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Bidard FC, Hardy-Bessard AC, Dalenc F, Bachelot T, Pierga JY, de la Motte Rouge T, Sabatier R, Dubot C, Frenel JS, Ferrero JM, Ladoire S, Levy C, Mouret-Reynier MA, Lortholary A, Grenier J, Chakiba C, Stefani L, Plaza JE, Clatot F, Teixeira L, D'Hondt V, Vegas H, Derbel O, Garnier-Tixidre C, Canon JL, Pistilli B, André F, Arnould L, Pradines A, Bièche I, Callens C, Lemonnier J, Berger F, Delaloge S, PISTILLI B, DALENC F, BACHELOT T, DE LA MOTTE ROUGE T, SABATIER R, DUBOT C, FRENEL JS, FERRERO JM, LADOIRE S, LEVY C, MOURET-REYNIER MA, HARDY-BESSARD AC, LORTHOLARY A, GRENIER J, CHAKIBA C, STEFANI L, SOULIE P, JACQUIN JP, PLAZA JE, CLATOT F, TEIXEIRA L, D'HONDT V, VEGAS H, DERBEL O, GARNIER TIXIDRE C, DELBALDO C, MOREAU L, CHENEAU C, PAITEL JF, BERNARD-MARTY C, SPAETH D, GENET D, MOULLET I, BONICHON-LAMICHHANE N, DEIANA L, GREILSAMER C, VENAT-BOUVET L, DELECROIX V, MELIS A, ORFEUVRE H, NGUYEN S, LEGOUFFE E, ZANNETTI A, LE SCODAN R, DOHOLLOU N, DALIVOUST P, ARSENE O, MARQUES N, PETIT T, MOLLON D, DAUBA J, BONNIN N, MORVAN F, GARDNER M, MARTI A, LEVACHE CB, LACHAIER E, ACHILLE M, VALMAR C, BOUAITA R, MEDIONI J, FOA C, BERNARD-MARTY C, DEL PIANO F, GOZY M, ESCANDE A, LEDUC N, LUCAS B, MILLE D, AMMARGUELLAT H, NAJEM A, TROUBOUL F, BARTHELEMY P, DESCLOS H, MAYEUR D, LORCHEL F, GUINET F, LAURENTY AP, BOUDRANT A, GISSEROT O, ALLEAUME C, DE GRAMONT A. Switch to fulvestrant and palbociclib versus no switch in advanced breast cancer with rising ESR1 mutation during aromatase inhibitor and palbociclib therapy (PADA-1): a randomised, open-label, multicentre, phase 3 trial. Lancet Oncol 2022; 23:1367-1377. [PMID: 36183733 DOI: 10.1016/s1470-2045(22)00555-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/25/2022] [Accepted: 08/31/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND In advanced oestrogen receptor-positive, HER2-negative breast cancer, acquired resistance to aromatase inhibitors frequently stems from ESR1-mutated subclones, which might be sensitive to fulvestrant. The PADA-1 trial aimed to show the efficacy of an early change in therapy on the basis of a rising ESR1 mutation in blood (bESR1mut), while assessing the global safety of combination fulvestrant and palbociclib. METHODS We did a randomised, open-label, phase 3 trial in 83 hospitals in France. Women aged at least 18 years with oestrogen receptor-positive, HER2-negative advanced breast cancer and an Eastern Cooperative Oncology Group performance status of 0-2 were recruited and monitored for rising bESR1mut during first-line aromatase inhibitor (2·5 mg letrozole, 1 mg anastrozole, or 25 mg exemestane, orally once per day, taken continuously) and palbociclib (125 mg orally once per day on days 1-21 of a 28-day cycle) therapy. Patients with newly present or increased bESR1mut in circulating tumour DNA and no synchronous disease progression were randomly assigned (1:1) to continue with the same therapy or to switch to fulvestrant (500 mg intramuscularly on day 1 of each 28-day cycle and on day 15 of cycle 1) and palbociclib (dosing unchanged). The randomisation sequence was generated within an interactive web response system using a minimisation method (with an 80% random factor); patients were stratified according to visceral involvement (present or absent) and the time from inclusion to bESR1mut detection (<12 months or ≥12 months). The co-primary endpoints were investigator-assessed progression-free survival from random assignment, analysed in the intention-to-treat population (ie, all randomly assigned patients), and grade 3 or worse haematological adverse events in all patients. The trial is registered with Clinicaltrials.gov (NCT03079011), and is now complete. FINDINGS From March 22, 2017, to Jan 31, 2019, 1017 patients were included, of whom 279 (27%) developed a rising bESR1mut and 172 (17%) were randomly assigned to treatment: 88 to switching to fulvestrant and palbociclib and 84 patients to continuing aromatase inhibitor and palbociclib. At database lock on July 31, 2021, randomly assigned patients had a median follow-up of 35·3 months (IQR 29·2-41·4) from inclusion and 26·0 months (13·8-34·3) from random assignment. Median progression-free survival from random assignment was 11·9 months (95% CI 9·1-13·6) in the fulvestrant and palbociclib group versus 5·7 months (3·9-7·5) in the aromatase inhibitor and palbociclib group (stratified HR 0·61, 0·43-0·86; p=0·0040). The most frequent grade 3 or worse haematological adverse events were neutropenia (715 [70·3%] of 1017 patients), lymphopenia (66 [6·5%]), and thrombocytopenia (20 [2·0%]). The most common grade 3 or worse adverse events in step 2 were neutropenia (35 [41·7%] of 84 patients in the aromatase inhibitor and palbociclib group vs 39 [44·3%] of 88 patients in the fulvestrant and palbociclib group) and lymphopenia (three [3·6%] vs four [4·5%]). 31 (3·1%) patients had grade 3 or worse serious adverse events related to treatment in the overall population. Three (1·7%) of 172 patients randomly assigned had one serious adverse event in step 2: one (1·2%) grade 4 neutropenia and one (1·2%) grade 3 fatigue among 84 patients in the aromatase inhibitor and palbociclib group, and one (1·1%) grade 4 neutropenia among 88 patients in the fulvestrant and palbociclib group. One death by pulmonary embolism in step 1 was declared as being treatment related. INTERPRETATION PADA-1 is the first prospective randomised trial showing that the early therapeutic targeting of bESR1mut results in significant clinical benefit. Additionally, the original design explored in PADA-1 might help with tackling acquired resistance with new drugs in future trials. FUNDING Pfizer.
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Affiliation(s)
- François-Clément Bidard
- Department of Medical Oncology, Institut Curie, Université Versailles Saint-Quentin, Université Paris-Saclay, Saint-Cloud, France; Circulating Tumour Biomarkers Laboratory, Inserm CIC-BT 1428, Institut Curie, Paris, France.
| | | | - Florence Dalenc
- Department of Medical Oncology, Institut Claudius-Regaud, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Thomas Bachelot
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
| | - Jean-Yves Pierga
- Circulating Tumour Biomarkers Laboratory, Inserm CIC-BT 1428, Institut Curie, Paris, France; Department of Medical Oncology, Institut Curie and Université de Paris, Paris, France
| | | | - Renaud Sabatier
- Department of Medical Oncology, Institut Paoli Calmettes, Aix-Marseille Université, Marseille, France
| | - Coraline Dubot
- Department of Medical Oncology, Institut Curie, Université Versailles Saint-Quentin, Université Paris-Saclay, Saint-Cloud, France
| | | | - Jean Marc Ferrero
- Department of Medical Oncology, Centre Antoine Lacassagne, Nice, France
| | - Sylvain Ladoire
- Department of Medical Oncology, Centre Georges François Leclerc, Dijon, France
| | - Christelle Levy
- Department of Medical Oncology, Centre François Baclesse, Caen, France
| | | | - Alain Lortholary
- Department of Medical Oncology, Hopital Privé du Confluent, Nantes, France
| | - Julien Grenier
- Department of Medical Oncology, Institut Sainte Catherine, Avignon, France
| | - Camille Chakiba
- Department of Medical Oncology, Institut Bergonié, Bordeaux, France
| | - Laetitia Stefani
- Department of Medical Oncology, Centre Hospitalier Annecy Genvoi, Pringy-Metz-Tessy, France
| | - Jérôme Edouard Plaza
- Department of Medical Oncology, UNEOS Site Hôpital Robert Schuman, Vantoux, France
| | - Florian Clatot
- Department of Medical Oncology, Centre Henri Becquerel, Rouen, France
| | - Luis Teixeira
- Department of Medical Oncology, Hôpital Saint Louis, Paris, France
| | - Véronique D'Hondt
- Department of Medical Oncology, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France
| | - Hélène Vegas
- Department of Medical Oncology, Centre Hospitalier de Tours, Hôpital Bretonneau, Tours, France
| | - Olfa Derbel
- Department of Medical Oncology, Hôpital Privé Jean Mermoz, Lyon, France
| | - Claire Garnier-Tixidre
- Department of Medical Oncology, Institut Daniel Hollard, G H Mutualiste de Grenoble, Grenoble, France
| | - Jean-Luc Canon
- Department of Medical Oncology, Grand Hôpital de Charleroi, Charleroi, Belgique
| | | | - Fabrice André
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | - Laurent Arnould
- Department of Pathology, Centre Georges François Leclerc, Dijon, France
| | - Anne Pradines
- INSERM U1037 CNRS ERL5294 UPS, Cancer Research Center of Toulouse, Toulouse, France; Prospective Biology Unit, Medical Laboratory, Claudius Regaud Institute, Toulouse University Cancer Institute, Toulouse, France
| | - Ivan Bièche
- Pharmacogenomic Unit, Genetics Laboratory, Department of Diagnostic and Theranostic Medicine, Institut Curie, PSL University, Saint-Cloud, Paris, France
| | - Céline Callens
- Pharmacogenomic Unit, Genetics Laboratory, Department of Diagnostic and Theranostic Medicine, Institut Curie, PSL University, Saint-Cloud, Paris, France
| | | | - Frédérique Berger
- Biometry Unit, Institut Curie, PSL University, Saint-Cloud, Paris, France
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