylaxis with Epoetin beta (Epo) (450IE/kg weekly) or Darbepoetin alfa (D) (4,5μg/kg biweekly).Allocation happened alternately by date of randomization. Patient outcome (rate of anemia and thromboembolic events, disease free survival (DFS), overall survival (OS)), overall and by regimen were compared according to ESF type applied and in subgroups defined by age.

Results

2994 patients were randomized to receive one of the dose dense chemotherapies and of these 1482 patients were given Darbepoetin alfa and 1512 received Epoetin beta. In the trial 84.7% of patients suffered from anemia in the Darbepoetin as well as in the Epoetin group and grade 3/4 anemia was observed in 3.6% vs 3.1% of patients, respectively. In the ETC arm anemia rates, especially grade 3/4 were slightly higher, but there was no significant difference within the treatment arms according to ESF applied (anemia any grade: D 86.1% vs. Epo 87.2%; EC-TX: D 83.2% vs. Epo 82.3%). In the ETC arm anemia was most frequently observed in patients aged 60+ years, but there was no significant difference between the ESF (D 90.5% vs. Epo 89.8%). No significant differences in the incidence of anemia by ESF treatment were observed in various age groups of the EC-TX arm. Thromboembolic events occurred in 9.1% in the Darbepoetin group and in 10.1% of patients treated with Epoetin (p=0.355). Interestingly there were more thromboembolic events in the EC-TX arm compared to the ETC arm (p&lt;0.001), but irrespective of the ESF type (EPC: D 7.0% vs. Epo 7.7%; EC-PX: D 11.3% vs. Epo 12.5%).

OS and DFS analyses showed no difference between ESF treatment overall as well as stratified by chemotherapy regimen.

Conclusion

High risk breast cancer patients treated with two different dose dense chemotherapy schedules have comparable incidences of anemia, thromboembolic events and a similar long term outcome if they receive a preventive treatment with either Darbepoetin alfa or Epoetin beta.

The trial is financially supported by Amgen and Roche.

Citation Format: van Mackelenbergh M, Loibl S, Jackisch C, Lück H-J, Schneeweiss A, Tesch H, Harbeck N, Schmatloch S, Fehm T, Huober J, Müller V, Bauerfeind I, Untch M, von Minckwitz G, Nekljudova V, Möbus V. Efficacy and safety of darbepoetin alfa or epoetin beta in 2994 high risk early breast cancer patients participating in the German adjuvant intergroup node-positive study (GAIN) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-11-04.

The West German Study Group Breast Cancer Intrinsic Subtype study: a prospective multicenter decision impact study utilizing the Prosigna assay for adjuvant treatment decision-making in estrogen-receptor-positive, HER2-negative early-stage breast cancer

PURPOSE

The West German Study Group (WSG) Breast Cancer Intrinsic Subtype (BCIST) study was designed to assess the influence of Prosigna gene signature assay results on physicians' adjuvant treatment recommendations by determining the extent of change in pre-test treatment recommendations following assay results. Secondary objectives were to assess the influence of Prosigna results on physicians' confidence in their therapeutic recommendations and on patients' decisional conflict status, anxiety levels, and functional status.

METHODS

This prospective, observational, decision impact study enrolled consecutive postmenopausal patients with estrogen-receptor (ER)-positive, HER2-negative, lymph-node-negative early-stage breast cancer in 11 centers in Germany. Physicians based their pre-test adjuvant treatment recommendations on standard clinico-pathological parameters. Tumor specimens were assayed using the Prosigna test in a WSG central pathology laboratory following manufacturer's guidelines. An independent pathology laboratory performed subsequent Prosigna assays on tumor sections to assess assay result concordance with the central laboratory. Physicians completed treatment confidence questionnaires prior to and after receiving Prosigna test results. Patients completed standardized questionnaires on decisional conflict, anxiety, and health status both before and after Prosigna testing.

RESULTS

The present study population consisted predominantly of low-to-intermediate risk patients (N = 198). Prosigna had 29.3% discordance in intrinsic subtyping with local immunohistochemistry test results. After Prosigna test results, a change in the adjuvant therapy recommendation occurred in 36 (18.2%) patients; 22 (11.1%) patients switched from no chemotherapy to chemotherapy. After Prosigna test results, physicians expressed increased confidence in their prognostic assessment in 87.9% of patients, and increased confidence in their treatment recommendation in 89.4%. Patients reported improved anxiety and emotional/functional well-being after receiving Prosigna test results.

CONCLUSIONS

Use of the Prosigna assay led to a change in 18.2% of adjuvant treatment decisions. Prosigna testing was associated with increased patient and physician confidence in treatment decisions, and with decreased patient anxiety and improved well-being. Any comparison of the therapeutic decision-making impacts of different genomic assays must account for potential confounding factors.

Abstract P4-13-07: Impact of physical activity/exercise on adverse events and quality of life during treatment with everolimus and exemestane for ER+ women - Results of the 3rd interim analysis of BRAWO

Introduction

BRAWO is a non-interventional study collecting data of 3000 breast cancer patients treated with everolimus and exemestane (advanced or metastatic, hormone-receptor-positive, HER2-negative breast cancer). We introduce results of the 3rd preplanned interim analysis with data cut-off 08/01/ 2015, including 1300 patients. Since physical activity/exercise was reported to influence side effects as well as quality of life (QoL) of various cancer types and therapies, this analysis focuses on the impact of the physical activity/exercise history, development on adverse effects (AE) of the medical treatment and QoL.

Methods

Patients were asked to complete the EORTC QLQ-C30 QoL questionnaire and visual analogue scales (VAS-KAS) measuring their present-, past ten year- and lifetime physical activity/exercise level. To differentiate between activity/exercise levels, VAS were divided in three equal components (inactive, somewhat active, very active). Questionnaires and information about AE (e. g. stomatitis, fatigue, nausea, diarrhea, etc.) were collected before starting the medical treatment and were repeated each three months. Logistic regression model was used to estimate the impact of baseline physical activity/exercise on AE at any time point of the therapy. ANOVA models were used to calculate the impact of the baseline activity/exercise level on QoL at the last completed data set of each patient.

Results

Median age of patients was 66 years, median weight was 70 kg, median BMI was 25.9, median time since primary diagnosis was 6.2 years, and 54.4% had visceral metastases at baseline. The median PFS for the first 1300 patients was 7.1 months (95% CI, 6.5-8.0). Patients who reported to be very active (exercise) at the week prior to baseline (4.4%) showed significant lower numbers of AE compared to patients who indicate to be somewhat (14.8%) or inactive (80.8%). In contrast to the exercise level, physical activity in everyday life did not affect the AE incidence. Neither lifetime nor past ten year activity/exercise level is associated with the occurrence of AE. Regarding QoL, very active as well as somewhat active women (measured at baseline for almost each time period) showed significant higher QoL values compared to inactive women during the last assessment before death/progress.

Conclusion

Exercise prior to medical treatment with Everolimus and Exemestane may impact AE during therapy. Since physical activity did not show such a relation, this analysis highlights the importance of specific guidelines for preventive/rehabilitative exercise programs. More knowledge about dose-response relationships is needed. Furthermore a livelong healthy, "active" lifestyle may increase QoL, even in patients with advanced and terminal breast cancer disease.

Citation Format: Bloch W, Baumann F, Zimmer P, Grischke E-M, Fasching PA, Decker T, Uleer C, Schneeweiss A, Salat C, Wimberger P, Mundhenke C, Förster F, Kluth-Pepper B, Schubert J, Tesch H, Schütz F, Lüftner D, Jackisch C. Impact of physical activity/exercise on adverse events and quality of life during treatment with everolimus and exemestane for ER+ women - Results of the 3rd interim analysis of BRAWO. [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 P4-13-07.