Model-Based Quantification of Impact of Genetic Polymorphisms and Co-Medications on Pharmacokinetics of Tamoxifen and Six Metabolites in Breast Cancer

Variations in clinical response to tamoxifen (TAM) may be related to polymorphic cytochromes P450 (CYPs) involved in forming its active metabolite endoxifen (ENDO). We developed a population pharmacokinetic (PopPK) model for tamoxifen and six metabolites to determine clinically relevant factors of ENDO exposure. Concentration-time data for TAM and 6 metabolites come from a prospective, multicenter, 3-year follow-up study of adjuvant TAM (20 mg/day) in patients with breast cancer, with plasma samples drawn every 6 months, and genotypes for 63 genetic polymorphisms (PHACS study, NCT01127295). Concentration data for TAM and 6 metabolites from 928 patients (n = 27,433 concentrations) were analyzed simultaneously with a 7-compartment PopPK model. CYP2D6 phenotype (poor metabolizer (PM), intermediate metabolizer (IM), normal metabolizer (NM), and ultra-rapid metabolizer (UM)), CYP3A4*22, CYP2C19*2, and CYP2B6*6 genotypes, concomitant CYP2D6 inhibitors, age, and body weight had a significant impact on TAM metabolism. Formation of ENDO from N-desmethyltamoxifen was decreased by 84% (relative standard error (RSE) = 14%) in PM patients and by 47% (RSE = 9%) in IM patients and increased in UM patients by 27% (RSE = 12%) compared with NM patients. Dose-adjustment simulations support an increase from 20 mg/day to 40 and 80 mg/day in IM patients and PM patients, respectively, to reach ENDO levels similar to those in NM patients. However, when considering Antiestrogenic Activity Score (AAS), a dose increase to 60 mg/day in PM patients seems sufficient. This PopPK model can be used as a tool to predict ENDO levels or AAS according to the patient's CYP2D6 phenotype for TAM dose adaptation.

Talazoparib versus chemotherapy in patients with germline BRCA1/2-mutated HER2-negative advanced breast cancer: final overall survival results from the EMBRACA trial

BACKGROUND

In EMBRACA, talazoparib prolonged progression-free survival versus chemotherapy (hazard ratio [HR] 0.542 [95% confidence interval (CI) 0.413-0.711]; P < 0.0001) and improved patient-reported outcomes (PRO) in germline BRCA1/2 (gBRCA1/2)-mutated advanced breast cancer (ABC). We report final overall survival (OS).

PATIENTS AND METHODS

This randomized phase III trial enrolled patients with gBRCA1/2-mutated HER2-negative ABC. Patients received talazoparib or physician's choice of chemotherapy. OS was analyzed using stratified HR and log-rank test and prespecified rank-preserving structural failure time model to account for subsequent treatments.

RESULTS

A total of 431 patients were entered in a randomized study (287 talazoparib/144 chemotherapy) with 412 patients treated (286 talazoparib/126 chemotherapy). By 30 September 2019, 216 deaths (75.3%) occurred for talazoparib and 108 (75.0%) chemotherapy; median follow-up was 44.9 and 36.8 months, respectively. HR for OS with talazoparib versus chemotherapy was 0.848 (95% CI 0.670-1.073; P = 0.17); median (95% CI) 19.3 months (16.6-22.5 months) versus 19.5 months (17.4-22.4 months). Kaplan-Meier survival percentages (95% CI) for talazoparib versus chemotherapy: month 12, 71% (66% to 76%)/74% (66% to 81%); month 24, 42% (36% to 47%)/38% (30% to 47%); month 36, 27% (22% to 33%)/21% (14% to 29%). Most patients received subsequent treatments: for talazoparib and chemotherapy, 46.3%/41.7% received platinum and 4.5%/32.6% received a poly(ADP-ribose) polymerase (PARP) inhibitor, respectively. Adjusting for subsequent PARP and/or platinum use, HR for OS was 0.756 (95% bootstrap CI 0.503-1.029). Grade 3-4 adverse events occurred in 69.6% (talazoparib) and 64.3% (chemotherapy) patients, consistent with previous reports. Extended follow-up showed significant overall improvement and delay in time to definitive clinically meaningful deterioration in global health status/quality of life and breast symptoms favoring talazoparib versus chemotherapy (P < 0.01 for all), consistent with initial analyses.

CONCLUSIONS

In gBRCA1/2-mutated HER2-negative ABC, talazoparib did not significantly improve OS over chemotherapy; subsequent treatments may have impacted analysis. Safety was consistent with previous observations. PRO continued to favor talazoparib.

Abstract CT072: Exploration of impact of tumor BRCA zygosity and genomic loss-of-heterozygosity (gLOH) on efficacy in Phase 3 EMBRACA study of talazoparib in patients (pts) with HER2-negative (HER2−) advanced breast cancer (ABC) and a germline BRCA1/2 (gBRCA1/2) mutation

Background: Loss-of-function mutations in genes encoding components of the homologous recombination machinery, notably BRCA1/2, are associated with tumor sensitivity to poly(ADP-ribose) polymerase (PARP) inhibitors. In EMBRACA, the PARP inhibitor talazoparib (TALA) demonstrated a significant improvement in the primary endpoint of progression-free survival (PFS) (HR [95% CI] 0.54 [0.41-0.71], P &lt; 0.001) vs physician's choice of chemotherapy (PCT) in pts with HER2− ABC and a gBRCA1/2 mutation.

Methods: Baseline tumor tissue (primary or metastatic sites) from 308 pts (71%) in the intent-to-treat population was sequenced using the FoundationOne CDx NGS panel. Mutations summarized below were known/likely pathogenic single-nucleotide variants, insertions, deletions, or rearrangements. Additional exploratory computational analyses pertinent to homologous recombination deficiency were performed, including somatic-germline-zygosity (SGZ) and gLOH assessments.

Results: 296/308 (96%) of evaluable pts exhibited ≥1 tumor BRCA mutation, with BRCA1 and BRCA2 mutations mainly mutually exclusive (4/308 [1%] pts had both BRCA1 and BRCA2 mutations). Of 12 pts with no apparent BRCA mutations, 7 exhibited tumor BRCA copy number alterations deemed pathogenic and 2 had BRCA single-nucleotide variants deemed of unknown pathogenicity. 195/236 (83%) BRCA-mutant (BRCAm) pts evaluable for BRCA LOH status were predicted to exhibit BRCA LOH by SGZ analysis. The potential impact of tumor BRCA mutational zygosity on PFS was explored in the TALA arm calculating HR by Cox proportional hazards model, comparing 122 pts with BRCA LOH with 27 pts without BRCA LOH. This analysis demonstrated no difference in PFS [HR (95% CI): 1.152 (0.680-1.951); P = 0.597)]. gLOH scores were variable, but mostly high: median (range), 21.8% (0.0, 52.7) and 20.5% (0.2, 40.5) for TALA and PCT arms, respectively. The potential association of gLOH scores with selected measures of efficacy was explored. Within both arms gLOH was similar in those pts achieving vs pts not achieving clinical benefit as defined by complete response, partial response, or stable disease ≥24 wks per RECIST v.1.1 as determined by investigator (P = 0.976 and 0.492, respectively, using 2-tailed t-test). In both arms, pts with gLOH ≥ median vs gLOH &lt; median exhibited similar PFS: HR (95% CI) 1.247 (0.828-1.879) for TALA; 1.238 (0.693-2.211) for PCT, with HR &lt;1 favoring gLOH ≥ median.

Conclusions: Selection based on gBRCA mutational status is appropriate to identify HER2− ABC pts with potential for clinical benefit with PARP inhibitors, with tumor BRCA zygosity and gLOH not impacting outcome (within the gBRCAm subset). Additional exploratory correlative analyses are ongoing and will be reported.

Citation Format: Jennifer K. Litton, A. Douglas Laird, Hope S. Rugo, Johannes Ettl, Sara A. Hurvitz, Miguel Martin, Henri Roché, Young-Hyuck Im, Annabel Goodwin, Joanne L. Blum, Wolfgang Eiermann, Ying Chen, Silvana Lanzalone, Jijumon Chelliserry, Akos Czibere, Lee A. Albacker, Garrett M. Frampton, Lida A. Mina. Exploration of impact of tumor BRCA zygosity and genomic loss-of-heterozygosity (gLOH) on efficacy in Phase 3 EMBRACA study of talazoparib in patients (pts) with HER2-negative (HER2−) advanced breast cancer (ABC) and a germline BRCA1/2 (gBRCA1/2) mutation [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT072.

Abstract P1-19-29: An integrated safety analysis of talazoparib monotherapy from five clinical trials (phase 1-3) in advanced cancers

Background: Talazoparib is a potent oral inhibitor of poly(ADP-ribose) polymerase (PARP) 1 and 2, which significantly improved progression-free survival versus standard-of-care chemotherapy in patients with HER2-negative advanced breast cancer (ABC; locally advanced/metastatic breast cancer) and a germline BRCA1/2 mutation (gBRCA1/2mut) in the Phase 3 EMBRACA trial (Litton J, et al. N Engl J Med. 2018;379:753-763). An integrated analysis of five clinical trials (Phase 1-3) in multiple tumor types was performed to evaluate the safety of talazoparib administered at 1 mg/day (d). Methods: Data were pooled from the ongoing Phase 3 randomized EMBRACA trial in HER2-negative gBRCA1/2mut ABC (NCT01945775), the Phase 2 non-randomized ABRAZO trial in gBRCA1/2mut ABC (NCT02034916), the Phase 1 trial in advanced/recurrent solid tumors (NCT01286987), the Phase 1 cardiac repolarization trial in advanced solid tumors (NCT03042910), and an ongoing open-label extension trial (NCT02921919). Results: 494 patients who received talazoparib 1 mg/d were included (Table). The most common all-grade adverse drug reactions (≥20%) with talazoparib were ANEMIA (includes preferred terms: anemia, decreased hemoglobin, decreased hematocrit; 49.6%), fatigue (47.6%), nausea (44.3%), NEUTROPENIA (neutropenia, decreased neutrophil count; 30.2%), THROMBOCYTOPENIA (thrombocytopenia, decreased platelet count; 29.6%), headache (26.5%), diarrhea (22.7%), alopecia (22.3%; Grade 1, 20.6%; Grade 2, 1.6%), vomiting (22.3%), and decreased appetite (20.2%). Grade 3/4 toxicities (≥10%) with talazoparib were ANEMIA (35.2%), NEUTROPENIA (17.4%), and THROMBOCYTOPENIA (16.8%). Overall 24 patients (4.9%) died within 30 days after the last dose of study drug; the most common cause of death was disease progression (13 patients; 2.6%). Other causes of death were reported in 1 patient each (cerebral hemorrhage, dyspnea, lung infection, lung metastases, respiratory failure, suspected veno-occlusive liver disease, and worsening of neurological symptoms); cause of death was not reported for 4 patients. The most common treatment-related serious adverse event was anemia (4.3%). Median duration of talazoparib exposure was 5.4 months (range, 0.0-61.1). Median relative dose intensity (defined as actual-dose intensity/planned-dose intensity) was 92.8%. Dosing interruptions due to TEAEs were reported for 48.6% of patients receiving talazoparib; median duration of dosing interruption due to TEAEs was 8.0 days (range, 1.0-121.0). Hematologic TEAEs (≥5%) associated with dose modification (interruption or reduction) included anemia (33.0%), neutropenia (15.8%), thrombocytopenia (13.4%), and decreased platelet count (5.9%); non-hematologic TEAEs (≥2%) associated with dose modification included fatigue (4.3%), vomiting (2.6%), and nausea (2.0%). Only 18 patients (3.6%) permanently discontinued due to a TEAE (anemia, 3 patients [0.6%]; other events, 1 patient each [0.2%]). Conclusions: Talazoparib monotherapy at 1 mg/d was generally well tolerated with few patients permanently discontinuing talazoparib due to AEs. Common toxicities were primarily hematologic and were manageable through dosing modifications and/or standard supportive care. Funding: Pfizer Inc.

Table Summary of TEAEsPhase 3 EMBRACA trialOpen-label trialsTalazoparibTalazoparib mg/dTalazoparib 1 mg/d1 mg/d populationbTalazoparibPCTABRAZONCT01286987NCT03042910OLEaTotalN=286N=126N=83N=77N=37N=46N=494Any TEAE282 (98.6)123 (97.6)81 (97.6)75 (97.4)28 (75.7)39 (84.8)484 (98.0)Grade 3 or 4 TEAE193 (67.5)80 (63.5)54 (65.1)52 (67.5)9 (24.3)21 (45.7)326 (66.0)Treatment-related Grade 3 or 4 TEAE159 (55.6)61 (48.4)48 (57.8)36 (46.8)3 (8.1)14 (30.4)260 (52.6)SAE91 (31.8)37 (29.4)23 (27.7)27 (35.1)3 (8.1)14 (30.4)156 (31.6)Treatment-related SAE26 (9.1)11 (8.7)11 (13.3)3 (3.9)1 (2.7)1 (2.2)42 (8.5)TEAE primary reason for permanent discontinuation13 (4.5)7 (5.6)3 (3.6)002 (4.3)18 (3.6)TEAE associated with dose modification190 (66.4)75 (59.5)55 (66.3)46 (59.7)4 (10.8)15 (32.6)308 (62.3)All data are number (%) of patients; d, day; OLE, open-label extension; PCT, physician’s choice of chemotherapy; SAE, serious adverse event; TEAE, treatment-emergent adverse event;aInitiated treatment with talazoparib; monotherapy (1 mg/d) in either the originating or the extension trial;b35 patients who initiated talazoparib 1 mg/d in two of the trials and continued in the OLE are counted only once in the total number of patients

Citation Format: Joannes Ettl, Jennifer Litton, Hope S. Rugo, Lida Mina, Miguel Martin, Nicholas Turner, Henri Roché, Zev Wainberg, Johann de Bono, Tiziana Usari, Mohamed Elmeliegy, Silvana Lanzalone, Akos Czibere, Liza DeAnnuntis, Sara A. Hurvitz. An integrated safety analysis of talazoparib monotherapy from five clinical trials (phase 1-3) in advanced cancers [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-19-29.

The importance of jointly analyzing treatment administration and toxicity associated with targeted therapies: a case study of regorafenib in soft tissue sarcoma patients

Background

Different methods have been proposed to analyze adverse events (AEs) associated with targeted therapies. While these AEs lead to dose adjustments for many patients, conventional reporting methods do not take drug administration into consideration. This paper underlines the importance of jointly reporting AEs and drug administration using prevalence, and proposes a complementary approach to reporting.

Patients and methods

The prevalence method estimates the probability of progression-free patients being in a particular health state (state 1: AEs with full dose; state 2: AEs with reduced dose; state 3: no AEs with reduced dose) at different time points. To take into account the impact of dose adjustments on efficacy, the weighted prevalence method can be used by assigning utility weights to the different health states. The benefit of these methods was illustrated using data from a phase II trial of regorafenib.

Results

Only 4.6% of progression-free patients developed mucositis/stomatitis (grade ≥2) at 3 months. The prevalence of patients not experiencing this AE but whose dose was reduced or treatment interrupted was 58.1%. The weighted prevalence of the regorafenib toxicity profile and dose reduction was higher in the control arm.

Conclusion

This case study confirms the importance of jointly analyzing AEs and drug administration. The weighted prevalence approach is an average score that incorporates the dimension of drug administration into AE assessment. This can be helpful for regulatory agencies as well as for clinicians to evaluate the benefit-risk ratio of therapies in their treatment choice.

Clinical trial

NCT01900743.

UCBG 2-04: Long-term results of the PACS 04 trial evaluating adjuvant epirubicin plus docetaxel in node-positive breast cancer and trastuzumab in the human epidermal growth factor receptor 2-positive subgroup

PURPOSE

We conducted a double-randomised phase III trial to evaluate a concomitant taxane-anthracycline regimen in node-positive breast cancer and the efficacy of trastuzumab in the human epidermal growth factor receptor 2 (HER2)-positive subpopulation.

METHODS

A total of 3010 patients with node-positive breast cancer were randomly assigned to receive 6 cycles of 500 mg/m² of fluorouracil, 100 mg/m² of epirubicin and 500 mg/m² of cyclophosphamide (FEC) or 75 mg/m² of epirubicin and 75 mg/m² of docetaxel (ED). Patients with HER2-positive tumours were secondary randomly assigned to either trastuzumab or observation. The primary end-point was disease-free survival (DFS) in the two chemotherapy arms.

RESULTS

After a 115-month median follow-up, DFS was not significantly better in the ED arm (DFS: 70%, 95% confidence interval [CI]: 67-72) than in the FEC arm (DFS: 68%, 95% CI: 65-70; hazard ratio [HR] = 0.88, 95% CI: 0.77-1.01; p = 0.064). The OS was not different between FEC (OS: 80%, 95% CI: 78-83) and ED (OS: 81%, 95% CI: 79-83); HR = 0.97, 95% CI: 0.81-1.16; p = 0.729). ED appeared more toxic. In the 528 HER2-positive subset, there was trend for a higher DFS, in the intention-to-treat population, in the trastuzumab arm (DFS: 68%, 95% CI: 61-74) than in the observation arm (DFS: 60%, 95% CI: 54-66; HR = 0.77, 95% CI: 0.57-1.03; p = 0.079). In the per-protocol population, DFS was significantly higher in the trastuzumab arm (DFS: 70%, 95% CI: 63-76) than in the observation arm (DFS: 59%, 95% CI: 53-65; HR = 0.69, 95% CI: 0.51-0.94; p = 0.0156). The OS was not different between these 2 arms.

CONCLUSION

This study did not show superiority of the concomitant anthracycline-taxane arm which was more toxic in high-risk node-positive breast cancer patients. Long-term results of the HER2-positive subpopulation are in line with those of the other adjuvant trastuzumab trials but quantitatively less pronounced mostly because of lack of power.

Factors Affecting Tamoxifen Metabolism in Patients With Breast Cancer: Preliminary Results of the French PHACS Study

In addition to the effect of cytochrome P450 (CYP) 2D6 genetic polymorphisms, the metabolism of tamoxifen may be impacted by other factors with possible consequences on therapeutic outcome (efficacy and toxicity). This analysis focused on the pharmacokinetic (PK)-pharmacogenetic evaluation of tamoxifen in 730 patients with adjuvant breast cancer included in a prospective multicenter study. Plasma concentrations of tamoxifen and six major metabolites, the genotype for 63 single-nucleotide polymorphisms, and comedications were obtained 6 months after treatment initiation. Plasma concentrations of endoxifen were significantly associated with CYP2D6 diplotype (P < 0.0001), CYP3A4*22 genotype (P = 0.0003), and concomitant intake of potent CYP2D6 inhibitors (P < 0.001). Comparison of endoxifen levels showed that the CYP2D6 phenotype classification could be improved by grouping intermediate metabolizer (IM)/IM and IM/poor metabolizer diplotype into IM phenotype for future use in tamoxifen therapy optimization. Finally, the multivariable regression analysis showed that formation of tamoxifen metabolites was independently impacted by CYP2D6 diplotype and CYP3A4*22, CYP2C19*2, and CYP2B6*6 genetic polymorphisms.

Biosimilar filgrastim treatment patterns and prevention of febrile neutropenia: a prospective multicentre study in France in patients with solid tumours (the ZOHé study)

Background

The ZOHé study was a prospective, non-interventional, multicentre study in France to assess the use of biosimilar filgrastim Zarzio® (Sandoz filgrastim) in routine clinical practice in patients at risk of neutropenia-inducing chemotherapy (CT).

Methods

Patients ≥ 18 years undergoing CT for a malignant disease and with a first prescription for Zarzio® were enrolled in two cohorts according to tumour type: solid tumour or haematological malignancy; results from the solid tumour cohort are reported here. Analyses primarily described the prescription and use of Zarzio® in current practice, and also included identification of factors linked to prescription for primary prophylaxis and comparison of Zarzio® use in relation to European Organisation for Research and Treatment of Cancer (EORTC) guidelines.

Results

Responses were obtained from 125 physicians and 1179 patients with solid tumours, allowing robust statistical analysis of the data. Use of Zarzio® in clinical practice was relatively standardised and followed label indication. The patient profile was in line with EORTC guidelines for granulocyte colony-stimulating factor (G-CSF) febrile neutropenia (FN) prophylaxis, and the majority of patients had ≥ 1 EORTC factor(s) for increased risk of febrile neutropenia. Some patients (10.8%) received Zarzio® despite receiving CT regimens categorised in guidelines as low (< 10%) FN risk (‘over prophylaxis’). Nearly half of patients’ CT regimens did not have a recommended FN risk category. Zarzio® was commonly initiated as primary prophylaxis; initiation in Cycle ≥ 2 of the current line of CT was associated more with a history of neutropenia. The safety profile of Zarzio® was confirmed.

Conclusions

Use of Zarzio® in routine clinical practice is generally in line with EORTC guidelines for prophylaxis of CT-induced neutropenia. Patient-related risk factors appear to be a stronger driver of clinicians’ decision to initiate Zarzio® than CT risk category for FN. The intrinsic risk of FN associated with a specific CT protocol is often miscategorised by physicians. In contrast to earlier reports of underuse of G-CSF prophylaxis, over prophylaxis is observed in a small subgroup of patients with FN risk of < 10%.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4986-1) contains supplementary material, which is available to authorized users.

UCBG 2-08: 5-year efficacy results from the UNICANCER-PACS08 randomised phase III trial of adjuvant treatment with FEC100 and then either docetaxel or ixabepilone in patients with early-stage, poor prognosis breast cancer

PURPOSE

UNICANCER-PACS08 compared adjuvant FEC (5-FU; epirubicin; cyclophosphamide) then docetaxel to FEC then ixabepilone in poor prognosis early breast cancer (BC). We evaluated whether replacing docetaxel with ixabepilone would increase 5-year disease-free survival (DFS).

PATIENTS AND METHODS

Triple-negative breast cancer (TNBC) or oestrogen receptor (ER)+/progesterone receptor (PR)-/HER2- BC patients were randomised to receive standard FEC (3 cycles) followed by 3 cycles of either docetaxel (100 mg/m²) or ixabepilone (40 mg/m²). Radiotherapy was mandatory after conservative surgery; ER+ patients received endocrine therapy.

RESULTS

Seven hundred sixty-two patients were enrolled between October 2007 and September 2010. Baseline characteristics were balanced between arms. Median follow-up was 66.7 months. Median DFS was not reached; 5-year DFS rate was 76% with docetaxel and 79% with ixabepilone (hazard ratio [HR] = 0.80; 95% confidence interval [CI] = 0.58-1.10; p = 0.175). Median overall survival (OS) was not reached; 5-year OS rate was 86% versus 84% (HR = 0.97; 95% CI = 0.66-1.42; p = 0.897). TNBC patients treated with ixabepilone had a 23% lower risk of relapse compared to docetaxel (HR for DFS = 0.77; 95% CI = 0.53-1.11; p = 0.168). DFS was longer with ixabepilone than docetaxel in patients with grade II-III lymphocytic infiltration (HR = 0.55; 95% CI = 0.29-1.05; p = 0.063). All patients experienced ≥1 adverse events (AEs): 75% reported grade III-IV AEs and two (<1%) had grade V AEs (both with neutropenia and infection receiving ixabepilone).

CONCLUSION

After adjuvant FEC, ixabepilone was comparable to docetaxel for treating poor prognosis early BC patients. The benefit of ixabepilone in subgroups (patients with TNBC and grade II-III lymphocytic infiltration) requires further evaluation.

Talazoparib in Patients with Advanced Breast Cancer and a Germline BRCA Mutation

BACKGROUND

The poly(adenosine diphosphate-ribose) inhibitor talazoparib has shown antitumor activity in patients with advanced breast cancer and germline mutations in BRCA1 and BRCA2 ( BRCA1/2).

METHODS

We conducted a randomized, open-label, phase 3 trial in which patients with advanced breast cancer and a germline BRCA1/2 mutation were assigned, in a 2:1 ratio, to receive talazoparib (1 mg once daily) or standard single-agent therapy of the physician's choice (capecitabine, eribulin, gemcitabine, or vinorelbine in continuous 21-day cycles). The primary end point was progression-free survival, which was assessed by blinded independent central review.

RESULTS

Of the 431 patients who underwent randomization, 287 were assigned to receive talazoparib and 144 were assigned to receive standard therapy. Median progression-free survival was significantly longer in the talazoparib group than in the standard-therapy group (8.6 months vs. 5.6 months; hazard ratio for disease progression or death, 0.54; 95% confidence interval [CI], 0.41 to 0.71; P<0.001). The interim median hazard ratio for death was 0.76 (95% CI, 0.55 to 1.06; P=0.11 [57% of projected events]). The objective response rate was higher in the talazoparib group than in the standard-therapy group (62.6% vs. 27.2%; odds ratio, 5.0; 95% CI, 2.9 to 8.8; P<0.001). Hematologic grade 3-4 adverse events (primarily anemia) occurred in 55% of the patients who received talazoparib and in 38% of the patients who received standard therapy; nonhematologic grade 3 adverse events occurred in 32% and 38% of the patients, respectively. Patient-reported outcomes favored talazoparib; significant overall improvements and significant delays in the time to clinically meaningful deterioration according to both the global health status-quality-of-life and breast symptoms scales were observed.

CONCLUSIONS

Among patients with advanced breast cancer and a germline BRCA1/2 mutation, single-agent talazoparib provided a significant benefit over standard chemotherapy with respect to progression-free survival. Patient-reported outcomes were superior with talazoparib. (Funded by Medivation [Pfizer]; EMBRACA ClinicalTrials.gov number, NCT01945775 .).

The 21-gene Recurrence Score® assay predicts distant recurrence in lymph node-positive, hormone receptor-positive, breast cancer patients treated with adjuvant sequential epirubicin- and docetaxel-based or epirubicin-based chemotherapy (PACS-01 trial)

Background

The 21-gene Recurrence Score (RS) result predicts outcome and chemotherapy benefit in node-negative and node-positive (N+), estrogen receptor-positive (ER+) patients treated with endocrine therapy. The purpose of this study was to evaluate the prognostic impact of RS results in N+, hormone receptor-positive (HR+) patients treated with adjuvant chemotherapy (6 cycles of FEC100 vs. 3 cycles of FEC100 followed by 3 cycles of docetaxel 100 mg/m²) plus endocrine therapy (ET) in the PACS-01 trial (J Clin Oncol 2006;24:5664-5671).

Methods

The current study included 530 HR+/N+ patients from the PACS-01 parent trial for whom specimens were available. The primary objective was to evaluate the relationship between the RS result and distant recurrence (DR).

Results

There were 209 (39.4%) patients with low RS (< 18), 159 (30%) with intermediate RS (18-30) and 162 (30.6%) with high RS (≥ 31). The continuous RS result was associated with DR (hazard ratio = 4.14; 95% confidence interval: 2.67-6.43; p <  0.001), adjusting for treatment. In multivariable analysis, the RS result remained a significant predictor of DR (p <  0.001) after adjustment for number of positive nodes, tumor size, tumor grade, Ki-67 (immunohistochemical status), and chemotherapy regimen. There was no statistically significant interaction between RS result and treatment in predicting DR (p = 0.79).

Conclusions

After adjustment for clinical covariates, the 21-gene RS result is a significant prognostic factor in N+/HR+ patients receiving adjuvant chemoendocrine therapy.

Trial registration

Not applicable.

Evaluation of the Theoretical Teaching of Postgraduate Radiation Oncology Medical Residents in France: a Cross-Sectional Study

This study's purpose was to have residents evaluate Radiation Oncology (RO) theoretical teaching practices in France. An anonymous electronically cross-functional survey on theoretical teaching practices in the RO residents was conducted by (i) collecting data from residents in the medical faculties in France, (ii) comparing the data across practices when possible and (iii) suggesting means of improvement. A total of 103 out of 140 RO residents responded to the survey (73.5% response rate). National, inter-university, university and internships courses do not exist in 0% (0), 16.5% (17), 53.4% (55) and 40.8% (42) of residents, respectively. Residents need additional training due to the shortage of specialised postgraduate degree training (49.5% (51)), CV enhancement to obtain a post-internship position (49.5% (51)) or as part of a career plan (47.6% (49)). The topics covered in teaching to be improved were the following: basic concept 61.2% (63), advanced concept 61.2 (63) and discussion of frequent clinical cases 50.5% (52). The topics not covered in teaching to be improved were the following: the development of career (66.0% (68)), medical English (56.3% (58)), the organisation of RO speciality (49.5% (51)) and the hospital management of RO department (38.8% (40)). This is the first national assessment of theoretical teaching of RO residents in France.

Abstract P3-12-03: Impact of genetic polymorphisms on plasma levels of tamoxifen and its metabolites and toxicity: 6-months results of the adjuvant breast cancer longitudinal PHACS study (NCT01127295)

Supported by a PHRC grant (#09-18-005)

Background: The role of CYP2D6 genetic polymorphisms and plasma levels of active metabolites of tamoxifen (TAM) on clinical response and occurrence of side effects remains controversial. We conducted a prospective, adjuvant, multicentre, 3-year follow-up study of breast cancer patients in order to evaluate the relationships between pharmacogenetics, pharmacokinetics and toxicity of TAM and its metabolites (n=879) or aromatase inhibitors (AI, n=1098). The present report focuses on the evaluation at 6 months after inclusion of 864 patients treated with 20 mg/day TAM.The clinical results and the AI PG/PK analyses are described elsewhere (abstracts #851544 and #851525).

Methods: Residual plasma concentrations for tamoxifen and its 6 major metabolites (endoxifen ENDO, 4-hydroxy-tamoxifen 4-OH-TAM, N-desmethyl TAM, TAM-N-oxyde, 4'-OH-TAM and Z'ENDO) at 6 months after start of treatment were measured by UPLC-MS/MS in 789 patients. Nine patients with TAM concentrations below the limit of quantification were excluded for non-compliance. SNP genotyping of 95 selected SNPs was performed on the Biomark (Fluidigm) in a microfluidic multiplex 96 dynamic array chip with Taqman assays and was available for 857 patients. Patients were classified according to their CYP2D6 metaboliser status (MS) (PM, IM, EM and UM) based on presence of functional, decreased function or no functional alleles (*4, *6, *7, *9, *10, *17, *41) and number of CYP2D6 copies (*5 or duplication). Metabolic ratios (MR) were calculated for TAM/4-OH-TAM, TAM/N-desmethyl tamoxifen (NDT), NDT/ENDO and 4-OH-TAM/ENDO. Anti-estrogenic activity score (AAS) was calculated according to a recently proposed algorithm (De Vries Schultink et al.,Breast Cancer Res Treat. 2017).Toxicity was measured as a binary outcome (first occurrence or worsening of hot flushes, fatigue, depression, pain, arthralgia, vaginal dryness). All genetic associations were adjusted for multiple testing.

Results: ENDO concentration and AAS increased significantly with CYP2D6 MS (p&lt;0.001). The presence of a CYP3A4*22 allele was significantly associated with endoxifen concentrations; this association remained significant after adjusting for CYP2D6 MS. TAM/4-OH-TAM MR was significantly influenced by the presence of CYP3A4*22, CYP2C19*2 and *17, and CYP2D6 status. The percentage of patients having an AAS&gt;=1798 (i.e., threshold previously associated with recurrence-free survival RFS by De Vries et al. 2017) was 6%, 50%, 84% and 91% of patients respectively classified as PM, IM, EM and UM. Side effects were not significantly associated with higher levels of TAM metabolites concentrations. After correction for multiple testing, SNPs or CYP2D6 MS were not significantly associated with occurrence or worsening of adverse events, premature treatment discontinuations or switch due to toxicity within the first 6 months.

Conclusions: In this large prospective study, we quantified the impact of PG on TAM PK and AAS, previously shown to predict RFS. Although the toxicity observed after 6 months of TAM does not seem correlated with PK or PG, these relationships need to be re-evaluated during the 3-year follow-up.

Citation Format: White-Koning M, Arellano C, Le Morvan V, Evrard A, Puzskiel A, Vachoux C, Dauba J, Houyau P, Poublanc M, Robert J, Boyer J-C, Roché H, Thomas F, Chatelut E. Impact of genetic polymorphisms on plasma levels of tamoxifen and its metabolites and toxicity: 6-months results of the adjuvant breast cancer longitudinal PHACS study (NCT01127295) [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 P3-12-03.

Abstract P1-07-07: Overtime distribution and predictors of local recurrences (LRs) in patients with hormone receptor positive (HR+) and node positive (N+) breast cancers (BCs): 10 -year follow-up analysis of UNICANCER-PACS 01 and PACS04 trials

Purpose:Incidence of LRs in patients (pts) treated for HR+ HER2- localized BC and distribution overtime have not been described in recent years after introduction of new generation of adjuvant therapies and more extensive use of radiotherapy. We evaluated the incidence and distribution overtime of LRs in pts with HR+ HER2- N+ BCs who entered PACS 01 and PACS04 trials.

Patients and Methods: Data were analyzed from 2909 pts with HR+/HER2- BC out of 5008 included in both trials. Pts underwent mastectomy or lumpectomy plus axillary dissection for a localized N+ BC and, according to study design, were randomized to: 6 cycles of FE100C (standard arm) versus FE100C x 3 cycles followed by docetaxel 100 mg/m2 x 3 cycles (FEC-D) (PACS01) or 6 cycles of Epirubicin 75mg/m2 and Docetaxel 75 mg/m2 (ED75)(PACS04). Loco-regional radiotherapy was mandatory after lumpectomy and recommended in other cases. All pts received 5 years of hormone therapy (HT). A competing risk multivariate analysis was conduct using Fine and Gray model to identify risk factors associated to isolated LRs. Competing events were nodal recurrence, contralateral BC, distant metastasis and death. Cumulative incidence associated to each event was estimated by a Kablfleish-Prentice estimator.

Results: Pts' median age was 50 (22-65); 67.2% underwent lumpectomy, 32.8% mastectomy; 67.6% had 1 to 3 N+, 32.4% more than 3 N+; 45.7% had lymphovascular invasion; 49.5% received FE100C, 35.8% ET75, 14.7% had FEC-D; while radiotherapy was given to 97.3% and HT to 92.2%, of whom 90.5% received tamoxifen. At a median follow-up of 9.1 years, 60 pts (2.1%) experienced LR as first event. The 5-year and 10-year cumulative incidence of LRs were 1.04% and 2.53%, respectively. The cumulative incidence of LRs increased from the 5th year, and the annual risk tended to remain constant over time. Multivariate analysis of competing risk showed that younger age, conservative surgery and omission of HT (not prescribed or non-adherence) were independently associated with risk of developing LRs.

Table 1. Multivariate analysis on competing risk of predictors of LRsVariablesHR 95%CIP valueAge at entry (&lt;35 years, ≥ 35)*0.95 [0.92; 0.99]0.009Mastectomy, lumpectomy0.39 [0.17; 0.86]0.020&gt; 20mm, ≤20 mm0.68 [0.37; 1.24]0.203N+ &gt;3, 1-31.73 [0.99; 3.02]0.055Grade II/III, I1.06 [0.50; 2.24]0.885PR+,PR-1.78 [0.70; 4.53]0.223Type of chemotherapy 3FEC-3D, 6FEC/6ET1.32 [0.65; 2.69]0.446Number of cycles 6, &lt;60.71 [0.17; 0.75]0.630Hormone therapy Yes,No0.36 [0.17; 0.75]0.006*treated as continuous variable

Conclusion: Our analysis showed that incidence of LRs in pts with HR+ N+ BCs treated within PACS trials were considerably lower as compared to earlier studies. These findings may reflect differences in treatment era, as the more extensive use of radiotherapy and new generation of adjuvant chemotherapy. Despite current adjuvant strategies, young age at diagnosis and omission of HT remain independent risk factors of LRs.

Citation Format: Pistilli B, Filleron T, Mazouni C, Zingarello A, Lacroix-Triki M, Rivera S, Coudert B, Serin D, Canon J-L, Campone M, Bachelot T, Goncalves A, Levy C, Cottu P, Petit T, Eymard J-C, Tunon De Lara C, Roché H, Roca L, Lemonnier J, Delaloge S. Overtime distribution and predictors of local recurrences (LRs) in patients with hormone receptor positive (HR+) and node positive (N+) breast cancers (BCs): 10 -year follow-up analysis of UNICANCER-PACS 01 and PACS04 trials [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 P1-07-07.

Abstract P3-12-10: First 6-month report of the longitudinal PHACS study (Pharmacology and Hormonotherapy (HT) for Adjuvant breast Cancer (BC) Study, NCT01127295)

Background: BC is a hormone-dependent disease for 75% of pts. HT is used in both adjuvant and metastatic settings for hormone–receptor (HR) positive tumors. In adjuvant situation, a 5-year HT period at least is recommended. Side-effects (SE) frequently alter quality of life and compliance, reducing the well-known benefits in risks of relapses and specific deaths. Underlying mechanisms are well understood for estrogen deprivation-induced events such as hot flashes, but little is known on arthralgia under aromatase inhibitors (AI). So, pharmacogenomics (PG), pharmacokinetics (PK), potential medications interactions are of value to explain individual drugs exposures, possible related side-effects and compliance to treatment.

Methods: We performed a prospective, multicenter, longitudinal study registering early clinical outcomes and SE during the first 3 years of adjuvant HT with tamoxifen (T) or AI. All tumors expressed at least one HR (&gt;10%). The choice of HT molecule and one-drug or sequential treatment were left to the investigator. Pts were followed every 6 months with clinical examination by the referent oncologist and PK sampling each time. Biologic research consisted in PG investigations of different genes involved in the PK and pharmacodynamics of T and AI (95 SNPs) at baseline. SE, concurrent medications and compliance were registered by both the pts on a diary card and the physician. Evaluation was done only on new occurrence or increased grade of symptoms.

Results: This first report focuses on characteristics of the population and the results after the 6 first months of treatment. Between June 2010 and October 2014, 23 centers recruited 2000 pts. 23 were excluded leaving 1977 fully evaluable women; 879 (44%) started with T, 1098 (55%) with AI (554 letrozole (L), 390 anastrozole (A), 154 exemestane (E)). 56% of them had previously received chemotherapy, 96% radiotherapy and 8% trastuzumab.

Main characteristics were well balanced between the 2 classes of drugs; T was given mainly for pre- or perimenopausal pts. Most frequent co-morbidities were hypertension (8% T, 31% AI) and dyslipidemia or diabetes (T 11%, AI 26%). To note, almost 30% of pts described arthralgias at entrance and 37% had hot flashes.

At 6 months, 122 pts (6%; 43 T, 79 AI) had stopped treatment mainly for toxicity (11 T; 12 AI), progression or death (7 T; 4 IA), personal reasons (15 T; 37AI); 4 asked for changing T and 52 AI (equally for the 3 drugs). All these events were significantly more frequent for AI pts (p=0.042) and with E within the AI class (p&lt;0.001).

Main changes in onset or increased intensity of symptoms concerned hot flushes with all drugs (30%), asthenia (20%), insomnia (20%), weight gain (17%), arthralgias (15% for T, 30% for AI), thrombotic events (24 of which 11 with T). 3 grade3 SAE HT-related were reported.

Biological data are reported in 2 other abst. (M. White-Koning. abst.#850248, F. Thomas, abst.#851525).

Conclusions: These preliminary data on the first 6-months exposure to HT on adjuvant setting in the real-life confirm early rates of withdraws and toxicities. Longer follow-up and subsequent PK analysis should help to understand persistent side-effects and reasons for non-compliance to adjuvant HT.

Citation Format: Roché H, Venat-Bouvet L, Debled M, Jacot W, Suc E, Dalenc F, Molnar-Stanciu D, Dohollou N, Franck D, Ferrer C, Laharie-Mineur H, Lavau-Denes S, Massabeau C, Mauries V, Robert J, Pinguet F, Marquet P, Evrard A, Chatelut E, Filleron T. First 6-month report of the longitudinal PHACS study (Pharmacology and Hormonotherapy (HT) for Adjuvant breast Cancer (BC) Study, NCT01127295) [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 P3-12-10.

Abstract PD7-06: MAAT: Menses after adjuvant treatment. Prediction of menses recovery after chemotherapy for early breast cancer (BC) by using a nomogram model in UNICANCER PACS04 and PACS05 trials

Purpose:The likelihood of menses recovery (MR) is largely variable in premenopausal patients (pts) receiving adjuvant chemotherapy for BC. Quantifying this probability for each single patient could impact discussion of chemotherapy side effects and better individualize fertility counseling.We performed a pooled analysis from PACS04 and PACS05 randomized trials aiming to develop a nomogram to estimate the probability of menses recovery at 6 and 18 months (mos) after the end of adjuvant chemotherapy (CT) for premenopausal pts with early BC.

Patients and Methods: The analyzed population consisted of 1683 pts who were premenopausal and ≤ 50 (out of 4524 enrolled in both trials). In PACS05 node-negative BC pts were randomized to 4 or 6 cycles of FE100C (standard arm); in PACS04 node-positive pts were randomized to 6 cycles of FE100C or 6 cycles of Epirubicin 75mg/m2 and Docetaxel 75 mg/m2 (ED75). Endocrine therapy (ET) (Tamoxifen) x 5 years was mandatory for ER+ BC. Variables significantly associated with MR in the univariate analysis (P&lt;0.20) were included in the multivariate analysis. Using this data set, a logistic regression-based nomogram was developed to predict MR at 6 and 18 mos.

Results: Pts' characteristics were: median age 43 (22-50), median body mass index (BMI) at baseline 22.6 (15.6-54.7), at the end of chemotherapy 22.8 (15.8-58.6). ED75 was administrated to 517 (30.7%), while 802 (47.7%) received 6FE100C, 364 (21.6) 4FE100C. Trastuzumab was given to 122 (7.2%), ET to 1229 (73%) pts. CT-induced amenorrhea was observed in 1407 (83.6%) pts. Factors associated to MR were assessed on 1210 pts (excluding pts who recovered menses during CT or of whom date of recovery was not specified). At a median follow-up of 90 mos, 28.2% (342/1210) of pts had recovered menstrual cycles: 11% (133/1210) at 6 mos and 24.3% (294/1210) at 18 mos. Multivariate analysis showed that younger age, higher BMI at the end of CT, non-alkylating agents and absence of ET were independently associated to MR.

Table 1 Multivariate Cox regression analysis of menses recoveryVariablesHR (95%CI)P valueAge1.49 (1.16-1.93)&lt; 0.002Age2*0.99 [0.98-0.99]&lt;0.0001BMI after CT1.02 (0.99-1.04)0.07Alkylating agents0.72 (0.57-0.90)0.004Endocrine Therapy0.50 (0.40-0.62)&lt;0.001* The quadratic term in the age variable accounts for the non-linearity of the relation between the age and the probability of recovering menses. Overall this probability tend to decrease when age increase with a greater decrease for the older patients.

Nomogram concordance-index was 0.749 and 0.750 for predicting MR at 6 and 18 mos respectively. A better calibration was observed at 18 mos, comparing nomogram predictions with the actual probability of MR in the 1210 women.

Conclusion:Our analysis confirmed the possibility of developing a user-friendly nomogram for predicting menses recovery after adjuvant chemotherapy. As next step, we will externally validate our nomogram on CANTO premenopausal population, one of the biggest national cohorts aiming to assess the long-term impact of cancer treatments toxicities (UNICANCER NCT01993498 - http://etudecanto.org/).

Citation Format: Pistilli B, Mazouni C, Zingarello A, Faron M, Saghatchian M, Grynberg M, Spielmann M, Kerbrat P, Roché H, Lorgis V, Bachelot T, Campone M, Levy C, Goncalves A, Lesur A, Veyrat C, Vanlemmens L, Lemonnier J, Delaloge S. MAAT: Menses after adjuvant treatment. Prediction of menses recovery after chemotherapy for early breast cancer (BC) by using a nomogram model in UNICANCER PACS04 and PACS05 trials [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 PD7-06.

Abstract P3-12-07: Pharmacogenetic determinants of aromatase inhibitors pharmacokinetics and side effects: 6-month results of the adjuvant breast cancer longitudinal PHACS study (NCT01127295)

Supported by a PHRC grant (#09-18-005)

Background: Recent literature has suggested that germline genetic variants of drug-metabolizing enzymes or CYP19A1 (coding for aromatase) may be involved in the systemic aromatase inhibitors (AI) concentrations or the occurrence of side effects (Hertz et al. Pharmacogenomics 2017). A prospective multicentre 3-year follow-up study was carried out to investigate the relationships between pharmacogenetics (PG), pharmacokinetics (PK) and toxicity in breast cancer patients treated with adjuvant AI (n=1098) or tamoxifen (n=879). The clinical results and the tamoxifen PG/PK analyses are described elsewhere (abstracts #851544 and #850248).

Methods: SNP genotyping of 95 SNPs was performed on the Biomark (Fluidigm) with Taqman assays and was available for 373, 515 and 151 patients treated with anastrozole (ANA), letrozole (LETRO) and exemestane (EXE) respectively. CYP2A6 metaboliser status (MS) (poor, intermediate or normal) was determined based on alleles function (*1, *9, *2) and number of CYP2A6 copies. Trough plasma concentrations of each drug were determined 6 months after the start of the study by UPLC-MS/MS and were available for 342, 463 and 130 patients of the ANA, LETRO and EXE arms. Patients with AI concentrations below the limit of quantification were excluded for non-compliance (9 patients for ANA, 8 patients for LETRO and 7 patients for EXE). Toxicity was measured as a binary outcome (occurrence or worsening of hot flushes, fatigue, pain, arthralgia, vaginal dryness). All genetic associations were adjusted for multiple testing.

Results: ANA concentration was significantly higher in patients experiencing pain (p=0.025) and was associated with rs28365063 (UGT2B7 g.372A&gt;G).

LETRO concentrations were strongly associated with CYP2A6 metabolizer status (p=0.0001) but did not differ in patients with or without toxicity.

In the EXE arm, patients with hot flushes or arthralgia had a significantly lower level of exemestane (p= 0.0002 and p=0.023 respectively) but since the metabolism of EXE leads to active 17-hydroexemestane, we can hypothesize that the lower EXE concentration is an indirect reflection of the metabolite formation. A SNP (rs2307424) in NR1I3 gene (coding for the constitutive androstane receptor CAR) was associated with EXE concentrations. CAR has been shown to regulate CYP2B6, which is involved in the formation of 6-hydroxy-methyl-exemestane (inactive metabolite).

Regarding the relationships between PG and toxicity, in the ANA arm, 3 SNPs of CYP19A1 gene tended to be associated with hot flushes worsening (rs934635) and arthralgia (rs10046 and rs2304463) but did not remain significant after multiple tests correction. In the EXE arm, several SNPs in NR1I3 gene were associated with fatigue.

In the LETRO arm, patients with a poor CYP2A6 MS had a higher risk of experiencing depression.

Conclusions: Our study confirms the predominant role of CYP2A6 in LETRO PK. To our knowledge, this is the first study to report on the role of UGT2B7 rs28365063 in ANA and NR1I3 in EXE PK and side effects. These relationships need to be re-evaluated with the drug concentrations obtained during the 3-year follow-up.

Citation Format: Thomas F, Marquet P, Pinguet F, White-Koning M, Robert J, Tafzi N, Solassol I, Despax R, Levasseur N, Ellis S, Massoubre A, Mbatchi L, Le Morvan V, Roché H, Chatelut E, Evrard A. Pharmacogenetic determinants of aromatase inhibitors pharmacokinetics and side effects: 6-month results of the adjuvant breast cancer longitudinal PHACS study (NCT01127295) [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 P3-12-07.

Abstract P2-02-05: Persistence of PIK3CA mutations detection in cell free tumor DNA as surrogate markers for hormonosensibility in patients with hormone receptor-positive breast cancer. The miRho clinical study

Background: HT resistance occurs in nearly all patients with mBC. The identification of early predictive biomarkers of HT failure could help tailoring monitoring or an early change in HT. Circulating biomarkers would allow, a global evaluation of all the metastatic sites without the need of invasive biopsies. Mutation in the phosphatidylinositol 3 phosphate kinase gene (PIK3CA) is one of the most frequent events in ER+ BC and has been involved in HT resistance. We evaluated the early predictive value of cell free DNA (cfDNA) PIK3CA detection in a population of first line HT BC patients.

Material and methods: 39 patients treated for an ER+/HER2- metastatic BC by first line HT in 2 French Comprehensive Cancer Centers were prospectively included in a dedicated clinical trial (NCT01612871) between June 2012 and January 2014. Serial blood sampling was performed before the initiation of HT (T0), 4 weeks (T1), 3 months (T3), 6 months (T6) and at tumor progression. Patients were followed until progression or end of the study (2 years follow-up). cfDNA was isolated from plasma using the QiaAmp circulating nucleic acid isolation kit (Qiagen). Mutation detection was performed using droplet digital PCR on a QX100TM system (Bio-Rad). The assay targeted wild type PIK3CA and mutations p.E542K, p.E545K in exon 9 and p.H1047R in exon 20. Target concentration was calculated as copies/reaction and cfDNA concentrations were reported as number of copies/mL of plasma. To assess the limit of detection of the three assays, isogenic reference DNA with known mutant allele frequency was used (Horizon Diagnostics). Based on confidence interval for Poisson parameter, a sample was considered positive if the average mutant copies detected was 4 copies and above per reaction.

Results: Median age of the population was 63 (range 40-86). HT was as follow: letrozole 32, tamoxifen 5, anastrozole 1 and exemestane 1 patients, respectively. Most patients (28, 71.8%) presented with non-measurable disease, precluding a relevant evaluation of predictive factors for response. Progression-free survival (PFS) was used instead as primary endpoint. Serum samples results were available for 37 and 35 patients at T0 and T1 respectively. PIK3CA mutations were present in 10 (27.8%) and 5 (14.3%) cases at T0 and T1 respectively. While presence of a cfDNA PIK3CA mutation in the T0 sample was not associated with PFS, the persistence of a detectable circulating mutation at T1 was highly significant of a worse PFS (40% vs. 76.7% at 1 year; p=0.0053).

Conclusions: In this dedicated clinical trial, 4-weeks persistence of cfDNA PIK3CA mutation appears highly correlated with PFS. Early identification of this mutated population could allow the evaluation of therapies targeting the PI3K/AKT/mTOR pathway in a selected population affected with an unfavorable prognosis. Dedicated studies and ancillary studies of such targeted therapies are warranted.

Citation Format: Jacot W, Dalenc F, Lopez-Crapez E, Chaltiel L, Durigova A, Gros N, Lacaze J-L, Pouderoux S, Gladieff L, Romieu G, Roché H, Filleron T, Lamy P-J. Persistence of PIK3CA mutations detection in cell free tumor DNA as surrogate markers for hormonosensibility in patients with hormone receptor-positive breast cancer. The miRho clinical study [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 P2-02-05.

Choosing a career in oncology: results of a nationwide cross-sectional study

BACKGROUND

Little information is currently available concerning young medical students desire to pursue a career in oncology, or their career expectations.

METHODS

This project is a cross-sectional epidemiological study. A voluntary and anonymous questionnaire was distributed to all young oncologists studying in France between the 2nd of October 2013 and the 23rd of February 2014.

RESULTS

The overall response rate was 75.6%. A total of 505 young oncologists completed the questionnaire. The main determining factors in the decision to practice oncology were the cross-sectional nature of the field (70.8%), the depth and variety of human relations (56.3%) and the multi-disciplinary field of work (50.2%). Most residents would like to complete a rotation outside of their assigned region (59.2%) or abroad (70.2%) in order to acquire additional expertise (67.7%). In addition, most interns would like to undertake a fellowship involving care, teaching and research in order to hone their skills (85.7%) and forge a career in public hospitals (46.4%). Career prospects mainly involve salaried positions in public hospitals. Many young oncologists are concerned about their professional future, due to the shortage of openings (40.8%), the workload (52.8%) and the lack of work-life balance (33.4%).

CONCLUSIONS

This investigation provides a comprehensive profile of the reasons young oncologists chose to pursue a career in oncology, and their career prospects.

Safety Results and Analysis of Eribulin Efficacy according to Previous Microtubules-Inhibitors Sensitivity in the French Prospective Expanded Access Program for Heavily Pre-treated Metastatic Breast Cancer

Purpose

Eribulin is approved for advanced breast cancers refractory to anthracyclines and taxanes. Efficacy according to sensitivity to previous therapies has been poorly explored.

Materials and Methods

Safety data were collected prospectively and we retrospectively collected efficacy data from the five French centres that participated in the Eribulin E7389-G000-398 expanded access program. Our main objectives were exploration of safety and analysis of eribulin efficacy (progression-free survival [PFS] and overall survival [OS]) according to sensitivity to the last microtubule-inhibiting agent administered.

Results

Median eribulin treatment duration was 3.3 months for the 250 patients included in this prospective single-arm study. Two hundreds and thirty-nine patients (95.6%) experienced an adverse event (AE) related to treatment including 129 (51.6%) with grade ≥ 3 AEs. The most frequently observed toxicities were cytopenias (59.6% of included patients), gastro-intestinal disorders (59.2%), and asthenia (56.4%). The most frequent grade 3-4 AE was neutropenia (37.2% with 4.8% febrile neutropenia). Median PFS and OS were 4.6 and 11.8 months, respectively. Patients classified as responders to the last microtubule-inhibiting therapy had a longer OS (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.51 to 0.94; p=0.017), and tended to display a better PFS (HR, 0.78; 95% CI, 0.58 to 1.04; p=0.086). OS improvement was still significant in multivariate analysis (adjusted HR, 0.53; 95% CI, 0.35 to 0.79; p=0.002).

Conclusion

This work based on a prospective study suggests that identification of patients likely to be more sensitive to eribulin could be based on their previous response to microtubules inhibitors.

hnRNP A1-mediated translational regulation of the G quadruplex-containing RON receptor tyrosine kinase mRNA linked to tumor progression

The expression and role of RNA binding proteins (RBPs) controlling mRNA translation during tumor progression remains largely uncharacterized. Analysis by immunohistochemistry of the expression of hnRNP A1, hnRNPH, RBM9/FOX2, SRSF1/ASF/SF2, SRSF2/SC35, SRSF3/SRp20, SRSF7/9G8 in breast tumors shows that the expression of hnRNP A1, but not the other tested RBPs, is associated with metastatic relapse. Strikingly, hnRNP A1, a nuclear splicing regulator, is also present in the cytoplasm of tumor cells of a subset of patients displaying exceedingly worse prognosis. Expression of a cytoplasmic mutant of hnRNP A1 leads to increased translation of the mRNA encoding the tyrosine kinase receptor RON/MTS1R, known for its function in tumor dissemination, and increases cell migration in vitro. hnRNP A1 directly binds to the 5′ untranslated region of the RON mRNA and activates its translation through G-quadruplex RNA secondary structures. The correlation between hnRNP A1 and RON tumoral expression suggests that these findings hold clinical relevance.

RESILIENCE: Phase III Randomized, Double-Blind Trial Comparing Sorafenib With Capecitabine Versus Placebo With Capecitabine in Locally Advanced or Metastatic HER2-Negative Breast Cancer

INTRODUCTION

Sorafenib is a multikinase inhibitor with antiangiogenic/antiproliferative activity. In this randomized, double-blind, placebo-controlled phase III trial, we assessed first- or second-line capecitabine with sorafenib or placebo in patients with locally advanced/metastatic HER2-negative breast cancer resistant to a taxane and anthracycline and with known estrogen/progesterone receptor status.

PATIENTS AND METHODS

A total of 537 patients were randomized to capecitabine 1000 mg/m² orally twice per day for days 1 to 14 every 21 days with oral sorafenib 600 mg/d or placebo. The primary end point was progression-free survival (PFS). Patients were stratified according to hormone receptor status, previous chemotherapies for metastatic breast cancer, and geographic region.

RESULTS

Treatment with sorafenib with capecitabine, compared with capecitabine with placebo, did not prolong median PFS (5.5 vs. 5.4 months; hazard ratio [HR], 0.973; 95% confidence interval [CI], 0.779-1.217; P = .811) or overall survival (OS; 18.9 vs. 20.3 months; HR, 1.195; 95% CI, 0.943-1.513; P = .140); or enhance overall response rate (ORR; 13.5% vs. 15.5%; P = .515). Any grade toxicities (sorafenib vs. placebo) included palmar-plantar erythrodysesthesia syndrome (PPES; 79.2% vs. 59.6%), diarrhea (47.3% vs. 37.8%), mucosal inflammation (15.4% vs. 6.7%), and hypertension (26.2% vs. 5.6%). Grade 3/4 toxicities included PPES (15.4% vs. 7.1%), diarrhea (4.2% vs. 6.4%), and vomiting (3.5% vs. 0.7%).

CONCLUSION

The combination of sorafenib with capecitabine did not improve PFS, OS, or ORR in patients with HER2-negative advanced breast cancer. Rates of Grade 3 toxicities were higher in the sorafenib arm.

New advances in DPYD genotype and risk of severe toxicity under capecitabine

Background

Deficiency in dihydropyrimidine dehydrogenase (DPD) enzyme is the main cause of severe and lethal fluoropyrimidine-related toxicity. Various approaches have been developed for DPD-deficiency screening, including DPYD genotyping and phenotyping. The goal of this prospective observational study was to perform exhaustive exome DPYD sequencing and to examine relationships between DPYD variants and toxicity in advanced breast cancer patients receiving capecitabine.

Methods

Two-hundred forty-three patients were analysed (88.5% capecitabine monotherapy). Grade 3 and grade 4 capecitabine-related digestive and/or neurologic and/or hemato-toxicities were observed in 10.3% and 2.1% of patients, respectively. DPYD exome, along with flanking intronic regions 3’UTR and 5’UTR, were sequenced on MiSeq Illumina. DPD phenotype was assessed by pre-treatment plasma uracil (U) and dihydrouracil (UH2) measurement.

Results

Among the 48 SNPs identified, 19 were located in coding regions, including 3 novel variations, each observed in a single patient (among which, F100L and A26T, both pathogenic in silico). Combined analysis of deleterious variants *2A, I560S (*13) and D949V showed significant association with grade 3–4 toxicity (sensitivity 16.7%, positive predictive value (PPV) 71.4%, relative risk (RR) 6.7, p<0.001) but not with grade 4 toxicity. Considering additional deleterious coding variants D342G, S492L, R592W and F100L increased the sensitivity to 26.7% for grade 3–4 toxicity (PPV 72.7%, RR 7.6, p<0.001), and was significantly associated with grade 4 toxicity (sensitivity 60%, PPV 27.3%, RR 31.4, p = 0.001), suggesting the clinical relevance of extended targeted DPYD genotyping. As compared to extended genotype, combining genotyping (7 variants) and phenotyping (U>16 ng/ml) did not substantially increase the sensitivity, while impairing PPV and RR.

Conclusions

Exploring an extended set of deleterious DPYD variants improves the performance of DPYD genotyping for predicting both grade 3–4 and grade 4 toxicities (digestive and/or neurologic and/or hematotoxicities) related to capecitabine, as compared to conventional genotyping restricted to consensual variants *2A, *13 and D949V.

Circulating oxysterol metabolites as potential new surrogate markers in patients with hormone receptor-positive breast cancer: Results of the OXYTAM study

Accumulating evidence indicates that cholesterol oxygenation products, also known as oxysterols (OS), are involved in breast cancer (BC) promotion. The impact of Tam, as well as aromatase inhibitors (AI), an alternative BC endocrine therapy (ET), on OS metabolism in patients is currently unknown. We conducted a prospective clinical study in BC patients receiving Tam (n=15) or AI (n=14) in adjuvant or in metastatic settings. The primary end point was the feasibility of detecting and quantifying 11 different OS in the circulation of patients before and after 28days of treatment with Tam or AI. Key secondary end points were the measurements of variations in the concentrations of OS according to differences between patients and treatments. OS profiling in the serum of patients was determined by gas chromatography coupled to mass spectrometry. OS profiling was conducted in all patients both at baseline and during treatment regimens. An important inter-individual variability was observed for each OS. Interestingly 5,6β-epoxycholesterol relative concentrations significantly increased in the entire population (p=0.0109), while no increase in Cholestane-triol (CT) levels was measured. Interestingly, we found that, in contrast to AI, Tam therapy significantly decreased blood levels of 24-hydroxycholesterol (24-HC), 7α-HC and 25-HC (a tumor promoter) (p=0.0007, p=0.0231 and p=0.0231, respectively), whereas 4β-HC levels increased (p=0.0010). Interestingly, levels of 27-HC (a tumor promoter) significantly increased in response to AI (p=0.0342), but not Tam treatment. According to these results, specific OS are promising candidate markers of Tam and AI efficacy. Thus, further clinical investigations are needed to confirm the use of oxysterols as biomarkers of both prognosis and/or the efficacy of ET.

External validation of a published nomogram for prediction of brain metastasis in patients with extra-cerebral metastatic breast cancer and risk regression analysis

BACKGROUND

Survival of patients with metastatic breast cancer (MBC) suffering from brain metastasis (BM) is limited and this event is usually fatal. In 2010, the Graesslin's nomogram was published in order to predict subsequent BM in patients with breast cancer (BC) with extra-cerebral metastatic disease. This model aims to select a patient population at high risk for BM and thus will facilitate the design of prevention strategies and/or the impact of early treatment of BM in prospective clinical studies.

PATIENTS AND METHODS

Nomogram external validation was retrospectively applied to patients with BC and later BM between January 2005 and December 2012, treated in our institution. Moreover, risk factors of BM appearance were studied by Fine and Gray's competing risk analysis.

RESULTS

Among 492 patients with MBC, 116 developed subsequent BM. Seventy of them were included for the nomogram validation. The discrimination is good (area under curve = 0.695 [95% confidence interval, 0.61-0.77]). Risk factors of BM appearance are: human epidermal growth factor receptor 2 (HER2) overexpression/amplification, triple-negative BC and number of extra-cerebral metastatic sites (>1). With a competing risk model, we highlight the nomogram interest for HER2+ tumour subgroup exclusively.

CONCLUSION

Graesslin's nomogram external validation demonstrates exportability and reproducibility. Importantly, the competing risk model analysis provides additional information for the design of prospective trials concerning the early diagnosis of BM and/or preventive treatment on high risk patients with extra-cerebral metastatic BC.

How to report toxicity associated with targeted therapies?

BACKGROUND

In the era of personalized medicine, molecularly targeted therapies (MTT) have modified the outcome of some cancer types. The price of tumor control needs to be balanced with toxicity since these new therapies are administered continuously for several months or sometimes for several years. For cytotoxic drugs, the incidence of adverse event (AE) was traditionally reported as frequency and intensity. This simple measure is not sufficient to capture the recurrent nature and duration of AE. This paper presents two methods to better describe the toxicity burden across the time: prevalence and Q-TWiST.

PATIENTS AND METHODS

Limitation of worst-grade method and advantages of prevalence and Q-TWiST in the analysis of toxicity were illustrated using data from a phase II trial and a hypothetically simulated clinical trial.

RESULTS

Prevalence integrates the recurrent nature of AE. Using prevalence, it is possible to obtain a time profile of AE. Q-TWiST method evaluates the weighted time spent in each health state and also considers the recurrent nature of side-effects in order to assess the 'risk-benefit' ratio of a treatment. When interpreting Q-TWiST results, it is necessary to take into account overall survival and progression-free survival and to define a clinically relevant difference according to the setting.

CONCLUSION

The two methods presented here capture different effects. They are helpful for physicians in their treatment choice (balance benefit risk), to counsel patients and to optimize supportive care. In order to ensure consistency and provide critical information required for medical decision-making, it is important to encourage the use of alternative statistical methods in the analysis of toxicities associated with MTT.

CLINICAL TRIAL

NCT00541008.

Coexpression of androgen receptor and FOXA1 in nonmetastatic triple-negative breast cancer: ancillary study from PACS08 trial

AIM

Microarray studies identified a subgroup of molecular apocrine tumors (estrogen receptor [ER] negative/androgen receptor [AR] positive) that express luminal genes including FOXA1. FOXA1 may direct AR to sites normally occupied by ER in luminal tumors, inducing an estrogen-like gene program that stimulated proliferation.

MATERIALS & METHODS

Expression of AR and FOXA1 was evaluated by immunohistochemistry in 592 patients with nonmetastatic triple-negative breast cancer (TNBC).

RESULTS

Coexpression of AR and FOXA1 was found in 15.2% of patients. These tumors were more frequently lobular, found in older patients and exhibited a lower nuclear grade and a greater degree of node involvement. They less often exhibited lymphocytic infiltrate, pushing margins, syncytial architecture, central fibrosis or necrosis.

CONCLUSION

TNBC with coexpression of AR and FOXA1 seems to behave like luminal tumors with a morphological profile distinct from other TNBC. These biomarkers could be useful to identify a subgroup of TNBC and could have future therapeutic implications.

Late epidermal growth factor receptor inhibitor-related papulopustular rash: a distinct clinical entity

We report four patients developing a late form of papulopustular rash induced by epidermal growth factor receptor inhibitors. These patients presented an unusual presentation of acneiform rash, characterized by late development (several months after treatment commenced), localization to the limbs with sparing of the face, and association with severe pruritus and Staphylococcus aureus superinfection in all cases. These clinical symptoms may suggest a distinct mechanism from the early acne-like rash frequently observed with these targeted anticancer therapies. Clinicians should be aware of this delayed adverse event, and we suggest the term 'late acneiform toxicity of EGFR inhibitors (LATE) syndrome' to permit better characterization of this clinical picture.

UNICANCER-PEGASE 07 study: a randomized phase III trial evaluating postoperative docetaxel-5FU regimen after neoadjuvant dose-intense chemotherapy for treatment of inflammatory breast cancer

BACKGROUND

Inflammatory breast cancer (IBC) is a rare and aggressive disease requiring a multimodal treatment. We evaluated the benefit of adding docetaxel-5-fluorouracil (D-5FU) regimen after preoperative dose-intense (DI) epirubicin-cyclophosphamide (EC) and locoregional treatment in IBC patients.

PATIENTS AND METHODS

PEGASE 07 was a national randomized phase III open-label study involving 14 hospitals in France. Women with nonmetastatic IBC were eligible and randomly assigned to receive either four cycles of DI EC (E 150 mg/m(2) and C 4000 mg/m(2) every 3 weeks with repeated hematopoietic stem cell support), then mastectomy with axillary lymph node dissection, and radiotherapy (arm A) or the same treatment followed by four cycles of D-5FU (D 85 mg/m(2), day 1 and 5FU 750 mg/m(2)/day continuous infusion, days 1-5 every 3 weeks) administered postradiotherapy (arm B). Patients with hormone receptor-positive tumors received hormonal therapy. Disease-free survival (DFS) was the primary end point. Secondary end points included tolerance, pathological complete response (pCR) rate, and overall survival (OS).

RESULTS

Between January 2001 and May 2005, 174 patients were enrolled and treated (87 in each arm). Median follow-up was similar in both arms: 59.6 months [95% confidence interval (CI) 58.4-60.3] in arm A and 60.5 months (95% CI 58.3-61.4) in arm B. The estimated 5-year DFS rates were not different: 55% (95% CI 43.9-64.7) in arm A and 55.5% (95% CI 44.3-65.3) in arm B [hazard ratio (HR) = 0.94 (0.61-1.48); P = 0.81]. Identical results were observed for 5-year OS: 70.2% (95% CI 59.1-78.8) in arm A and 70% (95% CI 58.8-78.7) in arm B [HR = 0.93 (0.55-1.60); P = 0.814]. Following DI EC induction, in-breast and global (breast plus nodes) pCR were 28.9% and 20.1%, respectively. Estrogen receptor and pCR status were independently associated with survival.

CONCLUSION

The addition of D-5FU after preoperative DI EC and standard local therapy did not improve DFS in IBC.

CLINICAL TRIAL NUMBER

ClinicalTrials.gov identifier: NCT02324088.

Abstract OT1-1-12: A phase 3, open-label, randomized, parallel, 2-arm multi-center study of the oral PARP inhibitor BMN 673 versus physician's choice in germline BRCA mutation subjects with locally advanced and/or metastatic breast cancer (EMBRACA study)

Background: Poly-ADP-ribose polymerase (PARP) represents a family of enzymes of which at least two (PARP1 and PARP2) play important roles in DNA repair. PARP inhibition induces synthetic lethality in tumor cells bearing mutations in the genes encoding breast cancer susceptibility gene 1 (BRCA 1) and breast cancer susceptibility gene 2 (BRCA 2), both of which are key components in the pathway of homologous recombination DNA repair. BMN 673 is the most potent preclinical PARP inhibitor described to date with the highest efficiency at trapping PARP-DNA complexes (Murai et al, 2014). BMN 673 is a novel and highly potent PARP inhibitor and has shown promising single-agent anti-tumor efficacy in several tumor types in an ongoing Phase 1/2 clinical study.

Methods: The purpose of this multi-center, international, open-label, 2:1 randomized Phase 3 trial (EMBRACA) is to compare the safety and efficacy of BMN 673 versus protocol-specific physician’s choice treatment (capecitabine, eribulin, gemcitabine or vinorelbine) in subjects who have locally advanced and/or metastatic breast cancer with germline BRCA mutations. The primary objective of the study is to compare progression free survival (PFS) of subjects treated with BMN 673 as a monotherapy relative to those treated with protocol-specific physician’s choice treatment. Secondary objectives include objective response rate (ORR), overall survival (OS), safety and pharmacokinetics of BMN 673. Exploratory objectives include duration of response (DOR) and health-related quality of life assessment. Patients may be eligible if they are 18 years or older, have histologically or cytologically confirmed carcinoma of the breast, locally advanced and/or metastatic disease appropriate for systemic single cytotoxic chemotherapy, documentation of a deleterious or pathogenic germline BRCA1 or BRCA2 mutation, ≤ 2 prior chemotherapy-inclusive regimens for locally advanced and/or metastatic disease, prior treatment with a taxane and/or anthracycline in the adjuvant or metastatic setting, ECOG performance status ≤ 1, and no prior platinum treatment for metastatic disease. Patients (n=429) will be randomized 2:1 to receive either BMN 673 oral capsules once daily (1.0 mg/day) in 21-day cycles or protocol-specific physician’s choice treatment. All eligible subjects will receive study drug treatment until disease progression or unacceptable toxicity. This trial is enrolling patients from the United States, Europe, Israel, Asia/Pacific, and South America (NCT01945775).

Citation Format: Jennifer K Litton, Joanne L Blum, Wolfgang Eiermann, Young-Hyuck Im, Miguel Martin, Lida Mina, Henri Roché, Hope S Rugo, Frances Visco, Charlie Zhang, Nathalie A Lokker, Debra L Lounsbury. A phase 3, open-label, randomized, parallel, 2-arm multi-center study of the oral PARP inhibitor BMN 673 versus physician's choice in germline BRCA mutation subjects with locally advanced and/or metastatic breast cancer (EMBRACA study) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr OT1-1-12.

Abstract P4-07-08: Circulating miRNAs as surrogate markers for hormonosensibility in patients with hormone receptor-positive metastatic breast cancer? A pilot study

Backgroud: Clinicians need new predictive biomarkers of response to therapy hormonal in patients with hormone receptor-positive (HR+) breast cancer (BC). Tumor-associated miRNAs are interesting new markers. Several data indicate the extensive alterations in miRNAs regulation upon estrogen pathway and suggest the utility of considering miRNAs expression in the understanding of hormonal therapy efficacy.

Methods: We have conducted a bicentric, prospective clinical trial in patients who must received an anti-estrogen (Tamoxifen) or an aromatase inhibitor (+/- LHRH agonist) in first line for a HR+ metastatic BC. Plasma of patients were collected before the first administration of hormonal therapy (T=0) and after 1 (T=1), 3, 6 months and therafter in case of objective response or/and progression disease. After extraction from plasma expression i) of 372 miRNAs was analyzed on microRNA Ready-to-Use PCR, Human panel I, V3 from Exiqonand ii) of a selection of candidate miRNAs described in the litterature to be associated with estrogen pathway and hormonotherapy response in tissues were analyzed using the BioMark™ 96.96 Dynamic Array (Fluidigm Corporation) with Exiqon primers. The primary end point of our study, was the feasibility of detection of circulating miRNAs as biomarkers in plasma of patients. Key secondary end points were to compare i) the concentration of determinated miRNAs according patients, under therapy hormonam and according the efficacy or not ii) the profile of miRNAs between patients at T=0 + T=1 month and in the same patient under treatment.

Results : From March 2012 to January 2014, 39 patients were enrolled (5 under tamoxifen and 34 under aromatase inhibitor). At first concentration of circulating miRNAs in pools of patient plasmas from T=0 and T=1 was compared by RTqPCR. miRNAs with a significative fold change ratio together with several miRNAs from the litterature were then further analyzed for individual patient plasmas at T=0 and T=1. Several miRNAs and notably miRNAs previously described in breast tumors to be associated with estrogen pathway and hormonotherapy response are well-detected in plasma and, some of them show difference between T=0 and T=1. After univariate and multivariate analysis, the plasma miRNAs significantly associated with a therapy response will be next examined at 3 and 6 months.

Conclusion : This pilot study provides that tumor-associated circulating miRNAs could be measured in the plasma of patients and that alterations in miRNAs concentration upon hormonal therapy could be observed. More results will be presented at the SABCS meeting.

Citation Format: Florence Dalenc, Monia Ouali, Thomas Filleron, Laurence Gladieff, Henri Roché, Jean-Louis Lacaze, William Jacot, Anna Durigova, Anne Pradines, Pauline Bringer, Magali Farella, Gilles Favre. Circulating miRNAs as surrogate markers for hormonosensibility in patients with hormone receptor-positive metastatic breast cancer? A pilot study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-07-08.

Abstract P6-16-07: Predict subsequent brain metastasis in patients with metastatic breast cancer: External validation of a published nomogram and competing risk regression analysis

Backgroud: Brain metastasis (BM) is a fatal event that nontheless alter seriously survival of patients suffering from breast cancer but also reduce their quality of life. Selection of an enriched patients population at high risk for BM is warranted to develope preventive strategies and/or to evaluate the impact early treatment of BM in prospective trials.

Methods: Electronic medical records of patients, treated in the Institut Claudius Regaud, with metastatic breast cancer and without BM at stade IV diagnosis or in the first month, were retrospectively reviewed for the period between January 2005 and December 2012. We first study the Graesslin’s nomogram (J Clin Oncol., 2010; 28(12): 2032-37) characteristics in our patients. The discrimination prediction of subsequent BM was evaluated by the area under the receiver operating characteristic curve (AUC) and we performed the calibration. Moreover, we have evaluated average and maximal errors between predictions and observations obtained from the calibration curve. Then, competing risk analysis was used to identify prognostic factors with time to BM appearance and death before BM.

Results: We identified 446 patients without BM at stage IV diagnosis or in the first month, 70 of them developed subsequent BM. Young age (≤ 50 years) at the diagnosis of breast cancer (p=0.01), ductal carcinoma (p=0.02), negative status of hormone receptor (p&lt;0.0001), HER2 overexpression/ amplification (p&lt;0.0001), grade III of primary tumour (p=0.04) and number of metastatic sites (p=0.05) were significatively associated with subsequent BM. The external validation of Graesslin’s nomogram shows a good discrimination with an AUC of 0.695 [95%CI, 0.61-0.77]. The calibration is correct with an E max = 0.076 and an E avg = 0.37. Interestingly, in our study the cumulative incidence of BM is 5.48%, 12.95% and 18.15% at 1, 3 and 5 years after the diagnosis of stade IV. In contrast, the cumulative incidence of death before the diagnosis of BM is 16.08%, 43.97% and 56.40% respectively. In multivariate analysis, HER2 overexpression/amplification (p&lt;0.0001), triple negative status (p=0.027) and number of metastasis sites (p=0.037) are associated with BM, while age &gt; 50 years (p=0.015) and triple negative status (p&lt;0.001) are associated with death before the BM diagnosis.

Conclusion : We have validate the robustness of Graesslin’s nomogram to predict subsequent BM in patients with metastatic breast cancer and suggest the best utility in patients with HER2+ breast cancer, looking forward new systemic therapies to control non BM in triple negative breast carcinoma.

Citation Format: Ludivine Genre, Henri Roché, Monia Ouali, Thomas Filleron, Florence Dalenc. Predict subsequent brain metastasis in patients with metastatic breast cancer: External validation of a published nomogram and competing risk regression analysis [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-16-07.

Abstract P3-05-12: Circulating oxysterol metabolites as potential new surrogate markers for hormonotherapy in patients with hormone receptor-positive breast cancer? A pilot study

Background: Clinicians need new predictive biomarkers of response to hormonal therapy in patients (pts) with hormone receptor-positive (HR+) breast cancer (BC). Current treatments used the selective estrogen receptor modulator tamoxifen (Tam) or aromatase inhibitors (AI). Several data from the literature and our preclinical results indicate that cholesterol metabolism pathway is involved in BC oncogenesis and sensitivity/resistance to Tam. Our team has established that Tam modulates cholesterol oxydative metabolism and modulate oxysterol (OS) levels in vitro and in vivo on BC cell lines. Tam is a potent inhibitor of the cholesterol-5,6-epoxide hydrolase (ChEH), which led to the accumulation of cholesterol epoxides (CEs) and the inhibition formation of cholesterol triol (CT). Importantly, we found that CEs mediated the cytotoxicity of Tam in BC. Therefore, an increase in CEs, and no increase in CT could be markers of the efficacy of Tam reflecting its inhibition of ChEH in pts. On the other hand 27-hydroxycholesterol (27HC), another OS, is an estrogen receptor ligand with tumor promoter properties in BC. The 27HC level could constitute a new risk factor for BC development that has to be measured. The impact of AI on cholesterol metabolism is totally unknown, it is thus important to study its impact on OS levels in pts.

Methods: We have conducted a monocentric, prospective, clinical trial in pts who must received Tam or AI in adjuvant or metastatic setting for a HR+ BC. The primary end point was the feasibility of detection of circulating OS (CEs, CT and 27HC) in the serum of patients before the first administration of hormonal therapy and at 1 month. Key secondary end points were to measure variations in the concentration of OS according to patients and treatments. 12 different OS including CEs, CT and 27HC were quantified by GC/MS.

Results : bCE relative concentration significantly increased in the entire population (p=0.0109) while no increase in CT was measured under HT treatment establishing that Tam inhibited ChEH in pts. It should be noted that an important inter-individual variability in pts was observed according the OS species considered. AI stimulated the accumulation of βCE (p=0.0022) suggesting that they modulate CEs metabolism. We found that AI were not direct inhibitors of ChEH in BC cells suggesting that they modulate CEs level through a different mechanism than Tam. Importantly, we found that letrozol, but not exemestane or Tam, increased the blood level in 27-HC. This suggests that letrozol increased a factor of BC risk since 27HC is a tumor promoter which may be involved in BC recurrence.

Conclusion: This pilot study provides the first evidence that circulating OS could be measured in the blood of pts with BC. The clinical utility of OS as biomarkers of sensibility/resistance to hormone therapy needs further clinical investigations. Based on the present study the CE/27HC ratio should be more specifically investigated. The mechanisms involved in the modulation of OS by AI deserve further studies.

Citation Format: Florence Dalenc, Luggi Iuliano, Thomas Filleron, Maud Voisin, Henri Roché, Sandrine Silvente-Poirot, Marc Poirot. Circulating oxysterol metabolites as potential new surrogate markers for hormonotherapy in patients with hormone receptor-positive breast cancer? A pilot study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-05-12.

Trebananib (AMG 386) plus weekly paclitaxel with or without bevacizumab as first-line therapy for HER2-negative locally recurrent or metastatic breast cancer: A phase 2 randomized study

INTRODUCTION

This phase 2 randomized study evaluated trebananib (AMG 386), a peptide-Fc fusion protein that inhibits angiogenesis by neutralizing the interaction of angiopoietin-1 and -2 with Tie2, in combination with paclitaxel with or without bevacizumab in previously untreated patients with HER2-negative locally recurrent/metastatic breast cancer.

METHODS

Patients received paclitaxel 90 mg/m(2) once weekly (3-weeks-on/1-week-off) and were randomly assigned 1:1:1:1 to also receive blinded bevacizumab 10 mg/kg once every 2 weeks plus either trebananib 10 mg/kg once weekly (Arm A) or 3 mg/kg once weekly (Arm B), or placebo (Arm C); or open-label trebananib 10 mg/kg once a week (Arm D). Progression-free survival was the primary endpoint.

RESULTS

In total, 228 patients were randomized. Median estimated progression-free survival for Arms A, B, C, and D was 11.3, 9.2, 12.2, and 10 months, respectively. Hazard ratios (95% CI) for Arms A, B, and D versus Arm C were 0.98 (0.61-1.59), 1.12 (0.70-1.80), and 1.28 (0.79-2.09), respectively. The objective response rate was 71% in Arm A, 51% in Arm B, 60% in Arm C, and 46% in Arm D. The incidence of grade 3/4/5 adverse events was 71/9/4%, 61/14/5%, 62/16/3%, and 52/4/7% in Arms A/B/C/D. In Arm D, median progression-free survival was 12.8 and 7.4 months for those with high and low trebananib exposure (AUCss ≥ 8.4 versus < 8.4 mg·h/mL), respectively.

CONCLUSIONS

There was no apparent prolongation of estimated progression-free survival with the addition of trebananib to paclitaxel and bevacizumab at the doses tested. Toxicity was manageable. Exposure-response analyses support evaluation of combinations incorporating trebananib at doses > 10 mg/kg in this setting.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00511459.

Identification by array comparative genomic hybridization of a new amplicon on chromosome 17q highly recurrent in BRCA1 mutated triple negative breast cancer

INTRODUCTION

Triple Negative Breast Cancers (TNBC) represent about 12% to 20% of all breast cancers (BC) and have a worse outcome compared to other BC subtypes. TNBC often show a deficiency in DNA double-strand break repair mechanisms. This is generally related to the inactivation of a repair enzymatic complex involving BRCA1 caused either by genetic mutations, epigenetic modifications or by post-transcriptional regulations. The identification of new molecular biomarkers that would allow the rapid identification of BC presenting a BRCA1 deficiency could be useful to select patients who could benefit from PARP inhibitors, alkylating agents or platinum-based chemotherapy.

METHODS

Genomic DNA from 131 formalin-fixed paraffin-embedded (FFPE) tumors (luminal A and B, HER2+ and triple negative BC) with known BRCA1 mutation status or unscreened for BRCA1 mutation were analysed by array Comparative Genomic Hybridization (array CGH). One highly significant and recurrent gain in the 17q25.3 genomic region was analysed by fluorescent in situ hybridization (FISH). Expression of the genes of the 17q25.3 amplicon was studied using customized Taqman low density arrays and single Taqman assays (Applied Biosystems).

RESULTS

We identified by array CGH and confirmed by FISH a gain in the 17q25.3 genomic region in 90% of the BRCA1 mutated tumors. This chromosomal gain was present in only 28.6% of the BRCA1 non-mutated TNBC, 26.7% of the unscreened TNBC, 13.6% of the luminal B, 19.0% of the HER2+ and 0% of the luminal A breast cancers. The 17q25.3 gain was also detected in 50% of the TNBC with BRCA1 promoter methylation. Interestingly, BRCA1 promoter methylation was never detected in BRCA1 mutated BC. Gene expression analyses of the 17q25.3 sub-region showed a significant over-expression of 17 genes in BRCA1 mutated TNBC (n = 15) as compared to the BRCA1 non mutated TNBC (n = 13).

CONCLUSIONS

In this study, we have identified by array CGH and confirmed by FISH a recurrent gain in 17q25.3 significantly associated to BRCA1 mutated TNBC. Up-regulated genes in the 17q25.3 amplicon might represent potential therapeutic targets and warrant further investigation.

Ixabepilone alone or with cetuximab as first-line treatment for advanced/metastatic triple-negative breast cancer

BACKGROUND

Despite high initial sensitivity to chemotherapy, TNBC is associated with a poor prognosis, highlighting the need for novel therapeutic strategies. The aim of this multicenter, randomized, open-label phase II trial was to assess the efficacy of ixabepilone as monotherapy, and the combination of ixabepilone with cetuximab, as first-line treatment in patients with triple-negative locally advanced nonresectable and/or metastatic breast cancer.

PATIENTS AND METHODS

Women were randomly assigned to receive either ixabepilone (40 mg/m(2)) every 21 days (n = 40), or ixabepilone (40 mg/m(2)) every 21 days with cetuximab (400 mg/m(2) loading dose, followed by 250 mg/m(2)) once weekly (n = 39). The primary end point of the trial was to estimate the response rates of ixabepilone monotherapy and ixabepilone with cetuximab combination therapy.

RESULTS

Of 79 randomized patients, 77 were treated. Based on an intent-to-treat analysis, an objective response rate of 30% (95% confidence interval [CI], 16.6-46.5) was observed in the monotherapy arm, and 35.9% (95% CI, 21.2-52.8) in the combination arm. Median progression-free survival was 4.1 months in both treatment groups. Safety findings were consistent with the known individual toxicity profiles of ixabepilone and cetuximab. Skin and subcutaneous tissue disorders were more common with combination therapy, as were discontinuations because of adverse events.

CONCLUSION

Ixabepilone monotherapy and the ixabepilone and cetuximab combination demonstrated similar levels of clinical activity in first-line treatment of advanced TNBC, with a predictable safety profile. Further investigation of novel therapies for TNBC is required to improve patient outcomes.

Ado-trastuzumab emtansine-associated telangiectasias in metastatic breast cancer: a case series

Treatment of HER2-positive metastatic breast cancer with ado-trastuzumab emtansine (T-DM1), a novel antibody-drug conjugate, has resulted in both improved progression-free and overall survival. Recognition and treatment of diverse adverse events related to T-DM1 is critical for safety and tolerability. The most frequent adverse events with T-DM1 include fatigue, diarrhea, anemia, elevated transaminases, and mild-to-moderate hemorrhagic events, which are thought to be related to induced thrombocytopenia. Here, we present five case series of cutaneous and mucosal telangiectasias, definitely related to T-DM1. The development of telangiectasias represents a newly recognized adverse effect of T-DM1. We provide description and timing of the telangiectasias and review the mechanisms that may explain the formation of these vascular lesions in association with T-DM1. Further, we describe associated bleeding events and propose that induced telangiectasias could represent an additional cause of T-DM1-associated hemorrhage.

[Breast ductal carcinoma in situ with microinvasion: pathological review and clinical implications]

PURPOSE

Recent improvements in the detection of breast cancer at an early stage have resulted in a rising incidence of breast ductal carcinoma in situ with microinvasion. So far, there is no consensus regarding its optimal management. We hereby report on our 10-year single institutional experience in breast ductal carcinoma in situ with microinvasion including pathological reviewing.

PATIENTS AND METHODS

All consecutive patients treated for a ductal carcinoma in situ with microinvasion at the Institut Claudius-Regaud (Toulouse, France) over a 10-year period were included in this study. We reviewed all available histological materials.

RESULTS

Sixty-three patients were eligible for this study. Two patients presented with a lymph node invasion at diagnosis. Each patient benefited from initial surgical management, which consisted either in mastectomy (n=25) or conservative resection (n=37). Axillary exploration was performed in 52 patients (82%). After a median follow-up of 61.3 months [46.9;69], the 5-year overall survival and disease free survival were 98.2 (95% CI=[88.2;99.7]) and 89.5% (95% CI=[76.3;95.6]) respectively. Two delayed invasive relapses occurred leading to one specific death. The pathological review highlighted a trend towards a loss of HR and HER2 expression (9%) in the microinvasive component in comparison with its surrounded in situ carcinoma.

CONCLUSION

The risk of initial lymph node involvement and delayed invasive local relapse deserve an optimal locoregional management including lymph node evaluation. The non-negligible discrepancy's rate between in situ and microinvasive components justifies HR status and HER2 expression assessment on the microinvasive component.

Abstract P6-12-08: Serum biomarkers identification using quantitative proteomics in patients with HER2-positive inflammatory breast cancer receiving trastuzumab plus bevacizumab-based chemotherapy (BEVERLY 2 trial)

Background

Inflammatory breast cancer (IBC) is a rare but aggressive form of locally advanced breast cancer, the optimal systemic treatment of which is still discussed. Beverly 2 trial was a phase II study evaluating the efficacy and safety of a preoperative regimen associating bevacizumab, trastuzumab, and chemotherapy in 52 patients with non-metastatic HER2-positive IBC, reporting a promising rate of pathological complete response (pCR, 63.5%, 95% CI 49.4–77.5; Pierga et al, Lancet Oncol, 2012). During the study, serum samples were collected at baseline and subjected to proteomic-based approaches to identify circulating biomarkers predictive of treatment response.

Methods

Baseline serum samples from responsive (pCR, according to Sataloff classification, n = 12) and non-responsive (no pCR, n = 11) patients were subjected to isobaric Tag for Relative and Absolute Quantification (iTRAQ)-based proteomics. Samples were pooled according to pCR and hormone receptor (HR) status, to constitute 4 independent mixes (pCR/HR-positive, pCR/HR-negative, nopCR/HR-positive, nopCR/HR-negative). Each of them underwent immuno-depletion of highly abundant proteins, concentration, reduction, alkylation and tryptic digestion. Then, each mix was fractionated and subjected to iTRAQ identification and quantitation using nano-liquid chromatography (LC) and electrospray ionisation (ESI)-orbitrap tandem mass spectrometry (MS/MS) (LTQ-orbitrap, Thermofisher). Differentially expressed proteins were analysed using IPA (IngenuitySystems) to highlight biological functions and signalling pathways that were most significantly enriched.

Results

iTRAQ-based measurements identified and quantified a total of 302 serum proteins. Among them, 48 proteins displayed a significant (fold-change &gt; 1.5 and p-value &lt; 0.05) differential expression between pCR and noPCR pts (18 proteins down-regultated and 30 proteins up-regulated in pCR patients), some of them previously described to be involved in breast cancer biology and/or angiogenesis, including : Alpha-1-acid glycoprotein 1, von Willebrand factor, Galectin-3-binding protein, serum amyloid A-1, Apolipoprotein E, Pigment epithelium-derived factor, Corticosteroid-binding globulin (down-regulated proteins in pCR patients); serum amyloid P-component, angiotensinogen, plasma serine protease inhibitor, carbonic anhydrase 1, mannose-binding protein C, hyaluronan-binding protein 2, peroxiredoxin-2, properdin, ADAMTS13, tetranectin, biotinidase, lumican (up-regulated proteins in pCR patients). Proteins with differential expression during treatment were involved in various biological processes, including cell-to-cell signaling and interaction, lipid metabolism, small molecule biochemistry, molecular transport, cellular function and maintenance as well as various canonical pathways such as acute phase response signalling, LXR/RXR activation and coagulation system.

Conclusion

iTRAQ-based quantitative proteomics identify serum proteins that could predict the therapeutic response to pre-operative trastuzumab plus bevacizumab-based chemotherapy in HER2-positive IBC.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-12-08.

Correlation of HER2, FCGR2A, and FCGR3A gene polymorphisms with trastuzumab related cardiac toxicity and efficacy in a subgroup of patients from UNICANCER-PACS 04 trial

The purpose of this study was to investigate, in the context of a prospective node-positive-breast cancer trial HER2 containing-regimen (UNICANCER-PACS 04 trial), the predictive value of HER2, FCGRIIA, and FCGRIIIA gene polymorphisms for cardiac toxicity and efficacy of trastuzumab. We analyzed HER2-I655V, FCGR2A-H131R, and FCGR3A-V158F single nucleotide polymorphisms in patients in adjuvant setting treated by six courses of either fluorouracil 500 mg/m(2), epirubicin 100 mg/m(2) and cyclophosphamide 500 mg/m(2), or epirubicin 75 mg/m(2) and docetaxel 75 mg/m(2) every 3 weeks then randomly assigned, in case of HER2 overexpressing tumor, to either trastuzumab for 1 year or nothing. Left ventricular ejection fraction and clinical examination were monitored in each patient, seven times throughout the study to detect congestive heart failure or asymptomatic subclinical cardiac toxicity. All genotypes were analyzed in relation to cardiac toxicity, EFS, and OS. One hundred and thirty-two HER2-positive breast cancer patients were analyzed. The HER2-I655V genotype was significantly associated with cardiac toxicity (p = 0.025). The FCGR2A-131 H/H genotype was significantly correlated with a shorter EFS (p = 0.027). The FCGR3A-158 V/V genotype was not correlated with EFS nor OS. These results might be useful in making a treatment choice of HER2 blockers in adjuvant setting by with an increase in efficacy and decrease in toxicity.