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Lehmann BD, Abramson VG, Dees EC, Shah PD, Ballinger TJ, Isaacs C, Santa-Maria CA, An H, Gonzalez-Ericsson PI, Sanders ME, Newsom KC, Abramson RG, Sheng Q, Hsu CY, Shyr Y, Wolff AC, Pietenpol JA. Atezolizumab in Combination With Carboplatin and Survival Outcomes in Patients With Metastatic Triple-Negative Breast Cancer: The TBCRC 043 Phase 2 Randomized Clinical Trial. JAMA Oncol 2024; 10:193-201. [PMID: 38095878 PMCID: PMC10722391 DOI: 10.1001/jamaoncol.2023.5424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/29/2023] [Indexed: 12/17/2023]
Abstract
Importance Agents targeting programmed death ligand 1 (PD-L1) have demonstrated efficacy in triple-negative breast cancer (TNBC) when combined with chemotherapy and are now the standard of care in patients with PD-L1-positive metastatic disease. In contrast to microtubule-targeting agents, the effect of combining platinum compounds with programmed cell death 1 (PD-1)/PD-L1 immunotherapy has not been extensively determined. Objective To evaluate the efficacy of atezolizumab with carboplatin in patients with metastatic TNBC. Design, Setting, and Participants This phase 2 randomized clinical trial was conducted in 6 centers from August 2017 to June 2021. Interventions Patients with metastatic TNBC were randomized to receive carboplatin area under the curve (AUC) 6 alone or with atezolizumab, 1200 mg, every 3 weeks until disease progression or unacceptable toxic effects with a 3-year duration of follow-up. Main Outcome and Measures The primary end point was investigator-assessed progression-free survival (PFS). Secondary end points included overall response rate (ORR), clinical benefit rate (CBR), and overall survival (OS). Other objectives included correlation of response with tumor PD-L1 levels, tumor-infiltrating lymphocytes (TILs), tumor DNA- and RNA-sequenced biomarkers, TNBC subtyping, and multiplex analyses of immune markers. Results All 106 patients with metastatic TNBC who were enrolled were female with a mean (range) age of 55 (27-79) years, of which 12 (19%) identified as African American/Black, 1 (1%) as Asian, 73 (69%) as White, and 11 (10%) as unknown. Patients were randomized and received either carboplatin (n = 50) or carboplatin and atezolizumab (n = 56). The combination improved PFS (hazard ratio [HR], 0.66; 95% CI, 0.44-1.01; P = .05) from a median of 2.2 to 4.1 months, increased ORR from 8.0% (95% CI, 3.2%-18.8%) to 30.4% (95% CI, 19.9%-43.3%), increased CBR at 6 months from 18.0% (95% CI, 9.8%-30.1%) to 37.5% (95% CI, 26.0%-50.6%), and improved OS (HR, 0.60; 95% CI, 0.37-0.96; P = .03) from a median of 8.6 to 12.6 months. Subgroup analysis showed PD-L1-positive tumors did not benefit more from adding atezolizumab (HR, 0.62; 95% CI, 0.23-1.65; P = .35). Patients with high TILs (HR, 0.12; 95% CI, 0.30-0.50), high mutation burden (HR, 0.50; 95% CI, 0.23-1.06), and prior chemotherapy (HR, 0.59; 95% CI, 0.36-0.95) received greater benefit on the combination. Patients with obesity and patients with more than 125 mg/dL on-treatment blood glucose levels were associated with better PFS (HR, 0.35; 95% CI, 0.10-1.80) on the combination. TNBC subtypes benefited from adding atezolizumab, except the luminal androgen receptor subtype. Conclusions and Relevance In this randomized clinical trial, the addition of atezolizumab to carboplatin significantly improved survival of patients with metastatic TNBC regardless of PD-L1 status. Further, lower risk of disease progression was associated with increased TILs, higher mutation burden, obesity, and uncontrolled blood glucose levels. Trial Registration ClinicalTrials.gov Identifier: NCT03206203.
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Affiliation(s)
- Brian D Lehmann
- Department of Medicine, Vanderbilt University, Nashville, Tennessee
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Tennessee
| | - Vandana G Abramson
- Department of Medicine, Vanderbilt University, Nashville, Tennessee
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Tennessee
| | - E Claire Dees
- Department of Medicine and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Payal D Shah
- Department of Medicine, University of Pennsylvania, Philadelphia
| | | | - Claudine Isaacs
- Department of Medical Oncology, Lombardi Cancer Center, Georgetown University, Washington, DC
| | - Cesar A Santa-Maria
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Hanbing An
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paula I Gonzalez-Ericsson
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Tennessee
- Breast Cancer Research Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melinda E Sanders
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Tennessee
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee
| | - Kimberly C Newsom
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Tennessee
| | - Richard G Abramson
- Department of Biomedical Engineering, Vanderbilt University School of Engineering, Nashville, Tennessee
| | - Quanhu Sheng
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chih-Yuan Hsu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yu Shyr
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Antonio C Wolff
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jennifer A Pietenpol
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Tennessee
- Department of Biochemistry, Vanderbilt University, Nashville, Tennessee
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