Long-term outcomes of a randomized, open-label, phase II study comparing cabazitaxel versus paclitaxel as neoadjuvant treatment in patients with triple-negative or luminal B/HER2-negative breast cancer (GENEVIEVE)

BACKGROUND

The GENEVIEVE study, comparing neoadjuvant cabazitaxel versus paclitaxel in triple-negative breast cancer (TNBC) and luminal B/human epidermal growth factor receptor 2 (HER2)-negative breast cancer (BC), previously reported significant differences in pathological complete response (pCR) rates. Effects on long-term outcome are unknown.

PATIENTS AND METHODS

GENEVIEVE randomized patients with cT2-3, any cN or cT1, cN+/pNSLN+, centrally confirmed TNBC or luminal B/HER2-negative BC (latter defined as estrogen/progesterone receptor-positive and >14% Ki-67-stained cells) to receive either cabazitaxel 25 mg/m2 q3w for four cycles or paclitaxel 80 mg/m2 weekly for 12 weeks. Anthracycline-containing chemotherapy was allowed in case of histologically proven invasive residuals as neoadjuvant treatment or after surgery as adjuvant treatment. Here we report the secondary endpoints invasive disease-free survival (iDFS), distant disease-free survival (DDFS), and overall survival (OS).

RESULTS

Of the 333 patients randomized, 74.7% and 83.2% completed treatment in the cabazitaxel and paclitaxel arms, respectively. After a median follow-up of 89.3 months (interquartile range 68.8-97.3 months), 80 iDFS events (43 after cabazitaxel and 37 after paclitaxel) and 47 deaths (23 after cabazitaxel and 24 after paclitaxel) were reported. IDFS rates were not significantly different between the cabazitaxel and paclitaxel arms after a 3-year (83.6% versus 85.0%) and 5-year follow-up (76.2% versus 78.3%) [hazard ratio (HR) = 1.27, 95% confidence interval 0.82-1.96, P = 0.294], respectively. DDFS rates at 3 years (88.6% versus 87.8%) and 5 years (82.1% versus 82.8%) for cabazitaxel and paclitaxel were comparable (HR = 1.15, P = 0.573). Similarly, OS rates at 3 years (91.6% versus 91.8%) and 5 years (89.2% versus 86.8%) showed no significant differences (HR = 1.05, P = 0.872). Subgroup analysis for TNBC and luminal B/HER2-negative BCs indicated no significant variations in 3- or 5-year iDFS, DDFS, or OS.

CONCLUSIONS

The significant differences in pCR rates observed in both treatment arms did not significantly impact long-term outcomes for patients treated with cabazitaxel versus paclitaxel in the GENEVIEVE trial.

Survival analysis of carboplatin added to an anthracycline/taxane-based neoadjuvant chemotherapy and HRD score as predictor of response-final results from GeparSixto

Background

In the neoadjuvant GeparSixto study, adding carboplatin to taxane- and anthracycline-based chemotherapy improved pathological complete response (pCR) rates in patients with triple-negative breast cancer (TNBC). Here, we present survival data and the potential prognostic and predictive role of homologous recombination deficiency (HRD).

Patients and methods

Patients were randomized to paclitaxel plus nonpegylated liposomal doxorubicin (Myocet®) (PM) or PM plus carboplatin (PMCb). The secondary study end points disease-free survival (DFS) and overall survival (OS) were analyzed. Median follow-up was 47.3 months. HRD was among the exploratory analyses in GeparSixto and was successfully measured in formalin-fixed, paraffin-embedded tumor samples of 193/315 (61.3%) participants with TNBC. Homologous recombination (HR) deficiency was defined as HRD score ≥42 and/or presence of tumor BRCA mutations (tmBRCA).

Results

A significantly better DFS (hazard ratio 0.56, 95% CI 0.34-0.93; P = 0.022) was observed in patients with TNBC when treated with PMCb. The improvement of OS with PMCb was not statistically significant. Additional carboplatin did not improve DFS or OS in patients with HER2-positive tumors. HR deficiency was detected in 136 (70.5%) of 193 triple-negative tumors, of which 82 (60.3%) showed high HRD score without tmBRCA. HR deficiency independently predicted pCR (ypT0 ypN0) [odds ratio (OR) 2.60, 95% CI 1.26-5.37, P = 0.008]. Adding carboplatin to PM significantly increased the pCR rate from 33.9% to 63.5% in HR deficient tumors (P = 0.001), but only marginally in HR nondeficient tumors (from 20.0% to 29.6%, P = 0.540; test for interaction P = 0.327). pCR rates with carboplatin were also higher (63.2%) than without carboplatin (31.7%; OR 3.69, 1.46-9.37, P = 0.005) in patients with high HRD score but no tmBRCA. DFS rates were improved with addition of carboplatin, both in HR nondeficient (hazard ratio 0.44, 0.17-1.17, P = 0.086) and HR deficient tumors (hazard ratio 0.49, 0.23-1.04, P = 0.059).

Conclusions

The addition of carboplatin to neoadjuvant PM improved DFS significantly in TNBC. Long-term survival analyses support the neoadjuvant use of carboplatin in TNBC. HR deficiency in TNBC and HRD score in non-tmBRCA TNBC are predictors of response. HRD does not predict for carboplatin benefit.

Thymosin beta 15A (TMSB15A) is a predictor of chemotherapy response in triple-negative breast cancer

Background:

Biomarkers predictive of pathological complete response (pCR) to neoadjuvant chemotherapy (NACT) of breast cancer are urgently needed.

Methods:

Using a training/validation approach for detection of predictive biomarkers in HER2-negative breast cancer, pre-therapeutic core biopsies from four independent cohorts were investigated: Gene array data were analysed in fresh frozen samples of two cohorts (n=86 and n=55). Quantitative reverse transcription polymerase chain reaction (qRT–PCR) was performed in formalin-fixed, paraffin-embedded (FFPE) samples from two neoadjuvant phase III trials (GeparTrio, n=212, and GeparQuattro, n=383).

Results:

A strong predictive capacity of thymosin beta 15 (TMSB15A) gene expression was evident in both fresh frozen cohorts (P<0.0001; P<0.0042). In the GeparTrio FFPE training cohort, a significant linear correlation between TMSB15A expression and pCR was apparent in triple-negative breast cancer (TNBC) (n=61, P=0.040). A cutoff point was then defined that divided TNBC into a low and a high expression group (pCR rate 16.0% vs 47.2%). Both linear correlation of TMSB15A mRNA levels (P=0.017) and the pre-defined cutoff point were validated in 134 TNBC from GeparQuattro (pCR rate 36.8% vs 17.0%, P=0.020). No significant predictive capacity was observed in luminal carcinomas from GeparTrio and GeparQuattro.

Conclusion:

In TNBC, TMSB15A gene expression analysis might help to select patients with a high chance for pCR after NACT.

Colposcopic appearance of cervical intraepithelial neoplasia is age dependent

OBJECTIVE

We investigated to determine whether colposcopic, histologic, and virologic parameters of cervical intraepithelial neoplasia are influenced by a patient's age.

STUDY DESIGN

A cohort of 967 women with a mean age of 37.1 years underwent screening for detection of cervical intraepithelial neoplasia by colposcopy, cytologic examination, and testing for high-risk human papillomaviruses with the Hybrid Capture System (Digene, Silver Springs, Md) and a general primer and type-specific primer polymerase chain reaction system. Cervicography was used for documentation and reproducible evaluation of the colposcopic appearance of the cervix. In 86% of patients with trivial colposcopic changes of doubtful significance (100/116) and 89% of patients with colposcopic changes consistent with cervical intraepithelial neoplasia (89/99), punch biopsy specimens were taken for histologic evaluation.

RESULTS

In patients with trivial colposcopic changes of doubtful significance, histologically confirmed cervical intraepithelial neoplasia was almost as frequent (32%, 37/116) as in patients with colposcopic changes consistent with cervical intraepithelial neoplasia (43%, 43/99, difference not significant). The ratio between colposcopic evidence of cervical intraepithelial neoplasia and trivial colposcopic changes was 1.9 in patients <35 years old with cervical intraepithelial neoplasia, versus 0.5 in patients >/=35 years old with cervical intra-epithelial neoplasia (P =.005). Patients with trivial colposcopic changes of doubtful significance were older (median age 36 years) than were patients with colposcopic changes consistent with cervical intraepithelial neoplasia (median age 29 years, P =. 008). In patients with cervical intraepithelial neoplasia who had no or trivial colposcopic changes, the thickness of neoplastic epithelium was smaller (P =.008) and the number of cellular layers was lower (P =.01) than in patients with cervical intraepithelial neoplasia who had colposcopic changes consistent with cervical intraepithelial neoplasia. In patients <35 years old the rate of positive results for a high-risk human papillomavirus (P <.005) and the viral load (difference not significant) were higher than in women >/=35 years old. The rate of positive results for high-risk human papillomaviruses differed independently of age among patients with normal colposcopic findings, patients with trivial colposcopic changes of doubtful significance, and patients with colposcopic changes consistent with cervical intraepithelial neoplasia (P <.005).

CONCLUSIONS

In women >/=35 years old cervical lesions associated with intraepithelial neoplasia are thinner and thus less colposcopically conspicuous than those in women <35 years old. Patients >/=35 years old with acetowhite cervical lesions consistent with trivial changes of doubtful significance should therefore undergo punch biopsy for histologic evaluation.

Human papillomavirus distribution in cervical tissues of different morphology as determined by hybrid capture assay and PCR

Distribution of various types of genital human Papillomavirus (HPV) in smears from histologically classified cervical lesions was determined by hybrid capture assay (HCA) and was compared with a polymerase chain reaction (PCR) system using general primers (GP) in first and type specific primers (TS) in a second step. The overall agreement of high-risk HPV by HCA and the more sensitive GP/TS PCR was 80.6% (204 of 253, kappa value 0.6). Human Papillomavirus frequency by GP/TS PCR was 14-20% higher compared with HCA (p = 0.02-0.004) independent of morphology. Only one sample was positive by HCA and negative by GP/TS PCR. A significantly higher frequency was found using HCA and GP/TS PCR in smears from histologically proven cervical intraepithelial lesions (CIN) II/III compared with CIN I, tissues with minimal changes (metaplasia, cervicitis, or lack of glycogenization), or normal morphology (61% and 81% vs 8-15% and 24-34%, p < or = 0.001). Semi-quantitative estimate of HPV DNA copies by GP-PCR coincided with estimated virus load by quantitative HCA and was significantly higher in patients with CIN II/III compared with CIN I (p < 0.001). Thus, the GP-PCR may be used to monitor the amount of HPV DNA copies in clinical samples. A direct correlation between morphologic changes and HPV detection as well as virus load was found by HCA and the more sensitive GP/TS PCR.

Different detectability of high-risk HPV in smears from incident and prevalent high-grade squamous intraepithelial lesions of the cervix

Human papillomavirus (HPV) status in cervical smears from cervical intraepithelial neoplasia (CIN) 2/3 diagnosed in 36 of 892 women with a history of normal cytology and colposcopy (incident CIN 2/3) was compared with CIN 2/3 in 40 patients with a history of abnormal cytology (prevalent CIN 2/3). In all patients cervical smears for HPV testing and cytology and two cervigrams were taken. The scrapes were collected in hybrid capture assay solution and analyzed with the hybrid capture and general primer/type-specific primer polymerase chain reaction system (GP/TS-PCR) after DNA extraction. Patients with incident and prevalent CIN 2/3 were similar with respect to age. By GP/TS-PCR carried out under suboptimal conditions due to DNA extraction, HPV DNA was detected in 69.4% (25 of 36) of smears from incident CIN 2/3 compared to 95% (38 of 40) in prevalent CIN 2/3 (P = 0.003). Using hybrid capture, smears of incident CIN 2/3 were HPV positive in 50% (18 of 36) compared to 80% (32 of 40) in prevalent CIN 2/3 (P = 0.006). High-risk HPVs were significantly less common in smears from incident CIN 2/3 compared with prevalent CIN 2/3: 36.1% vs 72.5% by GP/TS-PCR (P = 0.001) and 47.2% vs 80% by hybrid capture assay (P = 0.003), respectively. Virus load in HPV-positive smears of prevalent CIN 2/3 was significantly higher than of incident CIN 2/3 using semiquantitative PCR (P = 0.0005). Thus, high-risk HPV types were detected less frequently and in lower concentration in smears from incident CIN 2/3 than in smears from prevalent CIN 2/3.

New adjunctive methods for cervical cancer screening

The sensitivity of cytology for detection of cervical intraepithelial neoplasia (CIN) is effectively augmented by cervicography with the disadvantage of lower specificity. However, the combination of cytology and cervicography can decrease the number of recalls, biopsies, and unnecessary treatments, which reduces cost. Down-staging of invasive cancer by visual inspection seems a cost-effective alternative to the introduction of cytology in countries with limited health facilities. Other methods such as speculoscopy, polarprobe, laser-induced fluorescence, computerized digital imaging colposcopy, or computer imaging have a potential to be used for future screening or triaging; however, so far, insufficient data are available to evaluate the validity of these techniques.

Screening for cervical intraepithelial neoplasia grade 2/3: validity of cytologic study, cervicography, and human papillomavirus detection

OBJECTIVE

A commercial test for human papillomavirus detection (hybrid capture assay) was examined for its potential value to augment the sensitivity of cytologic study or cervicography for screening for cervical intraepithelial neoplasia grade 2/3.

STUDY DESIGN

In a cohort of 967 women with a mean age of 37.1 years who underwent routine cytologic screening, cytologic examination, cervicography, and testing for high-risk human papillomavirus by the hybrid capture assay were compared for their ability to detect cervical intraepithelial neoplasia grade 2/3. Cervical punch biopsy specimens were taken in 20.5% (198/967) patients because they had an atypical or positive cervigram or abnormal cytologic results in the primary screening smears. The data were analyzed by two-tailed chi(2) and Fisher's exact test.

RESULTS

Thirty-eight patients were diagnosed with cervical intraepithelial neoplasia grade 2/3 (prevalence 3.9%) by histologic study. Cytologic study identified 29%, cervicography 45%, and testing for high-risk human papillomavirus 50% of cervical intraepithelial neoplasia grade 2/3. When combined, detection of high-risk human papillomavirus or cervicography augmented sensitivity of cytologic study to 58% (p = 0.01) with positive predictive values of 23% and 17%, respectively. Results of the different techniques should be interpreted in relationship to each other and not as absolute values because collection of specimens for cytologic study was done with cotton swabs, which may be suboptimal for screening but is general practice in Germany.

CONCLUSIONS

Screening for cervical intraepithelial neoplasia grade 2/3 can significantly be improved by human papillomavirus testing with the hybrid capture assay.

[MSA--a new sensitive tumor marker in breast carcinoma]

Mammary serum antigen (MSA) serum levels were evaluated for its association with histopathologic outcome of breast biopsies. 212 women were undergoing a diagnostic extirpation for suspicious lesions of the breast. Invasive breast cancer was found in 24.5%, in-situ-carcinomas in 7.1% respectively. 56.1% of the women were diagnosed with proliferating benign breast diseases and normal breast tissue was found in 12.3% of the patients. In all women pretherapeutic MSA-serum levels were measured by Inhibition-ELISA using the monoclonal antibody 3E1.2. The positivity-rates of MSA, CA15-3, TPA and CEA were compared separately and in combination. MSA was positive in 25% of breast cancer patients when a cut-off level of 55 U/ml was applied. The addition of CA15-3, TPA or CEA increased the sensitivity to 42.3% and the increment of the positivity-rate was smaller by addition of CA15-3, when compared with TPA or CEA. The highest MSA serum levels and positivity-rates were associated with malignant tumours, but there was no significant difference compared with benign epithelial proliferations (19.5% positivity rate). The lowest positivity-rate was detected in mesenchymal proliferations of the breast (4.8%, p = 0.02). To sum up one can say that MSA serum levels do not allow to discriminate benign from malignant breast diseases and MSA is 2.5 to 3 times more sensitive for the prediction of early stages breast cancer compared to CA15-3, TPA and CEA.

Human papillomavirus detection in high-grade squamous intraepithelial lesions. Comparison of hybrid capture assay with a polymerase chain reaction system

The validity of human papillomavirus (HPV) detection using the hybrid capture assay (HCA) was compared with the polymerase chain reaction (PCR) in 38 patients with high-grade squamous intraepithelial lesions (HSILs). HCA and PCR showed 84% agreement for HPV detection. HCA missed a significant higher proportion of HSIL compared with PCR (21% vs. 5%; P = .04). Thus, the sensitivity of HCA should be increased before this test can be recommended for HSIL.