Abemaciclib plus a nonsteroidal aromatase inhibitor as initial therapy for HR+, HER2- advanced breast cancer: Final overall survival results of MONARCH 3

BACKGROUND

In MONARCH 2, the addition of abemaciclib to fulvestrant significantly improved both progression-free survival (PFS) and overall survival (OS) in patients with HR+, HER2- advanced breast cancer (ABC) with disease progression on prior endocrine therapy (ET). In MONARCH 3, the addition of abemaciclib to a nonsteroidal aromatase inhibitor (NSAI) as initial therapy for HR+, HER2- ABC significantly improved PFS. Here, we present the prespecified final OS results for MONARCH 3.

PATIENTS AND METHODS

MONARCH 3 is a randomized, double-blind, phase 3 study of abemaciclib plus NSAI (anastrozole or letrozole) versus placebo plus NSAI in postmenopausal women with HR+, HER2- ABC without prior systemic therapy in the advanced setting. The primary objective was investigator-assessed PFS; OS was a gated secondary endpoint, and chemotherapy-free survival (CFS) was an exploratory endpoint.

RESULTS

A total of 493 women were randomized 2:1 to receive abemaciclib plus NSAI (n = 328) or placebo plus NSAI (n = 165). After a median follow-up of 8.1 years, there were 198 OS events (60.4%) in the abemaciclib arm and 116 (70.3%) in the placebo arm (hazard ratio, 0.804; 95% confidence interval [CI], 0.637-1.015; P = 0.0664, non-significant). Median OS was 66.8 versus 53.7 months for abemaciclib versus placebo. In the subgroup with visceral disease (sVD), there were 113 OS events (65.3%) in the abemaciclib arm and 65 (72.2%) in the placebo arm (hazard ratio, 0.758; 95% CI, 0.558-1.030; P = 0.0757, non-significant). Median OS was 63.7 months versus 48.8 months for abemaciclib versus placebo. The previously demonstrated PFS benefit was sustained, and CFS numerically improved with the addition of abemaciclib. No new safety signals were observed.

CONCLUSION

Abemaciclib combined with an NSAI resulted in clinically meaningful improvement in median OS (ITT: 13.1 months; sVD: 14.9 months) in patients with HR+ HER2- ABC; however, statistical significance was not reached.

Open questions, current challenges, and future perspectives in targeting human epidermal growth factor receptor 2-low breast cancer

Approximately 60% of traditionally defined human epidermal growth factor receptor 2 (HER2)-negative breast cancers express low levels of HER2 [HER2-low; defined as immunohistochemistry (IHC) 1+ or IHC 2+/in situ hybridization (ISH)-]. HER2-low breast cancers encompass a large percentage of both hormone receptor-positive (up to 85%) and triple-negative (up to 63%) breast cancers. The DESTINY-Breast04 trial established that HER2-low tumors are targetable, leading to the approval of trastuzumab deruxtecan (T-DXd) as the first HER2-directed therapy for the treatment of HER2-low breast cancer in the United States and Europe. This change in the clinical landscape results in a number of questions and challenges-including those related to HER2 assessment and patient identification-and highlights the need for careful assessment of HER2 expression to identify patients eligible for T-DXd. This review provides context for understanding how to identify patients with HER2-low breast cancer with respect to sample types, scoring and reporting HER2 status, and testing methods and assays. It also discusses management of important T-DXd-related adverse events. Available evidence supports the efficacy of T-DXd in patients with any history of IHC 1+ or IHC 2+/ISH- scores; however, future research may further refine the population who could benefit from T-DXd or other HER2-directed therapies and identify novel methods for patient identification. Because HER2 expression can change with disease progression or treatment, and variability exists in scoring and interpretation of HER2 status, careful re-evaluation in certain scenarios may help to identify more patients who may benefit from T-DXd.

Response-guided neoadjuvant sacituzumab govitecan for localized triple-negative breast cancer: results from the NeoSTAR trial

BACKGROUND

Sacituzumab govitecan (SG), a novel antibody-drug conjugate (ADC) targeting TROP2, is approved for pre-treated metastatic triple-negative breast cancer (mTNBC). We conducted an investigator-initiated clinical trial evaluating neoadjuvant (NA) SG (NCT04230109), and report primary results.

PATIENTS AND METHODS

Participants with early-stage TNBC received NA SG for four cycles. The primary objective was to assess pathological complete response (pCR) rate in breast and lymph nodes (ypT0/isN0) to SG. Secondary objectives included overall response rate (ORR), safety, event-free survival (EFS), and predictive biomarkers. A response-guided approach was utilized, and subsequent systemic therapy decisions were at the discretion of the treating physician.

RESULTS

From July 2020 to August 2021, 50 participants were enrolled (median age = 48.5 years; 13 clinical stage I disease, 26 stage II, 11 stage III). Forty-nine (98%) completed four cycles of SG. Overall, the pCR rate with SG alone was 30% [n = 15, 95% confidence interval (CI) 18% to 45%]. The ORR per RECIST V1.1 after SG alone was 64% (n = 32/50, 95% CI 77% to 98%). Higher Ki-67 and tumor-infiltrating lymphocytes (TILs) were predictive of pCR to SG (P = 0.007 for Ki-67 and 0.002 for TILs), while baseline TROP2 expression was not (P = 0.440). Common adverse events were nausea (82%), fatigue (76%), alopecia (76%), neutropenia (44%), and rash (48%). With a median follow-up time of 18.9 months (95% CI 16.3-21.9 months), the 2-year EFS for all participants was 95%. Among participants with a pCR with SG (n = 15), the 2-year EFS was 100%.

CONCLUSIONS

In the first NA trial with an ADC in localized TNBC, SG demonstrated single-agent efficacy and feasibility of response-guided escalation/de-escalation. Further research on optimal duration of SG as well as NA combination strategies, including immunotherapy, are needed.

Prognostic value of HER2DX in early-stage HER2-positive breast cancer: a comprehensive analysis of 757 patients in the Sweden Cancerome Analysis Network-Breast dataset (SCAN-B)

BACKGROUND

The HER2DX risk-score has undergone rigorous validation in prior investigations involving patients with early-stage human epidermal growth factor receptor 2 (HER2)-positive (HER2+) breast cancer. In this study, we present the outcomes of the HER2DX risk-score within the most recent release of the Sweden Cancerome Analysis Network-Breast (SCAN-B) HER2+ cohort. This updated examination benefits from a larger patient sample, an extended follow-up duration, and detailed treatment information.

MATERIALS AND METHODS

Clinical and RNAseq data from the SCAN-B dataset were retrieved from Gene Expression Omnibus (GSE81538). Among the 6600 patients, 819 had HER2+ breast cancer, with 757 individuals with research-based HER2DX risk-scores and corresponding survival outcomes. The HER2DX risk-score was evaluated (i) as a continuous variable and (ii) using predefined cut-offs. The primary endpoint for this study was overall survival (OS). The Kaplan-Meier method and Cox models were used to estimate OS and a multistate model with four states was fitted to better characterize patients' follow-up.

RESULTS

The median follow-up time was 7.5 years (n = 757). The most common systemic therapy was chemotherapy with trastuzumab (82.0%) and most tumors were classified as T1-T2 (97.1%). The HER2DX risk-score as a continuous variable was significantly associated with OS after adjustment for clinical variables and treatment regimen [hazard ratios (HR) per 10-unit increment = 1.31, 95% confidence interval (CI) 1.13-1.51, P < 0.001] as well as within predefined risk groups (high versus low; HR = 2.57, 95% CI 1.36-4.85, P < 0.001). Patients classified as HER2DX high-risk also had higher risk of (i) breast cancer recurrence and (ii) death without previous recurrence. Within the subgroup of HER2+ T1N0 tumors (n = 297), those classified as high-risk demonstrated inferior OS compared to low-risk tumors (7-year OS 77.8% versus 96.8%, P < 0.001). The HER2DX mRNA ERBB2 score was associated with clinical HER2 status (area under the receiver operating characteristic curve = 0.91).

CONCLUSIONS

In patients with early-stage HER2+ breast cancer, HER2DX risk-score provides prognostic information beyond clinicopathological variables, including treatment regimen with or without trastuzumab.

Association of HER2DX with pathological complete response and survival outcomes in HER2-positive breast cancer

BACKGROUND

The HER2DX genomic test predicts pathological complete response (pCR) and survival outcome in early-stage HER2-positive (HER2+) breast cancer. Here, we evaluated the association of HER2DX scores with (i) pCR according to hormone receptor status and various treatment regimens, and (ii) survival outcome according to pCR status.

MATERIALS AND METHODS

Seven neoadjuvant cohorts with HER2DX and clinical individual patient data were evaluated (DAPHNe, GOM-HGUGM-2018-05, CALGB-40601, ISPY-2, BiOnHER, NEOHER and PAMELA). All patients were treated with neoadjuvant trastuzumab (n = 765) in combination with pertuzumab (n = 328), lapatinib (n = 187) or without a second anti-HER2 drug (n = 250). Event-free survival (EFS) and overall survival (OS) outcomes were available in a combined series of 268 patients (i.e. NEOHER and PAMELA) with a pCR (n = 118) and without a pCR (n = 150). Cox models were adjusted to evaluate whether HER2DX can identify patients with low or high risk beyond pCR status.

RESULTS

HER2DX pCR score was significantly associated with pCR in all patients [odds ratio (OR) per 10-unit increase = 1.59, 95% confidence interval 1.43-1.77; area under the ROC curve = 0.75], with or without dual HER2 blockade. A statistically significant increase in pCR rate due to dual HER2 blockade over trastuzumab-only was observed in HER2DX pCR-high tumors treated with chemotherapy (OR = 2.36 (1.09-5.42). A statistically significant increase in pCR rate due to multi-agent chemotherapy over a single taxane was observed in HER2DX pCR-medium tumors treated with dual HER2 blockade (OR = 3.11, 1.54-6.49). The pCR rates in HER2DX pCR-low tumors were ≤30.0% regardless of treatment administered. After adjusting by pCR status, patients identified as HER2DX low-risk had better EFS (P < 0.001) and OS (P = 0.006) compared with patients with HER2DX high-risk.

CONCLUSIONS

HER2DX pCR score and risk score might help identify ideal candidates to receive neoadjuvant dual HER2 blockade in combination with a single taxane in early-stage HER2+ breast cancer.

Management of patients with HER2-positive metastatic breast cancer after trastuzumab deruxtecan failure

The current treatment of patients with human epidermal growth factor receptor 2 (HER2)-positive advanced breast cancer (ABC) has been greatly impacted in the past decade by the introduction of antibody-drug conjugates (ADCs), which represent a relatively novel therapeutic class with the peculiar ability to deliver otherwise overtly toxic chemotherapeutics to tumor sites by exploiting the specificities of monoclonal antibodies. Indeed, drug engineering refinements in ADC design, such as through the introduction of cleavable linkers and hydrophobic payloads, resulted in improved patient outcomes in recent years. Two different ADCs, namely trastuzumab emtansine (T-DM1) and trastuzumab deruxtecan (T-DXd), have already entered clinical practice for the treatment of HER2-positive ABC. In this scenario, T-DXd has shown to portend better survival outcomes compared to T-DM1, while leaving a large unsought area of unmet medical need upon T-DXd failure. Treatment decision and benefit of cancer drugs following T-DXd still represent an area of clinical controversy, where a preclinical investigation and clinical development should be prioritized. As the pace of innovation is currently accelerating, and with novel ADC formulations advancing in early-phase clinical trials, the whole BC field is changing at an unprecedented rate, with potential broadenings of therapeutic indications. In this review, we present the clinical landscape of HER2-positive advanced BC and discuss our vision on how to tackle T-DXd resistance, providing a perspective on the priority areas of the cancer research in this setting.

ESMO expert consensus statements (ECS) on the definition, diagnosis, and management of HER2-low breast cancer

Human epidermal growth factor receptor 2 (HER2)-low breast cancer has recently emerged as a targetable subset of breast tumors, based on the evidence from clinical trials of novel anti-HER2 antibody-drug conjugates. This evolution has raised several biological and clinical questions, warranting the establishment of consensus to optimally treat patients with HER2-low breast tumors. Between 2022 and 2023, the European Society for Medical Oncology (ESMO) held a virtual consensus-building process focused on HER2-low breast cancer. The consensus included a multidisciplinary panel of 32 leading experts in the management of breast cancer from nine different countries. The aim of the consensus was to develop statements on topics that are not covered in detail in the current ESMO Clinical Practice Guideline. The main topics identified for discussion were (i) biology of HER2-low breast cancer; (ii) pathologic diagnosis of HER2-low breast cancer; (iii) clinical management of HER2-low metastatic breast cancer; and (iv) clinical trial design for HER2-low breast cancer. The expert panel was divided into four working groups to address questions relating to one of the four topics outlined above. A review of the relevant scientific literature was conducted in advance. Consensus statements were developed by the working groups and then presented to the entire panel for further discussion and amendment before voting. This article presents the developed statements, including findings from the expert panel discussions, expert opinion, and a summary of evidence supporting each statement.

Associations between KIR/KIR-ligand genotypes and clinical outcome for patients with advanced solid tumors receiving BEMPEG plus nivolumab combination therapy in the PIVOT-02 trial

Bempegaldesleukin (BEMPEG), a CD122-preferential IL2 pathway agonist, has been shown to induce proliferation and activation of NK cells. NK activation is dependent on the balance of inhibitory and excitatory signals transmitted by NK receptors, including Fc-gamma receptors (FCγRs) and killer immunoglobulin-like receptors (KIRs) along with their KIR-ligands. The repertoire of KIRs/KIR-ligands an individual inherits and the single-nucleotide polymorphisms (SNPs) of FCγRs can influence NK function and affect responses to immunotherapies. In this retrospective analysis of the single-arm PIVOT-02 trial, 200 patients with advanced solid tumors were genotyped for KIR/KIR-ligand gene status and FCγR SNP status and evaluated for associations with clinical outcome. Patients with inhibitory KIR2DL2 and its ligand (HLA-C1) observed significantly greater tumor shrinkage (TS, median change -13.0 vs. 0%) and increased PFS (5.5 vs. 3.3 months) and a trend toward improved OR (31.2 vs. 19.5%) compared to patients with the complementary genotype. Furthermore, patients with KIR2DL2 and its ligand together with inhibitory KIR3DL1 and its ligand (HLA-Bw4) had improved OR (36.5 vs. 19.6%), greater TS (median change -16.1 vs. 0%), and a trend toward prolonged PFS (8.4 vs. 3.6 months) as compared to patients with the complementary genotype. FCγR polymorphisms did not influence OR/PFS/TS.These data show that clinical response to BEMPEG plus nivolumab treatment in the PIVOT-02 trial may be associated with the repertoire of KIR/KIR-ligands an individual inherits. Further investigation and validation of these results may enable KIR/KIR-ligand genotyping to be utilized prospectively for identifying patients likely to benefit from certain cancer immunotherapy regimens.

Oncology clinical trial disruption during the COVID-19 pandemic: a COVID-19 and cancer outcomes study

Background

COVID-19 disproportionately impacted patients with cancer as a result of direct infection, and delays in diagnosis and therapy. Oncological clinical trials are resource-intensive endeavors that could be particularly susceptible to disruption by the pandemic, but few studies have evaluated the impact of the pandemic on clinical trial conduct.

Patients and methods

This prospective, multicenter study assesses the impact of the pandemic on therapeutic clinical trials at two large academic centers in the Northeastern United States between December 2019 and June 2021. The primary objective was to assess the enrollment on, accrual to, and activation of oncology therapeutic clinical trials during the pandemic using an institution-wide cohort of (i) new patient accruals to oncological trials, (ii) a manually curated cohort of patients with cancer, and (ii) a dataset of new trial activations.

Results

The institution-wide cohort included 4756 new patients enrolled to clinical trials from December 2019 to June 2021. A major decrease in the numbers of new patient accruals (−46%) was seen early in the pandemic, followed by a progressive recovery and return to higher-than-normal levels (+2.6%). A similar pattern (from −23.6% to +30.4%) was observed among 467 newly activated trials from June 2019 to June 2021. A more pronounced decline in new accruals was seen among academically sponsored trials (versus industry sponsored trials) (P < 0.05). In the manually curated cohort, which included 2361 patients with cancer, non-white patients tended to be more likely taken off trial in the early pandemic period (adjusted odds ratio: 2.60; 95% confidence interval 1.00-6.63), and substantial pandemic-related deviations were recorded.

Conclusions

Substantial disruptions in clinical trial activities were observed early during the pandemic, with a gradual recovery during ensuing time periods, both from an enrollment and an activation standpoint. The observed decline was more prominent among academically sponsored trials, and racial disparities were seen among people taken off trial.

Adjuvant Abemaciclib Combined with Endocrine Therapy for High Risk Early Breast Cancer: Safety and Patient-Reported Outcomes From the monarchE Study

BACKGROUND

In monarchE, abemaciclib plus endocrine therapy (ET) as adjuvant treatment of hormone receptor-positive, human epidermal growth factor 2-negative, high risk, early breast cancer demonstrated a clinically meaningful improvement in invasive disease-free survival versus ET alone. Detailed safety analyses conducted at a median follow-up of 27 months and key patient-reported outcomes (PRO) are presented.

PATIENTS AND METHODS

The safety population included all patients who received at least one dose of study treatment (n=5591). Safety analyses included incidence, management, and outcomes of common and clinically relevant adverse events (AEs). Patient-reported health-related quality-of-life, ET symptoms, fatigue, and side effect burden were assessed.

RESULTS

The addition of abemaciclib to ET resulted in higher incidence of Grade≥3 AEs (49.7% vs 16.3% with ET alone), predominantly laboratory cytopenias (e.g., neutropenia [19.6%]) without clinical complications. Abemaciclib-treated patients experienced more serious adverse events (SAEs; 13.3% vs 7.8%). Discontinuation of abemaciclib and/or ET due to AEs occurred in 18.5% of patients, mainly due to Grade1/2 AEs (66.8%). AEs were managed with comedications (e.g., antidiarrheals), abemaciclib dose holds (61.7%), and/or dose reductions (43.4%). Diarrhea was generally low grade (Grade1/2: 77%); Grade2/3 events were highest in the first month (20.5%), most short-lived (≤7 days) and did not recur. Venous thromboembolic events (VTE) were higher with abemaciclib+ET (2.5%) vs ET (0.6%); in the abemaciclib arm, increased VTE risk was observed with tamoxifen vs AIs (4.3% vs 1.8%). PROs were similar between arms, including being 'bothered by side effects of treatment', except for diarrhea. At ≥3 months, most patients reporting diarrhea reported "a little bit" or "somewhat".

CONCLUSION

In patients with high risk EBC, adjuvant abemaciclib+ET has an acceptable safety profile and tolerability is supported by PRO findings. Most AEs were reversible and manageable with comedications and/or dose modifications, consistent with the known abemaciclib toxicity profile.

Abstract TF2-2: Heterogeneity in treatment outcomes for HER2+ breast cancer - Clinical management strategies

HER2-positive breast cancers are complex tumors that are clinically and biologically heterogeneous. Even within HER2+ breast cancer, there are different molecular subtypes, mutational profiles, levels of HER2 protein, and immune infiltration. Additionally, HER2 may not be expressed homogeneously among all the cancer cells in the same tumor, some tumors may have low HER2 expression, while other tumors evolve during treatment. These molecular differences help explain why patients do not benefit to the same extent to HER2-directed therapies. We will review data regarding outcomes for tumors with known tumor heterogeneity, hormone receptor positivity, HER2-low positivity, and cases where brain metastases may be present. We will discuss optimal clinical management in the modern era with multiple HER2-directed therapies, including next-generation antibody-drug conjugates. Future strategies to tailor therapy to the individual patient will need to not just factor in anatomic tumor burden, but also key molecular features.

Citation Format: S Tolaney. Heterogeneity in treatment outcomes for HER2+ breast cancer - Clinical management strategies [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr TF2-2.

Adjuvant abemaciclib combined with endocrine therapy for high-risk early breast cancer: updated efficacy and Ki-67 analysis from the monarchE study

BACKGROUND

Adjuvant abemaciclib combined with endocrine therapy (ET) previously demonstrated clinically meaningful improvement in invasive disease-free survival (IDFS) and distant relapse-free survival (DRFS) in hormone receptor-positive, human epidermal growth factor receptor 2-negative, node-positive, high-risk early breast cancer at the second interim analysis, however follow-up was limited. Here, we present results of the prespecified primary outcome analysis and an additional follow-up analysis.

PATIENTS AND METHODS

This global, phase III, open-label trial randomized (1 : 1) 5637 patients to adjuvant ET for ≥5 years ± abemaciclib for 2 years. Cohort 1 enrolled patients with ≥4 positive axillary lymph nodes (ALNs), or 1-3 positive ALNs and either grade 3 disease or tumor ≥5 cm. Cohort 2 enrolled patients with 1-3 positive ALNs and centrally determined high Ki-67 index (≥20%). The primary endpoint was IDFS in the intent-to-treat population (cohorts 1 and 2). Secondary endpoints were IDFS in patients with high Ki-67, DRFS, overall survival, and safety.

RESULTS

At the primary outcome analysis, with 19 months median follow-up time, abemaciclib + ET resulted in a 29% reduction in the risk of developing an IDFS event [hazard ratio (HR) = 0.71, 95% confidence interval (CI) 0.58-0.87; nominal P = 0.0009]. At the additional follow-up analysis, with 27 months median follow-up and 90% of patients off treatment, IDFS (HR = 0.70, 95% CI 0.59-0.82; nominal P < 0.0001) and DRFS (HR = 0.69, 95% CI 0.57-0.83; nominal P < 0.0001) benefit was maintained. The absolute improvements in 3-year IDFS and DRFS rates were 5.4% and 4.2%, respectively. Whereas Ki-67 index was prognostic, abemaciclib benefit was consistent regardless of Ki-67 index. Safety data were consistent with the known abemaciclib risk profile.

CONCLUSION

Abemaciclib + ET significantly improved IDFS in patients with hormone receptor-positive, human epidermal growth factor receptor 2-negative, node-positive, high-risk early breast cancer, with an acceptable safety profile. Ki-67 index was prognostic, but abemaciclib benefit was observed regardless of Ki-67 index. Overall, the robust treatment benefit of abemaciclib extended beyond the 2-year treatment period.

Novel combinatorial strategies for boosting the efficacy of immune checkpoint inhibitors in advanced breast cancers

The year 2019 witnessed the first approval of an immune checkpoint inhibitor (ICI) for the management of triple negative breast cancers (TNBC) that are metastatic and programmed death ligand (PD)-L1 positive. Extensive research has focused on testing ICI-based combinatorial strategies, with the ultimate goal of enhancing the response of breast tumors to immunotherapy to increase the number of breast cancer patients benefiting from this transformative treatment. The promising investigational strategies included immunotherapy combinations with monoclonal antibodies (mAbs) against human epidermal growth factor receptor (HER)-2 for the HER2 + tumors versus cyclin-dependent kinase (CDK)4/6 inhibitors in the estrogen receptor (ER) + disease. Multiple approaches are showing signals of success in advanced TNBC include employing Poly (ADP-ribose) polymerase (PARP) inhibitors, tyrosine kinase inhibitors, MEK inhibitors, phosphatidylinositol 3‑kinase (PI3K)/protein kinase B (AKT) signaling inhibitors or inhibitors of adenosine receptor, in combination with the classical PD-1/PD-L1 immune checkpoint inhibitors. Co-treatment with chemotherapy, high intensity focused ultrasound (HIFU) or interleukin-2-βɣ agonist have also produced promising outcomes. This review highlights the latest combinatorial strategies under development for overcoming cancer immune evasion and enhancing the percentage of immunotherapy responders in the different subsets of advanced breast cancers.

Sacituzumab govitecan in previously treated hormone receptor-positive/HER2-negative metastatic breast cancer: final results from a phase I/II, single-arm, basket trial

BACKGROUND

Trophoblast cell-surface antigen-2 (Trop-2) is expressed in epithelial cancers, including hormone receptor-positive (HR+) metastatic breast cancer (mBC). Sacituzumab govitecan (SG; Trodelvy®) is an antibody-drug conjugate composed of a humanized anti-Trop-2 monoclonal antibody coupled to SN-38 at a high drug-to-antibody ratio via a unique hydrolyzable linker that delivers SN-38 intracellularly and in the tumor microenvironment. SG was granted accelerated FDA approval for metastatic triple-negative BC treatment in April 2020.

PATIENTS AND METHODS

We analyzed a prespecified subpopulation of patients with HR+/human epidermal growth factor receptor 2-negative (HER2-) HR+/HER2- mBC from the phase I/II, single-arm trial (NCT01631552), who received intravenous SG (10 mg/kg) and whose disease progressed on endocrine-based therapy and at least one prior chemotherapy for mBC. End points included objective response rate (ORR; RECIST version 1.1) assessed locally, duration of response (DOR), clinical benefit rate, progression-free survival (PFS), overall survival (OS), and safety.

RESULTS

Fifty-four women were enrolled between 13 February 2015 and 1 June 2017. Median (range) age was 54 (33-79) years and all received at least two prior lines of therapy for mBC. At data cut-off (1 March 2019), 12 patients were still alive. Key grade ≥3 treatment-related toxicities included neutropenia (50.0%), anemia (11.1%), and diarrhea (7.4%). Two patients discontinued treatment due to treatment-related adverse events. No treatment-related deaths occurred. At a median follow-up of 11.5 months, the ORR was 31.5% [95% confidence interval (CI), 19.5%-45.6%; 17 partial responses]; median DOR was 8.7 months (95% CI 3.7-12.7), median PFS was 5.5 months (95% CI 3.6-7.6), and median OS was 12 months (95% CI 9.0-18.2).

CONCLUSIONS

SG shows encouraging activity in patients with pretreated HR+/HER2- mBC and a predictable, manageable safety profile. Further evaluation in a randomized phase III trial (TROPiCS-02) is ongoing (NCT03901339).

TRIAL REGISTRATION

ClinicalTrials.gov NCT01631552; https://clinicaltrials.gov/ct2/show/NCT01631552.

A Food and Drug Administration analysis of survival outcomes comparing the Adjuvant Paclitaxel and Trastuzumab trial with an external control from historical clinical trials

BACKGROUND

Although the Adjuvant Paclitaxel and Trastuzumab (APT) trial has been adopted clinically, single-arm trials have limitations, and interest remains whether these patients with small node-negative human epidermal growth factor receptor 2 (HER2)-positive early breast cancer (EBC) would benefit from more intensive chemotherapy. This analysis explored whether external controls can contextualize single-arm studies to add to clinical decision making in the use of de-escalated therapy in patients with low-risk HER2-positive EBC.

PATIENTS AND METHODS

Patient-level data from five randomized trials supporting drug approval in adjuvant HER2-positive EBC were pooled, and patients with low-risk EBC were selected (n = 1770). Patients treated concurrently with trastuzumab and either anthracycline/cyclophosphamide/taxane/trastuzumab (ACTH) or taxane/carboplatin/trastuzumab (TCH; n = 1366) were matched (1:1) to patients treated with paclitaxel and trastuzumab (TH) in the APT trial (n = 406) using propensity scores. Patients treated with anthracycline/cyclophosphamide/taxane (ACT; n = 374) were also matched (1:1) to those treated with TH. Propensity scores were estimated using covariates of age, tumor stage, estrogen receptor status, progesterone receptor status, and histological grade.

RESULTS

After matching, the estimated probabilities of invasive disease-free survival (iDFS) at 3 and 5 years were 98.6% and 96.5% in the TH arm, and 96.6% and 92.9% in the ACTH/TCH arm, respectively. The estimated probabilities of overall survival (OS) at 3 and 5 years were 99.7% and 99.3% in the TH arm, and 99.0% and 97.4% in the ACTH/TCH arm, respectively. Comparing the TH arm with the ACT arm in the matched sample, the estimated difference in iDFS was 7.5% (TH 98.8% and ACT 91.3%) at 3 years and 12.6% (TH 96.1% and ACT 83.5%) at 5 years. The estimated difference in OS was 2.6% (TH 100% and ACT 97.4%) at 3 years, and 5.3% (TH 99.3% and ACT 94.0%) at 5 years.

CONCLUSIONS

Our analyses suggest that patients' outcomes in both arms were in general similar, thus providing additional reassurance regarding de-escalation of therapy.

Reversion and non-reversion mechanisms of resistance to PARP inhibitor or platinum chemotherapy in BRCA1/2-mutant metastatic breast cancer

BACKGROUND

Little is known about mechanisms of resistance to poly(adenosine diphosphate-ribose) polymerase inhibitors (PARPi) and platinum chemotherapy in patients with metastatic breast cancer and BRCA1/2 mutations. Further investigation of resistance in clinical cohorts may point to strategies to prevent or overcome treatment failure.

PATIENTS AND METHODS

We obtained tumor biopsies from metastatic breast cancer patients with BRCA1/2 deficiency before and after acquired resistance to PARPi or platinum chemotherapy. Whole exome sequencing was carried out on each tumor, germline DNA, and circulating tumor DNA. Tumors underwent RNA sequencing, and immunohistochemical staining for RAD51 foci on tumor sections was carried out for functional assessment of intact homologous recombination (HR).

RESULTS

Pre- and post-resistance tumor samples were sequenced from eight patients (four with BRCA1 and four with BRCA2 mutation; four treated with PARPi and four with platinum). Following disease progression on DNA-damaging therapy, four patients (50%) acquired at least one somatic reversion alteration likely to result in functional BRCA1/2 protein detected by tumor or circulating tumor DNA sequencing. Two patients with germline BRCA1 deficiency acquired genomic alterations anticipated to restore HR through increased DNA end resection: loss of TP53BP1 in one patient and amplification of MRE11A in another. RAD51 foci were acquired post-resistance in all patients with genomic reversion, consistent with reconstitution of HR. All patients whose tumors demonstrated RAD51 foci post-resistance were intrinsically resistant to subsequent lines of DNA-damaging therapy.

CONCLUSIONS

Genomic reversion in BRCA1/2 was the most commonly observed mechanism of resistance, occurring in four of eight patients. Novel sequence alterations leading to increased DNA end resection were seen in two patients, and may be targetable for therapeutic benefit. The presence of RAD51 foci by immunohistochemistry was consistent with BRCA1/2 protein functional status from genomic data and predicted response to later DNA-damaging therapy, supporting RAD51 focus formation as a clinically useful biomarker.

Prevalence and mutational determinants of high tumor mutation burden in breast cancer

BACKGROUND

High tumor mutation burden (TMB) can benefit immunotherapy for multiple tumor types, but the prevalence of hypermutated breast cancer is not well described. The aim of this study was to evaluate the frequency, mutational patterns, and genomic profile of hypermutated breast cancer.

PATIENTS AND METHODS

We used de-identified data from individuals with primary or metastatic breast cancer from six different publicly available genomic studies. The prevalence of hypermutated breast cancer was determined among 3969 patients' samples that underwent whole exome sequencing or gene panel sequencing. The samples were classified as having high TMB if they had ≥10 mutations per megabase (mut/Mb). An additional eight patients were identified from a Dana-Farber Cancer Institute cohort for inclusion in the hypermutated cohort. Among the patients with high TMB, the mutational patterns and genomic profiles were determined. A subset of patients was treated with regimens containing PD-1 inhibitors.

RESULTS

The median TMB was 2.63 mut/Mb. The median TMB significantly varied according to the tumor subtype (HR-/HER2- >HER2+ >HR+/HER2-, P < 0.05) and sample type (metastatic > primary, P = 2.2 × 10^-16). Hypermutated tumors were found in 198 patients (5%), with enrichment in metastatic versus primary tumors (8.4% versus 2.9%, P = 6.5 × 10^-14). APOBEC activity (59.2%), followed by mismatch repair deficiency (MMRd; 36.4%), were the most common mutational processes among hypermutated tumors. Three patients with hypermutated breast cancer-including two with a dominant APOBEC activity signature and one with a dominant MMRd signature-treated with pembrolizumab-based therapies derived an objective and durable response to therapy.

CONCLUSION

Hypermutation occurs in 5% of all breast cancers with enrichment in metastatic tumors. Different mutational signatures are present in this population with APOBEC activity being the most common dominant process. Preliminary data suggest that hypermutated breast cancers are more likely to benefit from PD-1 inhibitors.

Phase I study of the checkpoint kinase 1 inhibitor GDC-0575 in combination with gemcitabine in patients with refractory solid tumors

BACKGROUND

Checkpoint kinase 1 (Chk1) inhibition following chemotherapy-elicited DNA damage overrides cell cycle arrest and induces mitotic catastrophe and cell death. GDC-0575 is a highly-selective oral small-molecule Chk1 inhibitor that results in tumor shrinkage and growth delay in xenograft models. We evaluated the safety, tolerability, and pharmacokinetic properties of GDC-0575 alone and in combination with gemcitabine. Antitumor activity and Chk1 pathway modulation were assessed.

PATIENTS AND METHODS

In this phase I open-label study, in the dose escalation stage, patients were enrolled in a GDC-0575 monotherapy Arm (1) or GDC-0575 combination with gemcitabine Arm (2) to determine the maximum tolerated dose. Patients in arm 2 received either i.v. gemcitabine 1000 mg/m2 (arm 2a) or 500 mg/m2 (arm 2b), followed by GDC-0575 (45 or 80 mg, respectively, as RP2D). Stage II enrolled disease-specific cohorts.

RESULTS

Of 102 patients treated, 70% were female, the median age was 59 years (range 27-85), and 47% were Eastern Cooperative Oncology Group PS 0. The most common tumor type was breast (37%). The most frequent adverse events (all grades) related to GDC-0575 and/or gemcitabine were neutropenia (68%), anemia (48%), nausea (43%), fatigue (42%), and thrombocytopenia (35%). Maximum concentrations of GDC-0575 were achieved within 2 hours of dosing, and half-life was ∼23 hours. No pharmacokinetic drug-drug interaction was observed between GDC-0575 and gemcitabine. Among patients treated with GDC-0575 and gemcitabine, there were four confirmed partial responses, three occurring in patients with tumors harboring TP53 mutation. Pharmacodynamic data were consistent with GDC-0575 inhibition of gemcitabine-induced expression of pCDK1/2.

CONCLUSION

GDC-0575 can be safely administered as a monotherapy and in combination with gemcitabine; however, overall tolerability with gemcitabine was modest. Hematological toxicities were frequent but manageable. Preliminary antitumor activity was observed but limited to a small number of patients with a variety of refractory solid tumors treated with GDC-0575 and gemcitabine.

CLINICAL TRIAL NUMBER

NCT01564251.

The immune profile of small HER2-positive breast cancers: a secondary analysis from the APT trial

BACKGROUND

Previous data suggest that the immune microenvironment plays a critical role in human epidermal growth factor receptor 2 (HER2) -positive breast cancer; however, there is little known about the immune profiles of small HER2-positive tumors. In this study, we aimed to characterize the immune microenvironment of small HER2-positive breast cancers included in the Adjuvant paclitaxel and trastuzumab for node-negative, HER2-positive breast cancer (APT) trial and to correlate the immune markers with pathological and molecular tumor characteristics.

PATIENTS AND METHODS

The APT trial was a multicenter, single-arm, phase II study of paclitaxel and trastuzumab in patients with node-negative HER2-positive breast cancer. The study included 406 patients with HER2-positive, node-negative breast cancer, measuring up to 3 cm. Exploratory analysis of tumor infiltrating lymphocytes (TIL), programmed death-ligand 1 (PD-L1) expression (by immunohistochemistry), and immune gene signatures using data generated by nCounter PanCancer Pathways Panel (NanoString Technologies, Seattle, WA), and their association with pathological and molecular characteristics was carried out.

RESULTS

Of the 406 patients, 328 (81%) had at least one immune assay carried out: 284 cases were evaluated for TIL, 266 for PD-L1, and 213 for immune gene signatures. High TIL (≥60%) were seen with greater frequency in hormone-receptor (HR) negative, histological grades 2 and 3, as well in HER2-enriched and basal-like tumors. Lower stromal PD-L1 (≤1%) expression was seen with greater frequency in HR-positive, histological grade 1, and in luminal tumors. Both TIL and stromal PD-L1 were positively correlated with 10 immune cell signatures, including Th1 and B cell signatures. Luminal B tumors were negatively correlated with those signatures. Significant correlation was seen among these immune markers; however, the magnitude of correlation did not indicate a monotonic relationship between them.

CONCLUSION

Immune profiles of small HER2-positive breast cancers differ according to HR status, histological grade, and molecular subtype. Further work is needed to explore the implication of these findings on disease outcome.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT00542451.

Abstract P6-18-10: A phase 1b/2 study of ribociclib plus trastuzumab for the treatment of advanced, treatment-refractory HER2-positive breast cancer

Introduction:

Despite the success of anti-HER2 therapy, acquired resistance usually develops in the metastatic setting. CDK4/6 pathway activity has been identified as a mediator of this resistance, and in preclinical studies the combination of CDK4/6 and HER2 blockade can be more effective than either therapy alone. We conducted a single-arm phase 1b/2 study of the CDK4/6 inhibitor ribociclib given with trastuzumab or T-DM1 to subjects with advanced, treatment-refractory HER2-positive breast cancer. The results of the trastuzumab cohort are presented below. The primary objective was to determine the clinical benefit rate (CBR) at 24 weeks, and secondary endpoints included objective response rate (ORR), progression-free survival (PFS), and adverse events.

Methods: Individuals with locally advanced or metastatic, measurable HER2-positive breast cancer were eligible. All subjects must have previously received trastuzumab, pertuzumab, and T-DM1 as (neo)adjuvant or metastatic therapy. There was no limit on the number of prior lines of treatment. Patients with previous CDK4/6 inhibitor exposure, QTcF &gt; 450msec on EKG, or without stable brain metastases were excluded. An initial safety run-in phase (with dose-limiting toxicity (DLT) monitoring) included six subjects who received trastuzumab (8mg/kg loading then 6mg/kg IV three-weekly) and ribociclib 400mg PO daily on a continuous schedule (cycle length 21 days). The study had a two-stage design. The first stage required 20 patients, at least 6 of whom must have demonstrated clinical benefit (CR+PR+ SD&gt;24 weeks) in order to recruit 15 more patients to the second stage. All patients with accessible disease underwent metastatic tumor biopsies at baseline and C2D1.

Results: 13 patients were enrolled (6 in the safety run-in and 7 in the expansion cohort). One patient was found to have HER2-negative disease and did not receive treatment. Patient characteristics are shown in Table 1 No DLTs were observed during the safety run-in phase, and ribociclib was thus used at 400mg po daily for the expansion cohort. Grade 3/4 toxicities were observed in 5 patients (41.7%) and included neutropenia (n=2), and fatigue, pain, and muscle weakness (all n=1). No patient demonstrated QTc prolongation &gt;480 msec, or grade 3/4 LFTs. 1/12 patients ((8.3%); 95% CI 0.2%-38.5%) achieved stable disease&gt;24 weeks; no objective responses were observed, and median PFS was 41.5 days. The trastuzumab portion of study was closed early due to limited clinical activity observed (the T-DM1 with ribociclib cohort remains open).

Table 1Age (median, range)50.5 (42 - 71)Number of prior lines of systemic therapy for metastatic disease (median, range)5.5 (0-14)Number with Hormone receptor-positive disease (%)8 (67 %)Number of metastatic sites (median, range)2.5 (2 - 5)

Conclusions: The combination of trastuzumab and ribociclib (400mg daily continuous schedule) is safe, with no new safety signals observed. The limited activity seen in this heavily pretreated population suggests that future efforts to incorporate CDK4/6 inhibition should be limited to a less extensively treat population.

Citation Format: Goel S, Spring L, Rees R, Andrews C, Tahara RK, Mayer EL, Bardia A, Winer EP, Tolaney SM. A phase 1b/2 study of ribociclib plus trastuzumab for the treatment of advanced, treatment-refractory HER2-positive breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-10.

Abstract P1-15-01: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Metzger Filho O, Janiszewska M, Guo H, Yardley D, Mayer I, Spring L, Arteaga C, Wrabel E, DeMeo M, Freedman R, Tolaney S, Waks A, Bardia A, Parsons H, Partridge A, Mayer E, King T, Polyak K, Viale G, Winer E, Krop I. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-01.

Abstract P2-11-01: Safety and efficacy of sacituzumab govitecan (anti-Trop-2-SN-38 antibody-drug conjugate) as ≥3rd-line therapeutic option for treatment-refractory HER2-negative metastatic breast cancer (HER2Neg mBC)

Background: Sacituzumab govitecan is an antibody-drug conjugate consisting of SN-38, the active metabolite of irinotecan, conjugated to a humanized mAb targeting Trop-2 (trophoblastic antigen-2), which is highly expressed in many epithelial cancers. A phase I/II basket trial (NCT01631552) investigated its activity in patients (pts) with advanced epithelial cancers. Herein, we summarize pooled safety and efficacy findings in 162 pts with HER2-negative metastatic breast cancer (mBC) accrued between 7/2013 and 6/2017 who received at least 2 prior therapies for metastatic disease and were treated with sacituzumab govitecan at the 10 mg/kg dose level.

Methods: Patients with triple-negative (N=108) and patients with hormone-receptor positive (N=54) mBC received 10 mg/kg sacituzumab govitecan on days 1 & 8 of a 21-day cycle continued until progression or unacceptable toxicity. All pts had measurable disease by CT or MRI. Efficacy was assessed locally by RECIST 1.1 including overall response rate (ORR) and Kaplan-Meier estimates of duration of response (DOR), progression-free survival (PFS) and overall survival (OS). Adverse events (AE) were evaluated according to CTCAE v4.0

Results: The patient cohort (161 female /1 male; median age 55 yrs, range 31-80) received a median of 4 prior therapies for metastatic disease (range 2-17), with prior chemotherapy agents in the metastatic setting including taxane (68%), capecitabine (60%), platinum (59%), gemcitabine (44%), eribulin (41%), and anthracycline (38%). 77 pts have died, with 57 in long-term follow-up and 28 still on treatment at data cutoff. The median number of administered sacituzumab govitecan doses was 14 (range 1-88). Treatment was generally well tolerated. 29% of pts had dose reductions, 3% discontinued treatment due to drug-related AEs, and there were no treatment-related deaths. Based on currently available AE data, grade ≥ 3 toxicity included neutropenia (43%), anemia (9.5%), diarrhea (7.0%) and febrile neutropenia (6.3%). For the TNBC subgroup, with a median follow-up of 9.3 months, the ORR was 33% (3 CRs + 33 PRs /108) with a median DOR of 8.3 months (95% CI: 4.8 – 11.6). For the ER+ subgroup, with a median follow-up of 10.0 months, the ORR was 31% (17 PRs/54) with a median DOR of 7.4 months (95% CI: 4.4 – 18.3). The combined HER2Neg ORR was 33% (3 CRs+50 PRs/162), with a median DOR of 8.3 months (95% CI: 4.9 - 10.8), PFS of 5.6 months (95% CI: 5.1 – 6.9) and OS of 13.0 months (95% CI: 11.5 - 15.0). The ORR was comparable for pts ≤ 50 yrs. old [32.2% (19/59)] vs. &gt; 50 yrs old [33.0% (34/103)] and little different for pts with 2 prior therapies [35.4% (17/48)] vs. &gt;2 prior therapies [31.6% (36/114)].

Conclusions: Monotherapy with sacituzumab govitecan was well tolerated with a manageable safety profile, and achieved a 30+% objective response rate among heavily pre-treated patients with HER2-negative metastatic breast cancer regardless of ER status.

Citation Format: Kalinsky K, Isakoff SJ, Tolaney SM, Juric D, Mayer IA, Vahdat LT, Diamond JR, O'Shaughnessy J, Moroose RL, Santin AD, Shah NC, Abramson V, Goldenberg DM, Sharkey RM, Washkowitz SA, Wegener WA, Iannone R, Bardia A. Safety and efficacy of sacituzumab govitecan (anti-Trop-2-SN-38 antibody-drug conjugate) as ≥3rd-line therapeutic option for treatment-refractory HER2-negative metastatic breast cancer (HER2Neg mBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-11-01.

Abstract P6-18-19: Real-world survival of heavily pretreated patients with refractory HR+, HER2- metastatic breast cancer receiving single-agent chemotherapy - A comparison with MONARCH 1

Background

In MONARCH 1 (NCT02102490), abemaciclib demonstrated promising single-agent activity and tolerability in a population of heavily pretreated women with refractory HR+, HER2- metastatic breast cancer (MBC).1 Confirmed objective response rate (ORR) was 19.7% (95% CI: 13.3, 27.5) and at 18 months minimum follow-up median overall survival (OS) was 22.3 months. Due to the single-arm trial design of MONARCH 1, there is a need to view these results in clinical context relative to available treatment options. This study compared the OS results of abemaciclib in MONARCH 1 vs that in a real-world single-agent chemotherapy cohort with similar patient and disease characteristics.

Methods

MONARCH 1 study design and key eligibility criteria were previously described.1 The real-world cohort was based on Flatiron Health electronic health records-derived, nationally representative (USA-based) database comprising patient-level structured and unstructured data, curated via technology-enabled abstraction, for patients with MBC between January 1, 2011 through February 28, 2018. A real-world single-agent chemotherapy cohort was created based on the key eligibility criteria of MONARCH 1 and included patients diagnosed with HR+, HER2- MBC who received single-agent chemotherapy (eribulin, capecitabine, gemcitabine, or vinorelbine) following 1-2 prior chemotherapy regimens in the metastatic setting, had an ECOG PS of 0-1, and no prior CDK4 & 6 therapy. The index date was the start of the eligible single-agent chemotherapy, and patients were followed from the index date until date of death, loss to follow-up, or end of the database, whichever occurred earlier. OS results were adjusted using 2 methods (Mahalanobis distance matching and entropy balancing with bootstrapping) to account for baseline demographic and clinical differences between the real-world and trial cohorts.

Results

A real-world cohort (n=281) with eligibility criteria similar to the MONARCH 1 population (n=132) was identified. A subsequent matching based on Mahalanobis distance was performed to match MONARCH 1 population (n=108) with the real-world cohort (n=108). The matched cohorts demonstrated similar patient and disease characteristics. Median OS was 22.3 months in the abemaciclib arm vs 13.6 months in the matched cohort with an estimated hazard ratio (HR) of 0.54 (95% CI: 0.37, 0.77). Results of a sensitivity analysis performed using entropy balancing were consistent with an adjusted median OS of 12.7 months in the real-world cohort (n=281)with HR of 0.57 (95% CI from bootstrapping: 0.44, 0.78).

Conclusion

Methodological advances to adjust for potential biases, and improvements in data quality, have evolved enabling the ability to leverage a real-world cohort as an external comparator arm. This study demonstrates the ability to create a real-world chemotherapy cohort suitable to serve as a comparator for MONARCH 1. These exploratory results suggest a survival advantage and adequately place the clinical benefit of abemaciclib monotherapy in clinical context.

References

Dickler et al, CCR 2017

Citation Format: Rugo H, Dieras V, Cortes J, Patt D, Wildiers H, O'Shaughnessy J, Zamora E, Yardley DY, Carter GC, Sheffield KM, Li L, Andre VA, Derbyshire RE, Li XI, Frenzel M, Huang Y-J, Dickler MN, Tolaney SM. Real-world survival of heavily pretreated patients with refractory HR+, HER2- metastatic breast cancer receiving single-agent chemotherapy - A comparison with MONARCH 1 [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-19.

Abstract P5-12-02: PTEN alterations and tumor mutational burden (TMB) as potential predictors of resistance or response to immune checkpoint inhibitors (ICI) in metastatic triple-negative breast cancer (mTNBC)

Purpose: To date no biomarker has been identified that predicts response to ICI in mTNBC. This study aimed to explore if tumor genomic alterations correlate with efficacy of PD-1/PD-L1 inhibition in patients (pts) with mTNBC. Methods: Demographic, treatment response, and long-term outcome data were collected on patients with mTNBC treated at Dana-Farber Cancer Institute (DFCI) under several clinical trials incorporating PD-1/PD-L1 inhibitors, given as monotherapy or combined with chemotherapy (CT). Pts included in this analysis had available results of targeted exon sequencing performed using Oncopanel, our institutional gene sequencing panel, on archival tumor tissue. TMB was calculated by determining the number of non-synonymous somatic mutations that occur per megabase of exonic sequence data across all genes on the panel. High TMB was defined as 310 mutations/megabase. TMB and gene alterations were correlated with objective response rate (ORR) per RECIST 1.1, progression-free (PFS) and overall survival (OS). Results: A total of 50 pts with mTNBC were included in this analysis. At baseline, the median age was 55.9 years (31.8–75.9), 60% had ECOG 0 and 40% had ECOG 1, 72% had visceral metastasis, and 46% had received 31 prior lines of systemic therapy in the metastatic setting. While 26% of pts received monotherapy [pembrolizumab (n=7, NCT02447003); atezolizumab (n=6; NCT01375842)], 74% received combination with CT [pembrolizumab plus eribulin (n=31; NCT02513472); atezolizumab plus nab-paclitaxel (n=6; NCT01633970)]. PTEN alterations were present in 30% of pts (mutations = 7; one copy number loss = 7; two copy number loss = 1). Median follow-up was 14 months (1–40). Pts with tumors harboring PTEN alterations had lower ORR (7% vs 57%; P&lt;0.001), shorter median PFS (2.3 vs 6.3 months; P=0.027), and shorter median OS (8.1 vs 20.1 months; P=0.012) compared to pts without PTEN alterations. The median TMB was 6.6 mut/Mb (1.2–50.8), and 23% of pts had a high TMB. While high TMB was not associated with higher ORR (P=0.56), it was associated with better median PFS (16.5 vs 2.4 months; P=0.017), and better median OS (not reached vs 13.5 months; P=0.026). Both PTEN status and TMB remained significantly associated with PFS in the multivariable model. Only PTEN status remained significantly associated with OS in the multivariable analysis with the same covariables. Ongoing analysis to better understand if these predictors are specific for predicting benefit to immunotherapy and/or a marker of chemotherapy resistance will be presented at the symposium. Conclusion: PTEN genomic alterations and TMB may impact benefit from PD-1/PD-L1 inhibitors largely administered with chemotherapy in mTNBC. These observations warrant prospective validation and may inform the importance of stratifying pts according to these characteristics in future randomized studies with ICI.

Table 1.Multivariable analysis for PFS Hazard ratioConfidence Intervalp-valueCombination therapy0.420.16 – 1.130.009Visceral metastasis1.310.63 – 2.770.46Previous lines of therapy1.020.09 – 0.700.85ECOG 12.11.06 – 1.280.034PTEN altered3.741.65 – 8.440.002Hypermutated tumors0.850.75 – 0.970.011

Citation Format: Barroso-Sousa R, Tyekucheva S, Pernas-Simon S, Exman P, Jain E, Garrido-Castro AC, Hughes M, Bychkovsky B, Di Lascio S, Umeton R, Files J, Lindeman NI, MacConaill LE, Hodi FS, Krop IE, Dillon D, Winer EP, Wagle N, Lin NU, Mittendorf EA, Tolaney SM. PTEN alterations and tumor mutational burden (TMB) as potential predictors of resistance or response to immune checkpoint inhibitors (ICI) in metastatic triple-negative breast cancer (mTNBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-12-02.

Abstract P3-08-04: Transient state change, but not permanent subtype change, after HER2-targeted therapy for HER2-positive breast cancer

Background: In CALGB 40601 (Alliance, NCT00770809), a neoadjuvant phase III trial of paclitaxel and trastuzumab with or without lapatinib for 12 weeks for patients with HER2-positive breast cancer, 33% of pretreatment tumors were Luminal A subtype, however, 69% of post-treatment samples with residual disease were Luminal A subtype. In addition, 71% of Luminal B (12/17) and 67% of HER2-Enriched (6/9) tumors changed into Luminal A, while 80% of Luminal A (20/24) remained Luminal A (Carey et al. J Clin Oncol. 2016). It is not known whether this shift to Luminal A was transient or permanent.

Methods: We selected matched pairs of pre- and post-treatment 40601 samples with tumor purity &gt;10% based upon DNA analyses to ensure all samples contained tumor. PAM50 intrinsic subtyping was applied to the 40601 samples gene expression data using a two-step normalization process based on The Genome Cancer Atlas, and PAM50 training set. In addition, a HER2-enriched expression subtype patient-derived xenograft (PDX) tumor called WHIM35, was studied and was either untreated (n=10), or treated with lapatinib at 220 mg/kg for 1 week (wk) (n=5), for 2 wks (n=8), or for 3 wks (n=4). We also treated WHIM35 tumors with lapatinib for 2 wks (on) and then removed laptinib for 1 wk (off) (n=6), or for 2 wks on and 2-4 wk off (n=6), and finally for 3 wks on, and 1 wk off (n=3). PAM50 intrinsic subtyping was applied to the PDX gene expression data and subtype assessed as well as a genomic-based proliferation score. ANOVA p-values were calculated by comparing median values across all gene signature or correlation scores.

Results: We found 10 pairs of 40601 samples that kept their tumor purity values, however, their subtype changed to Luminal A after treatment (i.e., in the residual disease), and in these cases no minor tumor subclone became a dominant clone in the post treatment sample. Pretreatment subtypes were 6 Luminal B, 3 Luminal A, and 1 HER2-enriched. The tumor purity values did not change after the treatments, but correlation to Luminal A was significantly higher (p=0.01), while correlation to HER2-enriched (p=0.004) and proliferation signature scores (p=0.003) were significantly lower in the post-treatment samples. Among the WHIM35 PDX tumors, one sample changed its subtype from HER2-enriched to Luminal A after the lapatinib treatment and the rest remained HER2-enriched, suggesting environmental differences between patient samples and the PDX model. However, correlation to Luminal A was significantly higher in all lapatinib treated WHIM35 samples (p=8.3e-12), and notably went back to the initial low levels just one week after removing lapatinib. Likewise, correlation to HER2-enriched (p=1.2e-10) and proliferation signature scores (p=6.2e-12) also got lower while treated with lapatinib, but went back to the initial levels after cessation of treatment.

Conclusions: Our findings suggest that the apparent subtype change during HER2-targeting therapy is not permanent, but is more likely a transient state change from a HER2-enriched subtype into a more Luminal A-like state. When we plan additional treatment strategies using residual disease phenotypes, it may not be clear what is the true subtype of the sample due to this inherent plasticity.

Citation Format: Tanioka M, Parker JS, Henry LN, Tolaney S, Dang C, Krop IE, Harris L, Polley M, Berry DA, Winer EP, Carey LA, Perou CM. Transient state change, but not permanent subtype change, after HER2-targeted therapy for HER2-positive breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-08-04.

Abstract P4-04-02: Identifying ERBB-2 activating mutations (mts) in HER2 negative tumors for clinical trials – Impact of institute-wide genomic testing and trial matching on trial enrollment in clinical practice

Introduction

Tailored treatment trials with biomarker-driven hypotheses are becoming an important strategy in drug development. Umbrella, basket and enrichment trials with eligibility predicated upon results of tumor sequencing are increasingly common. Several institutional and commercial genomic assays have been developed. However, the value of broad-based testing in recruiting patients (pts) to molecular-based clinical trials designed for small subgroups has not been fully evaluated and has been challenging to assess in a real-world setting. We evaluated the likelihood of trial enrollment based upon an institute-wide genomic test.

Methods

Since 2013, all pts with metastatic breast cancer (MBC) seen at least once at Dana-Farber Cancer Institute have been offered the option of tumor sequencing using multiplexed copy number variation (CNV) and mts detection across the full coding regions of a total of 447 cancer genes and 191 regions across 60 genes for rearrangement detection (Oncopanel; OP). For our primary analysis, we selected the ongoing multi-center phase II trial (NCT01670877) activated at our site on Sep 30, 2013, evaluating neratinib in ERBB-2 mutated pts, as the study provided a clear delineation of eligible mts, and timing of slot availability was retrievable retrospectively over an extended time frame. Our primary aim was to describe the proportion of pts with a qualifying ERBB-2 mt detected by OP who enrolled on the selected trial. Secondary objectives included median time from OP result to trial registration and description of ERBB-2 mts spectrum within each subtype. Associations were calculated by Fisher's test.

Results

We identified a total of 1,046 pts with HER-2 negative MBC and who had OP results between Sep 1, 2013 and Jun 1, 2017. A total of 43 pts (4.1%) were found to have ERBB-2 mts. Of these, 20 (1.9%) had activating eligible mts. The proportion of these pts who enrolled in the trial was 30% (6/20). Of the remaining 14 pts, 5 screen-failed and 2 were enrolled with known ERBB-2 mt through other testing modalities. Seven of 20 (35%) molecularly eligible pts were not approached (3 pts lost to follow-up, 3 enrolled in other clinical trials and 1 pt chose standard treatment). The median time from OP result to trial enrollment was 85 days (34-554). A significantly higher frequency of ERBB2 activating mts was found in ER+ compared to ER- primary tumors (2.5% vs. 0.3%, p =0.036), and in lobular tumors compared with ductal (5.5% vs. 1.25%, p=0.003). Frequency of eligible mts in primary tumors were similar to metastatic site (1.9% and 1.8%, respectively p=1.0)

Discussion

In this cohort, activating ERBB-2 mts were present in 20 of 1046 (1.9%) pts tested. Although over half of pts with eligible mts on OP testing were approached for NCT01670877, only 0.5% of the total tested population were enrolled (6/1046). Our data illustrate the substantial challenges in screening and enrolling to trials of rare subsets, even within a large academic institution, and point to the need for creative and novel approaches to leverage pts and community- and academic-based providers to more effectively support the success of such studies.

Citation Format: Exman P, Garrido-Castro A, Hughes ME, Freedman RA, Ma C, Bose R, Cerami E, Wagle N, Barroso-Sousa R, Fitz CD, Lindeman NI, MacConaill L, Bychkovsky BL, Lloyd MR, Mackichan CR, Kumari P, Tolaney SM, Krop IE, Winer EP, Dillon DA, Lin NU. Identifying ERBB-2 activating mutations (mts) in HER2 negative tumors for clinical trials – Impact of institute-wide genomic testing and trial matching on trial enrollment in clinical practice [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-04-02.

Abstract P6-19-02: Tumor subtypes and survival in male breast cancer: SEER 2010-2014

Background: Male breast cancer (MaBC) is an uncommon disease, and population-based information regarding prognostic factors is limited. Most MaBC are hormone receptor (HR) positive, however, the association of tumor subtypes with overall survival (OS) and breast cancer-specific survival (BCSS) is unclear. The aim of this study was to analyze the characteristics of each tumor subtype and its impact on OS and BCSS.

Methods: Using Surveillance, Epidemiology, and End Results (SEER) data, we identified men with invasive breast cancer between 2010 and 2014 with known estrogen receptor and progesterone receptor (together HR) status and human epidermal growth factor receptor 2 (HER2) status. Tumor subtypes were classified as: HR+/HER2-, HR+/HER2+, HR-/HER2+ and triple negative (TN). We examined tumor subtypes by patient (pt) characteristics and performed multivariate Cox proportional hazards analyses to determine the associations of each variable with OS and BCSS.

Results: We included 1508 pts with a median follow-up of 24 months (range 0-60). Median age was 65 years (range 26-97). At diagnosis, 86.6% of tumors were ductal, 97.1% HR+, 42.1% T1, 55.7% N0, 7.9% M1. Tumor subtype distribution was: 85.5% HR+/HER2-, 11.6% HR+/HER2+, 0.9% HR-/HER2+ and 2% TN. Compared with other subtypes, pts with TN tumors had higher grade disease, presented with more advanced stage and died more often from breast cancer (all p&lt;0.0001); whereas pts with HR+/HER2- tumors were older (p=0.02) and more often white (p=0.02). In univariate analysis, OS at 5 years for all HER2- and all HER2+ was 74.2% and 64.1%, respectively (p=0.002); while BCSS at 5 years for all HER2- and all HER2+ was 88.4% and 78.8%, respectively (p=0.009). Of all subtypes, TN had the worst OS and BCSS (p&lt;0.0001). Breast cancer was the cause of death in 43.7% of HR+/HER2-, 54.2% of all HER2+ and 100% of TN (p&lt;0.0001). In multivariate analyses for OS, older pts (Hazard ratio [HaR] 3 vs. &lt;50 years; p=0.001), stage IV (HaR 9 vs. stage I; p&lt;0.001), HR+/HER2+ tumors (HaR 1.9 vs. HR+/HER2-; p=0.003), TN tumors (HaR 8.5 vs. HR+/HER2-; p&lt;0.001) and unmarried pts (HaR 1.9 vs. married; p=0.002) had significantly worse survival. In multivariate analyses for BCSS, stage IV (HaR 25.7 vs. stage I; p&lt;0.001), HR+/HER2+ tumors (HaR 2.1 vs. HR+/HER2-; p=0.019), TN tumors (HaR 17 vs. HR+/HER2-; p&lt;0.001) and unmarried pts (HaR 2.2 vs. married; p=0.009) had significantly worse survival.

Conclusion: We observed significant differences in outcomes by tumor type in men with breast cancer which mirror those previously observed for women with breast cancer. Among the limited numbers of men with HER2+ and TN disease in our sample, outcomes were poor, suggesting possible under-treatment, aggressive tumor biology, and/or more advanced of disease at presentation. Studies to better understand the inferior survival for men with these subtypes are warranted and efforts to ensure appropriate treatment are paramount.

Citation Format: Leone J, Freedman RA, Zwenger AO, Lin NU, Tolaney SM, Vallejo CT, Leone BA, Winer EP, Leone JP. Tumor subtypes and survival in male breast cancer: SEER 2010-2014 [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-19-02.

Abstract GS3-02: Invasive disease-free survival and gene expression signatures in CALGB (Alliance) 40601, a randomized phase III neoadjuvant trial of dual HER2-targeting with lapatinib added to chemotherapy plus trastuzumab

Purpose

Dual HER2 targeting increases pathologic complete response (pCR) rate to neoadjuvant therapy and improves outcomes in both early and metastatic HER2-positive disease. CALGB 40601 is a randomized phase III trial examining the impact of dual HER2 blockade consisting of trastuzumab (H) and lapatinib (L) added to paclitaxel (T) on pCR, considering tumor and microenvironment molecular features. We previously found that pCR was numerically but not significantly increased with dual therapy, and that tumor molecular subtype and evidence of immune activation significantly and independently affected pCR (Carey et al, JCO 2016). In this secondary analysis, we sought to evaluate the effects of treatment arm and gene expression-defined subgroups on invasive disease free survival (IDFS).

Patients and Methods

Patients (Pts) with stage II to III HER2-positive breast cancer underwent tumor biopsy followed by random assignment with equal probabilityto paclitaxel plus trastuzumab alone (TH) or with the addition of lapatinib (THL) for 16 weeks before surgery. A paclitaxel plus lapatinib (TL) arm was closed early based on reports of futility from other trials. A secondary endpoint was IDFS, defined as the time from surgery until local or distant recurrence, new primary, or death from any cause, whichever was first. Gene expression signatures were identified by RNA sequencing.

Results

Between 12/2008 and 2/2012, 305 pts were enrolled. 261 pts had IDFS and gene expression information available (THL, n = 103; TH, n =101; TL, n = 57); there were no significant differences in clinical characteristics between this subset and the entire population. The median IDFS follow-up was 4.6 years with 40 IDFS events having occurred (THL, n=7; TH, n=19; TL, n=14). IDFS was significantly longer in the THL arm compared to standard TH (HR=0.34; 95% CI: 0.14-0.82; p=0.02). IDFS was also significantly longer among pCR than non-pCR pts (HR=0.40; 95% CI: 0.19-0.81; p=0.01), and did not differ by hormone receptor (HR) status, clinical stage, tumor size, race, menopausal status or age. Among gene expression signatures, only immune activation measured by an IgG signature was associated with longer IDFS (HR=0.71; 95% CI: 0.51-0.98; p=0.04); this signature was previously also associated with pCR. Multivariate analysis showed dual therapy (HR=0.35; p=0.02), pCR (HR=0.36; p=0.01), IgG (HR=0.69; p=0.05), and molecular subtype (LumA vs HER2E, HR=0.24, p=0.005) were associated with longer IDFS. A subgroup analysis by hormone receptor status revealed that among pts with HR+ disease, pts with luminal A experienced longer IDFS (HR=0.23; p=0.02) compared to those with luminal B or HER2-enriched molecular subtypes.

Conclusion

Dual HER2-targeting with lapatinib added to 16 weeks of TH produced significantly longer IDFS than TH alone, despite modest effects on pCR. Similar to pts with HER2-negative disease, pts with luminal A had better IDFS than those with other molecular subtypes. Immune activation as measured by RNA-based signature independently predicted both pCR and IDFS.

Support: U10CA180882, U10CA180821, U24CA196171, P50-CA58823, Susan G Komen, BCRF

Citation Format: Krop IE, Hillman D, Polley M-Y, Tanioka M, Parker J, Huebner L, Henry NL, Tolaney SM, Dang C, Harris L, Berry DA, Perou CM, Partridge A, Winer EP, Carey LA. Invasive disease-free survival and gene expression signatures in CALGB (Alliance) 40601, a randomized phase III neoadjuvant trial of dual HER2-targeting with lapatinib added to chemotherapy plus trastuzumab [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 GS3-02.

Abstract OT2-07-07: ATR inhibitor M6620 (formerly VX-970) with cisplatin in metastatic triple-negative breast cancer: Preliminary results from a phase 1 dose expansion cohort (NCT02157792)

Background: ATR is a critical regulator of the cellular response to replication stress; it signals DNA damage repair, mediated through homologous recombination. Many cancers depend on ATR to survive DNA damage. M6620 is a potent, selective inhibitor of ATR that augments the anticancer activity of cisplatin in preclinical triple-negative breast cancer (TNBC) models. Given the high prevalence of TP53 mutations in TNBC and limited platinum responsiveness in patients lacking a BRCA1/2 mutation, this study was designed to evaluate the safety and efficacy of M6620 in combination with cisplatin in an expansion cohort of patients with BRCA1/2 wild-type advanced/metastatic TNBC.

Methods: Eligible patients had advanced/metastatic ER-, PR-, and HER2- breast cancer with 0-2 prior non–platinum-based therapies and measurable disease per RECIST 1.1. First line patients were eligible if relapse occurred ≥3 months after prior (neo)adjuvant chemotherapy. Of a maximum 50 patients planned for enrollment, ≥30 were required to have BRCA1/2 germline wild-type status and basaloid molecular subtype tumors on central testing. Patients received intravenous cisplatin 75 mg/m2 on day 1 with intravenous M6620 140 mg/m2 on days 2 and 9 of each 21-day cycle. In patients intolerant of cisplatin or at investigator's discretion, cisplatin could be switched to carboplatin AUC 5 with M6620 90 mg/m2.

Results: At the time of abstract submission, 35 female patients were enrolled in this study; 18 patients with confirmed BRCA1/2 wild-type and basaloid metastatic TNBC who received ≥1 cycle of study drug and had ≥1 baseline scan and ≥1 on-treatment scan at the time of the data cut were included in the primary efficacy analysis. Median progression-free survival (PFS) was 4.1 months (90% CI, 1.6-6.9 months). PFS was ≥ 6 months in 2 patients and ≥ 3 months in 8 patients. Preliminary unconfirmed objective response [complete response or partial response (PR)] was observed in 38.9% (90% CI, 19.9%-60.8%) of patients. All 7 patients with preliminary objective response had PR as best overall response; the longest duration of response was 183 days. Response was ongoing in 4 patients with PR at the time of data cutoff. Grade ≥3 related treatment-emergent adverse events occurred in 16 of 35 patients: neutropenia (n=8), anemia (n=5), vomiting (n=4), nausea (n=3), and, in 1 patient each, thrombocytopenia, neutrophil count decreased, platelet count decreased, hypokalemia, generalized weakness, rigors, and acute kidney injury.

Conclusions: Combination of M6620 and cisplatin shows encouraging antitumor activity and tolerability in patients with advanced/metastatic TNBC. The study is ongoing; updated safety and efficacy results will be presented.

Citation Format: Telli ML, Lord S, Dean E, Abramson V, Arkenau H-T, Murias C, Becerra C, Tang R, Penney MS, Pollard J, Conboy G, Fields SZ, Shapiro G, Tolaney SM. ATR inhibitor M6620 (formerly VX-970) with cisplatin in metastatic triple-negative breast cancer: Preliminary results from a phase 1 dose expansion cohort (NCT02157792) [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 OT2-07-07.

Abstract P5-21-10: Phase 2 study and correlative analyses of ruxolitinib, a selective JAK1/2 inhibitor, in patients with metastatic, triple-negative breast cancer

Background: Preclinical data supports a role for the IL-6/JAK2/STAT3 signaling pathway in breast cancer (BC). Ruxolitinib is an orally bioavailable receptor tyrosine inhibitor targeting JAK1 and JAK2. We evaluated the safety and efficacy of ruxolitinib in patients with metastatic BC and performed correlative analyses.

Methods: This was a non-randomized, phase 2 study of patients with refractory, metastatic, triple-negative BC (TNBC). Patients with inflammatory BC (IBC) of any subtype were also enrolled. The primary endpoint was objective response by RECIST 1.1. Secondary endpoints included progression-free survival (PFS), overall survival (OS), and toxicity. The study was designed to enroll only patients whose archival tumor tissue was pSTAT3 moderately to strongly positive in the tumor epithelial cells by central immunohistochemistry (IHC). 16 patients underwent pre-treatment biopsy, of whom 4 also had a second biopsy prior to cycle 2. Biopsy samples and paired primary tumor samples (when available) were subjected to multi-color immunofluorescence and/or immune-FISH for leukocyte markers, pSTAT3, and JAK2. RNA sequencing was performed on available on-study frozen biopsy specimens. 17 patients had plasma collected with cell-free DNA (cfDNA) extracted and subjected to low coverage whole-genome sequencing.

Results: Of 217 patients who consented to archival tumor testing, T-score for pSTAT3 was 'high' (&gt;5) in 69 patients (31.8%), demonstrating frequent activation of the JAK/STAT pathway in metastatic TNBC or IBC. 23 pSTAT3 high patients were enrolled. Ruxolitinib was generally well-tolerated. The most commonly observed adverse events (any grade) were anemia, neutropenia, thrombocytopenia, constipation, nausea, and increased AST/ALT. Grade 3 or higher toxicities were uncommon. No objective responses were seen among 21 evaluable patients, therefore the study was closed to accrual based on study design. Intensive correlative analyses revealed important insights regarding ruxolitinib effects. Pharmacodynamic analyses of baseline versus cycle 2 biopsies demonstrate downregulation of JAK2 target genes, STAT3 signatures, and JAK/STAT gene ontology gene sets, suggesting on-target activity. There was evidence of immune microenvironment modulation: gene set enrichment analysis implicated reduced macrophage/myeloid phenotypes after treatment and CIBERSORT analysis of inferred immune cell subsets demonstrated reduced monocyte/macrophage proportion after treatment (t-test p=0.013). Multi-color immunofluorescence analyses of immune microenvironment are ongoing and will be reported. 17 patients underwent cfDNA analysis with 8 patients (47%) demonstrating gain or amplification of JAK2.

Conclusions: Ruxolitinib, as a single agent, did not meet the primary efficacy endpoint in this refractory patient population. Correlative studies demonstrate evidence of on-target activity and immune microenvironment modulation. Frequent JAK/STAT pathway activation and JAK2 locus chromosomal gains in this cohort suggest that the JAK/STAT pathway remains a potential therapeutic target in BC.

Citation Format: Stover DG, Gil Del Alcazar CR, Tolaney SM, Bardia A, Guo H, Balko JM, Overmoyer BA, Gelman RS, Lloyd M, Wang V, Brock JE, Winer EP, Polyak K, Lin NU. Phase 2 study and correlative analyses of ruxolitinib, a selective JAK1/2 inhibitor, in patients with metastatic, triple-negative breast cancer [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 P5-21-10.

Abstract GS3-07: Genome-wide copy number analysis of chemotherapy-resistant metastatic triple-negative breast cancer from cell-free DNA

Introduction:

Triple-negative breast cancer (TNBC) is a poor prognosis breast cancer subset characterized by relatively few mutations but extensive copy number alterations (CNAs). Cell-free DNA (cfDNA) offers the potential to overcome infrequent tumor biopsies in metastatic TNBC (mTNBC) and interrogate the genomics of chemotherapy resistance.

Methods:

506 archival or fresh plasma samples were identified from 164 patients with mTNBC who had previously received chemotherapy. We performed low coverage whole genome sequencing to determine genome-wide copy number and estimate 'tumor fraction' of cfDNA (TFx) using our recently-developed approach, ichorCNA. In patient samples with TFx &gt;10%, we identified regions that were significantly gained or lost using GISTIC2.0. We compared CNAs of 20 paired primary-metastatic samples and also mTNBCs from cfDNA versus primary TNBCs from TCGA and METABRIC.

Results:

We successfully obtained high quality, low coverage whole genome sequencing data for 478 (94.5%) plasma samples from 158 patients, with 1 to 14 samples per patient. TFx and copy number profiles were highly concordant with paired metastatic biopsy (n=10, range 0-7 days from biopsy to blood draw) with sensitivity of 0.86 and specificity of 0.90 and reproducible in independently-processed blood draws (TFx intraclass correlation coefficient 0.984). Median overall survival from time of first blood draw was 8 months, and TFx was highly correlated independent of primary stage, primary receptor status, age at primary diagnosis, BRCA status, and metastatic line of therapy: adjusted hazard ratio between 4th and 1st quartiles = 2.14 (95% CI 1.40-3.28; p=0.00049). 101/158 patients (63.9%) had at least one sample with TFx &gt;10%, our threshold for high confidence CNA calls. Copy number profiles and percent genome altered were remarkably similar between mTNBCs and primary TNBCs in TCGA and METABRIC (n=433), suggesting that large-scale chromosomal events are infrequent in TNBC metastatic progression. We identified chromosomal gains that demonstrated significant enrichment in mTNBCs relative to paired primary TNBCs (n=20) and also TCGA/METABRIC, including driver genes (NOTCH2, AKT2, AKT3) and putative antibody-drug conjugate targets. Finally, we identify a novel association of gains of 18q11 and/or 19p13 with poor metastatic prognosis, independent of clinicopathologic factors and TFx.

Conclusions:

Here, we present the first large-scale genomic characterization of metastatic TNBC to our knowledge, derived exclusively from cfDNA. 'Tumor fraction' of cfDNA is an independent prognostic marker in mTNBC. Primary and metastatic TNBC have remarkably similar copy number profiles yet we identify alterations enriched and prognostic in mTNBC. Collectively, these data have potential implications in the understanding of metastasis, therapeutic resistance, and novel therapeutic targets.

Citation Format: Stover DG, Parsons HA, Ha G, Freeman S, Barry B, Guo H, Choudhury A, Gydush G, Reed S, Rhoades J, Rotem D, Hughes ME, Dillon DA, Partridge AH, Wagle N, Krop IE, Getz G, Golub TA, Love JC, Winer EP, Tolaney SM, Lin NU, Adalsteinsson VA. Genome-wide copy number analysis of chemotherapy-resistant metastatic triple-negative breast cancer from cell-free DNA [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 GS3-07.

Abstract OT1-02-02: A phase II study of pembrolizumab in combination with palliative radiotherapy for metastatic hormone receptor positive breast cancer

BACKGROUND: Despite recent advances in the treatment of patients with metastatic hormone receptor positive (HR+)/HER2- breast cancer (BC), it remains an incurable disease. The activity of immune checkpoint inhibitors (ICI) as monotherapy in patients with metastatic HR+/HER2- BC has been limited. Therefore, the addition of other strategies that elicit an immunogenic tumor microenvironment may be needed. We hypothesize that radiation therapy (RT) will potentiate the efficacy of the PD-1 inhibitor pembrolizumab in patients with metastatic HR+/HER2- BC. METHODS: Trial Design: This is a phase II single arm study assessing objective response rate (ORR) according to RECIST 1.1 in patients with metastatic HR+/HER2- BC who will receive pembrolizumab in combination with palliative RT. Pembrolizumab 200 mg intravenously will be administered 2-7 days before day 1 of RT, and will be given every 21 days until disease progression. Biopsies will be performed in the same lesion at baseline (mandatory if tumor tissue is accessible outside the field of RT) and during cycle 2 within 7-14 days before the day 1 of cycle 3 of pembrolizumab. Key Eligibility Criteria: Patients with metastatic HR+/HER2- BC, with measurable disease outside the field of radiation, for whom palliative RT to at least one bone, lymph node, or soft tissue lesion is indicated. Radiation of visceral lesions (such as lung or hepatic lesions) is not permitted. Although prior RT is allowed, patients must be at least 3 months free from RT; Re-irradiation of the same field is not allowed. There is no limit to the number of previous treatments, and systemic treatment naive patients for metastatic disease are also eligible. Specific Aims: The primary aim is to evaluate the efficacy of the combination, as defined by objective response rate (ORR) outside the field of RT according to RECIST 1.1. Secondary objectives include to determine the ORR according to immune-related criteria, the progression-free survival, the abscopal response rate, the clinical benefit rate, the safety and the tolerability of the combination. In addition, correlative studies will be performed to explore the correlation of immunosuppressive and/or immune-stimulating immune marker profiles at baseline and after cycle 2 to disease response to therapy. Statistical Methods: Using the Simons “optimal” method, in the first stage, 8 patients will be enrolled. If there is at least 1 response, accrual will continue to the second stage where up to 19 additional patients will be enrolled. If at least 3 of these 27 patients have an objective response (≥10%), the regimen will be considered worthy of further study. With this design, the probability of stopping the trial early is 78% if the true response rate is 3%. If the true response rate is 20% the chance that the regimen is declared worthy of further study is 80%. Patient accrual and target accrual: The trial opened in April/2017, and so far, has accrued 2 patients with a target accrual of 27 patients. Accrual should be complete in 14-25 months. Clinical trial information: NCT03051672.

Citation Format: Barroso-Sousa R, Gao H, Barry WT, Krop IE, Schoenfeld JD, Tolaney SM. A phase II study of pembrolizumab in combination with palliative radiotherapy for metastatic hormone receptor positive breast cancer [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 OT1-02-02.

Abstract PD6-09: The immune microenvironment in hormone receptor-positive breast cancer patients and relationship to treatment outcome following preoperative chemotherapy plus bevacizumab

Background: Hormone receptor-positive (HR+) tumors have fewer tumor-infiltrating lymphocytes (TILs) and lower response rates to immune checkpoint inhibitors (ICI), either as single agents or in combination with chemotherapy, than triple negative cancers. However, some HR+ cancers do respond to ICI and biomarkers that accurately reflect the immune microenvironment may help guide the use of ICI therapy. Prior evidence suggests that macrophage-related immune pathways may be relevant to the pathophysiology of HR+ BC.

Methods: HR+/HER2- patients were identified from a prospective trial of preoperative bevacizumab (preop bev) followed by bev with adriamycin/cyclophosphamide/paclitaxel dose-dense chemotherapy (chemo). Tumor samples were collected at diagnosis and surgery (pre-tx and post-tx), and PD-L1 expression (by immunohistochemistry), TILs, and Nanostring PanCancer Immune Profiling Panel were evaluated on both pre-tx and post-tx specimens. Pre-tx whole transcriptome sequencing was performed. Pathologic response at surgery was centrally assessed by Miller-Payne (MP) and residual cancer burden (RCB) scores. An immune score was calculated for each pre-tx specimen by integrating 10 published immune signatures. Immune cell subsets were inferred from bulk transcriptional data using CIBERSORT and immune cell-specific signatures from MSigDB.

Results: 55 patients who received trial therapy and had at least 1 evaluable specimen were included for analysis. Pre-tx TILs and tumor PD-L1 (tPD-L1) scores are shown in the table. 18% of pre-tx tumors had “high” (≥10%) TILs and “high” TILs were associated with significantly higher immune signature score (p=0.004). Immune score correlated highly with proportion of CIBERSORT anti-tumor M1 macrophages as well as CD8 T-cell signatures (r&gt;0.65 and p&lt;0.001). Higher pre-tx TILs, tPD-L1, or immune score were each significantly associated with more favorable RCB and MP in unadjusted analyses (all Spearman p&lt;0.01 for pathologic markers; ANOVA p&lt;0.04 for immune score). After adjustment for age and tumor grade, higher pre-tx TILs and tPD-L1 were associated with favorable RCB (p&lt;0.01 for both), and higher pre-tx tPD-L1 correlated with favorable MP (p=0.03). Pathologic complete response occurred in 4 pts; all 4 had high pre-tx TILs, pre-tx tPD-L1, or both. Among patients with residual disease, large changes (&gt;5%) in TILs or tPD-L1 from pre-tx to post-tx were rare: 2 pts each had large changes in TIL or tPD-L1 score (N=38/N=31 pairs, respectively).

Conclusions: High levels of tumor-lymphocyte interaction were seen in only a minority of untreated HR+ breast tumors, and did not typically change with chemo plus bev. An immune score derived from bulk RNAseq correlated with histological observations in these specimens. Nonetheless, TILs, tPD-L1, and signature-derived immune score were significantly associated with pathologic response to preop treatment in HR+ disease. Early data suggest that the role of M1 macrophages in HR+ tumors warrants further investigation.

ScoreTILs (N=50 evaluable)Tumor PD-L1 (N=51)0%0 pts (0%)28 pts (55%)&gt;0-5% (low)19 (38%)18 (35%)&gt;5-10% (intermediate)22 (44%)3 (6%)&gt;10% (high)9 (18%)2 (4%)

Citation Format: Waks AG, Stover DG, Barry W, Dillon D, Gjini E, Rodig SJ, Brock J, Baltay M, Savoie J, Winer EP, Krop I, Tolaney SM. The immune microenvironment in hormone receptor-positive breast cancer patients and relationship to treatment outcome following preoperative chemotherapy plus bevacizumab [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 PD6-09.

Abstract P1-13-12: Quality of life and patient-reported outcomes in US patients enrolled in the MONALEESA-2 study

Background: Improvement to and maintenance of the highest possible health-related quality of life (QoL), in addition to disease control, are key goals of treatment in patients with advanced breast cancer (ABC). Endocrine therapy is preferred as first-line therapy in ABC because of its preferable safety profile compared with chemotherapy. In the MONALEESA-2 study, the cyclin-dependent kinases 4 and 6 inhibitor ribociclib, in combination with letrozole, significantly extended progression-free survival (PFS) compared with placebo + letrozole in patients with hormone receptor–positive (HR+), human epidermal growth factor receptor 2–negative (HER2−) ABC. Patient-reported outcomes demonstrated similar QoL among patients in both treatment groups. Here, we present data from US patients enrolled in the MONALEESA-2 study on overall QoL as well as individual domains.

Methods: Postmenopausal women (N=668) with HR+, HER2− ABC who did not receive prior systemic treatment for ABC and had an Eastern Cooperative Oncology Group performance status score of ≤1, adequate bone marrow and organ function, and no history of active cardiac dysfunction were randomized 1:1 to receive either ribociclib (600 mg/d, 3 weeks on/1 week off) + letrozole (2.5 mg/d, continuous) or placebo + letrozole. The primary end point was locally assessed PFS. Quality of life was reported using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), the EuroQol 5-domain 5 level (EQ-5D-5L) visual analog scale (VAS) of overall health, and the breast symptom score of the EORTC QLQ-Breast Cancer 23 (EORTC QLQ-BR23) module. Data cutoff in this analysis was January 29, 2016.

Results: Patient characteristics and QoL survey reports were well balanced across treatment groups in US patients (n=213). The global health status/QoL scores of the EORTC QLQ-C30 were maintained between groups, and improved over time in the ribociclib group (mean ± standard deviation [SD] score at baseline, 69.1 ± 19.0; at 8 months, 71.3 ± 18.2; and at 16 months, 73.0 ± 16.0) and the placebo group (mean ± SD score at baseline, 69.9 ± 20.0; at 8 months, 75.9 ± 19.2; and at 16 months, 77.0 ± 15.0), which was consistent with scores in the overall population. At 16 months, the proportion of patients who did not experience ≥10% deterioration of all QoL scores was similar among treatment groups.

Quality of Life Outcomes of US Patients in the MONALEESA-2 Study at 16 MonthsOutcomeTreatment, nPatients without ≥10% deterioration in score, % (95% CI, %)EORTC QLQ-C30  Global health status/QoLRIB + LET, 2664.0 (49.4–75.4) PBO + LET, 3550.5 (36.2–63.2)Physical functioningRIB + LET, 2175.7 (62.6–84.7) PBO + LET, 1773.1 (57.2–83.9)Emotional functioningRIB + LET, 2271.6 (58.6–81.2) PBO + LET, 3159.7 (45.7–71.2)Social functioningRIB + LET, 1780.1 (68.5–87.8) PBO + LET, 2660.2 (44.1–73.0)EORTC QLQ-BR23 breast symptom scoreRIB + LET, 888.0 (76.6–94.0) PBO + LET, 886.2 (70.6–93.9)EQ-5D-5L VAS of overall healthRIB + LET, 1386.6 (76.9–92.4) PBO + LET, 1873.4 (56.8–84.4)LET, letrozole; PBO, placebo; RIB, ribociclib.

Conclusions: Addition of ribociclib to letrozole in US patients enrolled in MONALEESA-2 led to significant prolongation of PFS while maintaining QoL.

Citation Format: Tolaney SM, Tan-Chiu E, Truica C, Volas-Redd G, Shtivelband M, Dalal AA, Chandiwana D, Hortobagyi G. Quality of life and patient-reported outcomes in US patients enrolled in the MONALEESA-2 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 P1-13-12.

Abstract P1-12-01: Withdrawn

This abstract was withdrawn by the authors.

Abstract P4-22-12: Ribociclib + fulvestrant in postmenopausal women with HR+, HER2– advanced breast cancer (ABC)

Background: Endocrine therapy (ET) is the treatment backbone for hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–) ABC, but efficacy is limited by ET resistance. The cyclin-dependent kinase (CDK) 4/6–cyclin D (CCND1)–retinoblastoma (Rb) and phosphatidylinositol 3-kinase (PI3K)/mammalian target of rapamycin (mTOR) pathways have been implicated in ET resistance. CDK4/6 and PI3K/mTOR inhibitors act synergistically with ET in preclinical and clinical studies of HR+ breast cancer. Ribociclib (LEE011; CDK4/6 inhibitor) + fulvestrant ± alpelisib (BYL719) or buparlisib (BKM120) in HR+, HER2– ABC is being investigated in a Phase Ib/II study (NCT02088684). Here, we present results from the ribociclib + fulvestrant combination, with intermittent and continuous ribociclib dosing.

Methods: Postmenopausal patients (pts) with HR+, HER2– ABC refractory to aromatase inhibitors received ribociclib intermittently (600 mg/day, 3-weeks-on/1-week-off; Arm A) or continuously (400 mg/day; Arm B; following Arm A safety evaluation) + fulvestrant (500 mg; Cycle 1 Day 1 and 15; subsequent cycles Day 1). Primary objective: dose-limiting toxicities (DLTs) to confirm the recommended Phase II dose of ribociclib + fulvestrant. Secondary objectives: safety, pharmacokinetics, and preliminary antitumor activity (RECIST v1.1); biomarkers that may correlate with response were also assessed.

Results: As of March 10, 2016, 24 pts received ribociclib + fulvestrant (Arm A, n=13; Arm B, n=11); 4 pts in Arm B were ongoing; median duration of exposure was 7.4 (Arm A) and 4.5 (Arm B) months. Median number of prior regimens: 4 (Arm A) and 3 (Arm B). Treatment discontinuation (n; Arm A, Arm B) was due to disease progression (11, 4), physician decision (1, 2), and adverse events (AEs; 1, 1). DLTs in Cycle 1 (n; Arm A, Arm B) were Grade [G] 3 pulmonary embolism (1, 0) and G3 aspartate aminotransferase elevation (0, 1). The most common G3/4 drug-related AE (Arm A, Arm B) was neutropenia (62%, 36%); 5 pts had QTcF prolongation &gt;60 ms (n; 4, 1).

Common all-Grade drug-related AEs (&gt;35% pts) n (%)Arm A (n=13)Arm B (n=11)Neutropenia10 (77)7 (64)Fatigue9 (69)3 (27)Nausea6 (46)5 (46)Anemia6 (46)0 (0)Reduced appetite5 (39)1 (9)

Best overall responses (BORs; n; Arm A, Arm B): partial response (PR; 3, 1), stable disease (SD; 9, 6), and neither complete response nor progressive disease (NCRNPD; non-measurable disease; 1, 4). Overall response rate: 23% (Arm A) and 9% (Arm B); disease control rate (BOR of complete response, PR, SD, or NCRNPD): 100% in both arms. Next-generation sequencing data (n; Arm A, Arm B) were available for 16 pts (7, 9): 5 pts had CCND1 alterations (PR [1, 0], SD [2, 1], and NCRNPD [0, 1]); 11 pts had PIK3CA alterations (PR [1, 0], SD [3, 4], and NCRNPD [1, 2]); 2 of these pts had both CCND1 and PIK3CA alterations (SD [1, 0] and NCRNPD [0, 1]).

Conclusions: Ribociclib + fulvestrant has a manageable safety profile and shows preliminary clinical activity in pretreated pts with HR+, HER2– ABC. Both ribociclib intermittent and continuous dosing schedules were well tolerated. Clinical responses were observed in tumors with and without CDK4/6–cyclin D–Rb and PI3K/mTOR pathway alterations.

Citation Format: Tolaney SM, Forero-Torres A, Boni V, Bachelot T, Lu Y-S, Maur M, Fasolo A, Motta M, Pan C, Dobson J, Hewes B, Chin Lee S. Ribociclib + fulvestrant in postmenopausal women with HR+, HER2– advanced breast cancer (ABC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-22-12.

Abstract ES3-2: Optimizing Her2- directed treatment in early stage disease

Amplification of HER2 is present in approximately 18-20% of all breast cancer, and targeted anti-HER2 therapies have transformed our approach for this subtype of disease. Trastuzumab-based chemotherapy remains the standard therapy for these patients, however, there remain several questions in determining the optimal treatment regimen: (1) What is the role of anthracyclines? ; (2) What is the optimal preoperative regimen?; (3) How do we treat small, node-negative HER2+ breast cancers?; (4) Should all patients receive pertuzumab, and in what setting?; (5)Does Trastuzumab-DM1 have a role in the early stage setting? This educational session will review the available data to address each of these questions, and will provide recommendations for optimizing HER2- directed therapy in the early stage setting.

Citation Format: Tolaney S. Optimizing Her2- directed treatment in early stage disease [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr ES3-2.

Abstract P5-11-02: Impact of pre-operative exercise and mind-body interventions on patient-reported outcomes in women with newly diagnosed breast cancer

Background: Breast cancer diagnosis has a number of adverse psychological effects. The Pre-Operative Health and Body (PreHAB) Study tested the impact of exercise and mind-body interventions upon on mood, quality of life, and patient-reported outcomes in women with newly diagnosed breast cancer.

Methods: Women with newly diagnosed Stage I-III breast cancer were enrolled through Dana-Farber Cancer Institute and Yale University breast cancer clinics prior to surgery. Participants were randomized 1:1 to an aerobic and strength-training exercise intervention, comprised of twice-weekly meetings with an exercise trainer and home based aerobic exercise, or to a self-directed mind-body relaxation intervention, comprised of a book and CD focused on relaxation and visualization. Participants engaged in the interventions between enrollment and surgery. The EORTC QLQ C-30, Hospital Anxiety and Depression Scale, and Perceived Stress Scale were collected at enrollment and prior to surgery.

Results: 49 women were randomized (27 exercise and 22 control). Mean time between enrollment and surgery was 4.2 weeks. At baseline, patients reported moderate levels of anxiety, stress, insomnia, and lack of appetite, as well as diminished emotional and cognitive functioning (Table). Exercise participants significantly increased minutes of weekly exercise vs. mind-body participants (increase of 203 vs. 23 min/wk, p&lt;0.0001). Mind body participants engaged in the intervention on average 69% of days during the intervention period. Pre-post changes demonstrated that participation in the mind-body intervention led to improvements in emotional and cognitive functioning and a reduction in anxiety and stress, and participation in the exercise intervention led to improvements in global quality of life, insomnia, appetite, and stress (Table). Women in the mind-body group experienced a significantly greater improvement in cognitive functioning as compared to women in the exercise group.

Conclusions: Women with newly diagnosed breast cancer reported a number of physical and psychological symptoms in the pre-operative period. Exercise and mind-body interventions demonstrated promising benefits in improving functioning and reducing symptoms. More work is needed to develop pre-operative programs to help reduce the distress imparted by a cancer diagnosis in the critical time between diagnosis and surgery.

Table*

 Exercise Mind Body Between Groups BaselineChangep valueBaselineChangep valuep valueEmotional Functioning68.6 (23.3)4.7 (18.3)0.2966.3 (24.2)10.0 (20.5)0.050.64Cognitive Functioning79.5 (24.6)-3.3 (24.1)0.6273.8 (22.1)11.7 (15.4)0.0020.03QOL74.0 (15.3)9.7 (15.9)0.00569.0 (21.1)7.5 (18.5)0.110.78Insomnia35.9 (32.6)-16.7 (32.6)0.0334.9 (35.7)-8.3 (21.3)0.060.52Lack of Appetite17.9 (27.0)-13.3 (27.2)0.0311.1 (19.2)-5.0 (22.4)0.530.29Anxiety8.3 (3.4)-0.6 (2.9)0.259.2 (2.5)-1.6 (2.3)0.0060.35Stress14.7 (7.2)-2.2 (4.9)0.0618.4 (5.5)-3.1 (6.8)0.060.77

*Results reported as means (SD). Positive scores on functional and QOL measures indicate improvements; negative scores on symptom measures indicate a decrease in symptoms.

Citation Format: Ligibel JA, Giobbie-Hurder A, Dillion D, Shockro L, Campbell N, Rhei E, Troyan S, Dominici L, Golshan M, Chagpar A, Yung R, Freedman R, Tolaney S, Winer E, Frank E, McTiernan A, Irwin M. Impact of pre-operative exercise and mind-body interventions on patient-reported outcomes in women with newly diagnosed breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-11-02.