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Jhaveri K, Eli LD, Wildiers H, Hurvitz SA, Guerrero-Zotano A, Unni N, Brufsky A, Park H, Waisman J, Yang ES, Spanggaard I, Reid S, Burkard ME, Vinayak S, Prat A, Arnedos M, Bidard FC, Loi S, Crown J, Bhave M, Piha-Paul SA, Suga JM, Chia S, Saura C, Garcia-Saenz JÁ, Gambardella V, de Miguel MJ, Gal-Yam EN, Rapael A, Stemmer SM, Ma C, Hanker AB, Ye D, Goldman JW, Bose R, Peterson L, Bell JSK, Frazier A, DiPrimeo D, Wong A, Arteaga CL, Solit DB. Neratinib + fulvestrant + trastuzumab for HR-positive, HER2-negative, HER2-mutant metastatic breast cancer: outcomes and biomarker analysis from the SUMMIT trial. Ann Oncol 2023; 34:885-898. [PMID: 37597578 DOI: 10.1016/j.annonc.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/21/2023] Open
Abstract
BACKGROUND HER2 mutations are targetable alterations in patients with hormone receptor-positive (HR+) metastatic breast cancer (MBC). In the SUMMIT basket study, patients with HER2-mutant MBC received neratinib monotherapy, neratinib + fulvestrant, or neratinib + fulvestrant + trastuzumab (N + F + T). We report results from 71 patients with HR+, HER2-mutant MBC, including 21 (seven in each arm) from a randomized substudy of fulvestrant versus fulvestrant + trastuzumab (F + T) versus N + F + T. PATIENTS AND METHODS Patients with HR+ HER2-negative MBC with activating HER2 mutation(s) and prior cyclin-dependent kinase 4/6 inhibitor (CDK4/6i) therapy received N + F + T (oral neratinib 240 mg/day with loperamide prophylaxis, intramuscular fulvestrant 500 mg on days 1, 15, and 29 of cycle 1 then q4w, intravenous trastuzumab 8 mg/kg then 6 mg/kg q3w) or F + T or fulvestrant alone. Those whose disease progressed on F + T or fulvestrant could cross-over to N + F + T. Efficacy endpoints included investigator-assessed objective response rate (ORR), clinical benefit rate (RECIST v1.1), duration of response, and progression-free survival (PFS). Plasma and/or formalin-fixed paraffin-embedded tissue samples were collected at baseline; plasma was collected during and at end of treatment. Extracted DNA was analyzed by next-generation sequencing. RESULTS ORR for 57 N + F + T-treated patients was 39% [95% confidence interval (CI) 26% to 52%); median PFS was 8.3 months (95% CI 6.0-15.1 months). No responses occurred in fulvestrant- or F + T-treated patients; responses in patients crossing over to N + F + T supported the requirement for neratinib in the triplet. Responses were observed in patients with ductal and lobular histology, 1 or ≥1 HER2 mutations, and co-occurring HER3 mutations. Longitudinal circulating tumor DNA sequencing revealed acquisition of additional HER2 alterations, and mutations in genes including PIK3CA, enabling further precision targeting and possible re-response. CONCLUSIONS The benefit of N + F + T for HR+ HER2-mutant MBC after progression on CDK4/6is is clinically meaningful and, based on this study, N + F + T has been included in the National Comprehensive Cancer Network treatment guidelines. SUMMIT has improved our understanding of the translational implications of targeting HER2 mutations with neratinib-based therapy.
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Affiliation(s)
- K Jhaveri
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York; Weill Cornell Medical College, New York.
| | - L D Eli
- Clinical Development, Puma Biotechnology, Los Angeles, USA
| | - H Wildiers
- University Hospitals Leuven, Leuven, Belgium
| | - S A Hurvitz
- David Geffen School of Medicine, UCLA, Los Angeles, Santa Monica, USA
| | - A Guerrero-Zotano
- Medical Oncology Department, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - N Unni
- UT Southwestern Medical Center, Dallas
| | - A Brufsky
- Magee-Womens Hospital of UPMC, Pittsburgh
| | - H Park
- Washington University School of Medicine, St. Louis
| | - J Waisman
- City of Hope Comprehensive Cancer Center, Duarte
| | - E S Yang
- University of Alabama at Birmingham, Birmingham, USA
| | - I Spanggaard
- Department of Oncology, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
| | - S Reid
- Division of Hematology/Oncology (Breast Oncology), The Vanderbilt-Ingram Cancer Center, Nashville
| | - M E Burkard
- Division of Hematology/Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - S Vinayak
- Seattle Cancer Care Alliance, Seattle, USA
| | - A Prat
- Hospital Clínic de Barcelona, Barcelona, Spain
| | - M Arnedos
- Department of Medical Oncology, Gustave Roussy, Villejuif
| | - F-C Bidard
- Department of Medical Oncology, UVSQ/Paris-Saclay University, Institut Curie, Saint Cloud, France
| | - S Loi
- Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne; The Sir Peter MacCallum Department of Medical Oncology, The University of Melbourne, Parkville, Australia
| | - J Crown
- St. Vincent's University Hospital, Dublin, Ireland
| | - M Bhave
- Department of Hematology/Oncology, Emory University, Winship Cancer Institute, Atlanta
| | - S A Piha-Paul
- Department of Investigational Cancer Therapeutics, University of Texas MD Anderson Cancer Center, Houston
| | - J M Suga
- Kaiser Permanente, Department of Medical Oncology, Vallejo, USA
| | - S Chia
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, Canada
| | - C Saura
- Medical Oncology Service, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Barcelona
| | - J Á Garcia-Saenz
- Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), CIBERONC, Madrid
| | - V Gambardella
- Hospital Clínico de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia
| | - M J de Miguel
- START Madrid - Hospital Universitario Madrid Sanchinarro, Madrid, Spain
| | - E N Gal-Yam
- Institute of Breast Oncology, Sheba Medical Center, Ramat Gan
| | - A Rapael
- Sourasky Medical Center, Tel Aviv
| | - S M Stemmer
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva; Tel Aviv University, Tel Aviv, Israel
| | - C Ma
- Division of Medical Oncology, Department of Medicine and Siteman Cancer Center, Washington University, St. Louis
| | - A B Hanker
- UT Southwestern Simmons Comprehensive Cancer Center, Dallas
| | - D Ye
- UT Southwestern Simmons Comprehensive Cancer Center, Dallas
| | | | - R Bose
- Division of Medical Oncology, Department of Medicine and Siteman Cancer Center, Washington University, St. Louis
| | - L Peterson
- Division of Medical Oncology, Department of Medicine and Siteman Cancer Center, Washington University, St. Louis
| | | | - A Frazier
- Clinical Development, Puma Biotechnology, Los Angeles, USA
| | - D DiPrimeo
- Clinical Development, Puma Biotechnology, Los Angeles, USA
| | - A Wong
- Clinical Development, Puma Biotechnology, Los Angeles, USA
| | - C L Arteaga
- UT Southwestern Simmons Comprehensive Cancer Center, Dallas
| | - D B Solit
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
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