Advanced and Metastatic Breast Cancer

In HER2-positive breast cancer patients with brain metastases treated with trastuzumab and capecitabine, add-on tucatinib increased median overall survival from 12 months to 18.1 months in a phase 2 trial.

The results were presented as part of the American Society of Clinical Oncology virtual scientific program and published simultaneously in the Journal of Clinical Oncology.

At 1 year, 70% of the 198 patients who had been randomized to tucatinib were alive versus 47% of the 93 patients randomized to placebo. Tucatinib reduced the risk of death by 42% (P = .005).

“This is the first double-blind, randomized trial of systemic therapy to our knowledge [that demonstrated] clinically meaningful gains in [overall survival] among patients with [brain metastases], including those with active metastases,” Nancy Lin, MD, associate chief of the division of breast oncology at Dana-Farber Cancer Institute in Boston and colleagues wrote in the Journal of Clinical Oncology.

The findings come from a substudy of the HER2CLIMB trial, which had similar outcomes but didn’t separate women with brain metastases from others. The study won tucatinib’s maker, Seattle Genetics, Food and Drug Administration approval for tucatinib in combination with trastuzumab and capecitabine for patients with unresectable or metastatic HER2-postive disease after failure of at least one treatment for advanced disease. In the United States, tucatinib costs over $18,000 a month, according to GoodRX and other sources.



The newly approved indication for tucatinib includes patients with brain metastases, but Dr. Lin and colleagues drove the point home by analyzing HER2CLIMB data solely in the 291 subjects who had baseline CNS lesions, which occur in up to half of women with advanced HER2-positive breast cancer.

Amy Tiersten, MD, a professor at Mount Sinai Hospital in New York, was not involved in the study but is convinced of the clinical benefit of tucatinib. Tucatinib “will be the standard of care for all patients with brain metastases ... regardless of” previous treatments, she said.

“It’s a total game changer. The addition of tucatinib made a large difference, including a hefty impact on overall survival. It will be interesting to see if this drug will be useful in earlier stages to help prevent brain metastases,” Dr. Tiersten said.

Among the large benefits she alluded to, the median CNS progression-free survival (PFS) – free of lesion progression or death – was 9.9 months with tucatinib versus 4.2 months with placebo (P < .00001).

At 1 year, 40% of tucatinib patients, but no patients in the placebo arm, were alive and free of CNS progression. Tucatinib reduced the risk of intracranial progression or death by 68%.

 

Active vs. stable brain metastasis

Among the 117 patients who entered the trial with stable, treated brain metastases – most by radiation, the rest by surgery – the median CNS PFS was 13.9 months with tucatinib versus 5.6 months with placebo (P = .002). In this group, the median overall survival was 15.7 months in the tucatinib arm and 13.6 month in the placebo arm (P = .70).

“Overall survival [in stable patients] numerically favored tucatinib to a small extent, but this did not reach statistical significance, albeit in a relatively small number of patients,” Dr. Lin said in her presentation.

Between-arm differences were significant in the 174 patients who entered the trial with active brain metastases, which refers to those that were either known but untreated, newly discovered on baseline MRI, or progressed after treatment. At 1 year, 35% of these patients in the tucatinib arm were still alive and free of CNS progression; however, there were no such patients in the placebo arm.

The median CNS PFS among patients with active brain metastases at study entrance was 9.5 months with tucatinib versus 4.1 months in the placebo arm (P < .0001). The median overall survival was 20.7 months and 11.6 months, respectively (P = .004).

Intracranial response was confirmed by MRI in 47% of tucatinib-treated patients with active brain metastasis at baseline versus 20% of patients on placebo (P = .03).
 

Re-treatment after progression

Thirty subjects – 21 on tucatinib and 9 on placebo – returned to their study arm after radiation for brain lesion progression.

The risk of second progression or death was reduced 67% when patients restarted tucatinib instead of placebo.

The median time from first CNS progression to a second progression or death was 7.6 months with tucatinib versus 3.1 months with placebo (P = .02).

“The data suggest a potential benefit for continuation of tucatinib beyond first isolated CNS progression,” Dr. Lin said.

As for why tucatinib helps, she and her colleagues speculated that, because tyrosine kinase inhibitors are small molecules, they can cross the blood brain barrier and effectively treat CNS lesions, while larger, antibody-based anti-HER2 agents, such as trastuzumab and pertuzumab, cannot.

Study entry required prior treatment with trastuzumab, pertuzumab, and ado-trastuzumab emtansine, as well as an Eastern Cooperative Oncology Group performance score of 0 or 1. More than 99% of the subjects in the analysis were women, and the median age was 52 years.

The treatment groups were well balanced. A bit over half of the subjects in both arms were in North America, and 57% were estrogen and/or progesterone receptor positive. Adverse events were reported previously.

This research was funded by tucatinib’s maker, Seattle Genetics. Dr. Lin and colleagues disclosed financial relationships with Seattle Genetics, including employment. Dr. Tiersten reported no relevant conflicts of interest.

aotto@mdedge.com

SOURCE: Lin NU et al. ASCO 2020, Abstract 1005; J Clin Oncol. 2020 May 29. doi: 10.1200/JCO.20.00775

In HER2-positive breast cancer patients with brain metastases treated with trastuzumab and capecitabine, add-on tucatinib increased median overall survival from 12 months to 18.1 months in a phase 2 trial.

The results were presented as part of the American Society of Clinical Oncology virtual scientific program and published simultaneously in the Journal of Clinical Oncology.

At 1 year, 70% of the 198 patients who had been randomized to tucatinib were alive versus 47% of the 93 patients randomized to placebo. Tucatinib reduced the risk of death by 42% (P = .005).

“This is the first double-blind, randomized trial of systemic therapy to our knowledge [that demonstrated] clinically meaningful gains in [overall survival] among patients with [brain metastases], including those with active metastases,” Nancy Lin, MD, associate chief of the division of breast oncology at Dana-Farber Cancer Institute in Boston and colleagues wrote in the Journal of Clinical Oncology.

The findings come from a substudy of the HER2CLIMB trial, which had similar outcomes but didn’t separate women with brain metastases from others. The study won tucatinib’s maker, Seattle Genetics, Food and Drug Administration approval for tucatinib in combination with trastuzumab and capecitabine for patients with unresectable or metastatic HER2-postive disease after failure of at least one treatment for advanced disease. In the United States, tucatinib costs over $18,000 a month, according to GoodRX and other sources.



The newly approved indication for tucatinib includes patients with brain metastases, but Dr. Lin and colleagues drove the point home by analyzing HER2CLIMB data solely in the 291 subjects who had baseline CNS lesions, which occur in up to half of women with advanced HER2-positive breast cancer.

Amy Tiersten, MD, a professor at Mount Sinai Hospital in New York, was not involved in the study but is convinced of the clinical benefit of tucatinib. Tucatinib “will be the standard of care for all patients with brain metastases ... regardless of” previous treatments, she said.

“It’s a total game changer. The addition of tucatinib made a large difference, including a hefty impact on overall survival. It will be interesting to see if this drug will be useful in earlier stages to help prevent brain metastases,” Dr. Tiersten said.

Among the large benefits she alluded to, the median CNS progression-free survival (PFS) – free of lesion progression or death – was 9.9 months with tucatinib versus 4.2 months with placebo (P < .00001).

At 1 year, 40% of tucatinib patients, but no patients in the placebo arm, were alive and free of CNS progression. Tucatinib reduced the risk of intracranial progression or death by 68%.

 

Active vs. stable brain metastasis

Among the 117 patients who entered the trial with stable, treated brain metastases – most by radiation, the rest by surgery – the median CNS PFS was 13.9 months with tucatinib versus 5.6 months with placebo (P = .002). In this group, the median overall survival was 15.7 months in the tucatinib arm and 13.6 month in the placebo arm (P = .70).

“Overall survival [in stable patients] numerically favored tucatinib to a small extent, but this did not reach statistical significance, albeit in a relatively small number of patients,” Dr. Lin said in her presentation.

Between-arm differences were significant in the 174 patients who entered the trial with active brain metastases, which refers to those that were either known but untreated, newly discovered on baseline MRI, or progressed after treatment. At 1 year, 35% of these patients in the tucatinib arm were still alive and free of CNS progression; however, there were no such patients in the placebo arm.

The median CNS PFS among patients with active brain metastases at study entrance was 9.5 months with tucatinib versus 4.1 months in the placebo arm (P < .0001). The median overall survival was 20.7 months and 11.6 months, respectively (P = .004).

Intracranial response was confirmed by MRI in 47% of tucatinib-treated patients with active brain metastasis at baseline versus 20% of patients on placebo (P = .03).
 

Re-treatment after progression

Thirty subjects – 21 on tucatinib and 9 on placebo – returned to their study arm after radiation for brain lesion progression.

The risk of second progression or death was reduced 67% when patients restarted tucatinib instead of placebo.

The median time from first CNS progression to a second progression or death was 7.6 months with tucatinib versus 3.1 months with placebo (P = .02).

“The data suggest a potential benefit for continuation of tucatinib beyond first isolated CNS progression,” Dr. Lin said.

As for why tucatinib helps, she and her colleagues speculated that, because tyrosine kinase inhibitors are small molecules, they can cross the blood brain barrier and effectively treat CNS lesions, while larger, antibody-based anti-HER2 agents, such as trastuzumab and pertuzumab, cannot.

Study entry required prior treatment with trastuzumab, pertuzumab, and ado-trastuzumab emtansine, as well as an Eastern Cooperative Oncology Group performance score of 0 or 1. More than 99% of the subjects in the analysis were women, and the median age was 52 years.

The treatment groups were well balanced. A bit over half of the subjects in both arms were in North America, and 57% were estrogen and/or progesterone receptor positive. Adverse events were reported previously.

This research was funded by tucatinib’s maker, Seattle Genetics. Dr. Lin and colleagues disclosed financial relationships with Seattle Genetics, including employment. Dr. Tiersten reported no relevant conflicts of interest.

aotto@mdedge.com

SOURCE: Lin NU et al. ASCO 2020, Abstract 1005; J Clin Oncol. 2020 May 29. doi: 10.1200/JCO.20.00775

In HER2-positive breast cancer patients with brain metastases treated with trastuzumab and capecitabine, add-on tucatinib increased median overall survival from 12 months to 18.1 months in a phase 2 trial.

The results were presented as part of the American Society of Clinical Oncology virtual scientific program and published simultaneously in the Journal of Clinical Oncology.

At 1 year, 70% of the 198 patients who had been randomized to tucatinib were alive versus 47% of the 93 patients randomized to placebo. Tucatinib reduced the risk of death by 42% (P = .005).

“This is the first double-blind, randomized trial of systemic therapy to our knowledge [that demonstrated] clinically meaningful gains in [overall survival] among patients with [brain metastases], including those with active metastases,” Nancy Lin, MD, associate chief of the division of breast oncology at Dana-Farber Cancer Institute in Boston and colleagues wrote in the Journal of Clinical Oncology.

The findings come from a substudy of the HER2CLIMB trial, which had similar outcomes but didn’t separate women with brain metastases from others. The study won tucatinib’s maker, Seattle Genetics, Food and Drug Administration approval for tucatinib in combination with trastuzumab and capecitabine for patients with unresectable or metastatic HER2-postive disease after failure of at least one treatment for advanced disease. In the United States, tucatinib costs over $18,000 a month, according to GoodRX and other sources.



The newly approved indication for tucatinib includes patients with brain metastases, but Dr. Lin and colleagues drove the point home by analyzing HER2CLIMB data solely in the 291 subjects who had baseline CNS lesions, which occur in up to half of women with advanced HER2-positive breast cancer.

Amy Tiersten, MD, a professor at Mount Sinai Hospital in New York, was not involved in the study but is convinced of the clinical benefit of tucatinib. Tucatinib “will be the standard of care for all patients with brain metastases ... regardless of” previous treatments, she said.

“It’s a total game changer. The addition of tucatinib made a large difference, including a hefty impact on overall survival. It will be interesting to see if this drug will be useful in earlier stages to help prevent brain metastases,” Dr. Tiersten said.

Among the large benefits she alluded to, the median CNS progression-free survival (PFS) – free of lesion progression or death – was 9.9 months with tucatinib versus 4.2 months with placebo (P < .00001).

At 1 year, 40% of tucatinib patients, but no patients in the placebo arm, were alive and free of CNS progression. Tucatinib reduced the risk of intracranial progression or death by 68%.

 

Active vs. stable brain metastasis

Among the 117 patients who entered the trial with stable, treated brain metastases – most by radiation, the rest by surgery – the median CNS PFS was 13.9 months with tucatinib versus 5.6 months with placebo (P = .002). In this group, the median overall survival was 15.7 months in the tucatinib arm and 13.6 month in the placebo arm (P = .70).

“Overall survival [in stable patients] numerically favored tucatinib to a small extent, but this did not reach statistical significance, albeit in a relatively small number of patients,” Dr. Lin said in her presentation.

Between-arm differences were significant in the 174 patients who entered the trial with active brain metastases, which refers to those that were either known but untreated, newly discovered on baseline MRI, or progressed after treatment. At 1 year, 35% of these patients in the tucatinib arm were still alive and free of CNS progression; however, there were no such patients in the placebo arm.

The median CNS PFS among patients with active brain metastases at study entrance was 9.5 months with tucatinib versus 4.1 months in the placebo arm (P < .0001). The median overall survival was 20.7 months and 11.6 months, respectively (P = .004).

Intracranial response was confirmed by MRI in 47% of tucatinib-treated patients with active brain metastasis at baseline versus 20% of patients on placebo (P = .03).
 

Re-treatment after progression

Thirty subjects – 21 on tucatinib and 9 on placebo – returned to their study arm after radiation for brain lesion progression.

The risk of second progression or death was reduced 67% when patients restarted tucatinib instead of placebo.

The median time from first CNS progression to a second progression or death was 7.6 months with tucatinib versus 3.1 months with placebo (P = .02).

“The data suggest a potential benefit for continuation of tucatinib beyond first isolated CNS progression,” Dr. Lin said.

As for why tucatinib helps, she and her colleagues speculated that, because tyrosine kinase inhibitors are small molecules, they can cross the blood brain barrier and effectively treat CNS lesions, while larger, antibody-based anti-HER2 agents, such as trastuzumab and pertuzumab, cannot.

Study entry required prior treatment with trastuzumab, pertuzumab, and ado-trastuzumab emtansine, as well as an Eastern Cooperative Oncology Group performance score of 0 or 1. More than 99% of the subjects in the analysis were women, and the median age was 52 years.

The treatment groups were well balanced. A bit over half of the subjects in both arms were in North America, and 57% were estrogen and/or progesterone receptor positive. Adverse events were reported previously.

This research was funded by tucatinib’s maker, Seattle Genetics. Dr. Lin and colleagues disclosed financial relationships with Seattle Genetics, including employment. Dr. Tiersten reported no relevant conflicts of interest.

aotto@mdedge.com

SOURCE: Lin NU et al. ASCO 2020, Abstract 1005; J Clin Oncol. 2020 May 29. doi: 10.1200/JCO.20.00775

Adding pembrolizumab to standard chemotherapy significantly improved progression-free survival for patients with metastatic triple-negative breast cancer, but only if their tumors were enriched with comparatively high levels of the target programmed death ligand-1 (PD-L1), results of the KEYNOTE 355 trial showed.

Among 843 patients with triple-negative breast cancer (TNBC) randomized to receive either investigator’s choice of chemotherapy plus pembrolizumab (Keytruda) or placebo, patients whose tumors had a PD-L1 combined positive score (CPS) of 10 or higher had a median progression-free survival (PFS) of 9.7 months when treated with pembrolizumab and chemotherapy, compared with 5.6 months among patients treated with chemotherapy and placebo, reported Javier Cortes, MD, PhD, from the Vall d´Hebron Institute of Oncology in Madrid and Barcelona.

However, among patients with CPS between 1 and 10, there was no significant difference in PFS between the treatment arms, he said in a presentation made as a part of the 2020 American Society of Clinical Oncology virtual scientific program.

“The inclusion of taxanes and a known taxane/platinum–based regimen permits assessment of the clinical benefit of pembro in combination with several routinely used chemo partners. A trend toward improved efficacy with PD-L1 enrichment was observed in patients treated with pembro plus chemo. The improvement in progression-free survival with chemotherapy and pembrolizumab was observed across patient subgroups,” said Dr. Cortes.

In the KEYNOTE-522 study, adding pembrolizumab to chemotherapy in the neoadjuvant setting increased the likelihood that women with stage III or early node-positive TNBC would have a pathologic complete response and sustained clinical benefit.

KEYNOTE-355 examined whether pembrolizumab in combination with chemotherapy could provide additional benefit over chemotherapy alone in patients with previously untreated locally recurrent inoperable or metastatic TNBC.

Patients with previously untreated metastatic triple-negative breast cancer who had at least 6 months between definite surgery or last dose of adjuvant chemotherapy (whichever came last) and first disease recurrence were stratified by study chemotherapy received, tumor PD-L1 expression at baseline, and prior treatment with the same class of chemotherapy in the neoadjuvant and/or adjuvant setting.

The patients were then randomized in a 2:1 ratio to pembrolizumab plus chemotherapy based on the investigator’s choice of nab-paclitaxel, paclitaxel, or carboplatin-gemcitabine (562 patients) or to chemotherapy alone (281).

Pembrolizumab and placebo were administered in a double-blind fashion for up to 35 doses. Chemotherapy was given at the investigator’s discretion according to local guidelines. This trial was not powered or designed to compare differential efficacy of the various chemotherapy regimens, Dr. Cortes noted.

The trial had dual primary endpoints of PFS in patients with PD-L1–positive tumors (CPS > 10 and > 1) and in the intention-to-treat population, and overall survival both in PD-L1-positive patients and the ITT population. Overall survival results will be reported at a later date.

As noted before, the primary endpoint was met in the population of patients with CPS higher than 10, with median PFS of 9.7 among those receiving pembrolizumab versus 5.6 months among those receiving placebo, and an estimated 1 year PFS of 39.1% versus 23% for controls, translating into a hazard ratio for progression on pembrolizumab of 0.65 (P = .0012).

In the patients with CPS higher than 1, however, the median PFS was 7.6 months with pembrolizumab compared with 5.6 months with placebo, translating into a hazard ratio of 0.74. However, the results did not meet the prespecified boundary for significance. Because of this, the statistical significance in the ITT population was not tested.

“In patients with PD-L1 CPS 10 or higher tumors, the benefit of pembro/chemo on progression-free survival was generally consistent across most predefined subgroups, including eight geographic regions, ECOG performance status, on-study chemo, and prior treatment with the same class of chemo,” Dr. Cortes said.

Treatment-related adverse events occurred in 96.3% of the patients on pembrolizumab and 95% of patients on placebo. Grade 3 or greater adverse events occurred in 68.1% versus 66.9%, respectively. Two patients in the pembrolizumab arm died from a treatment-related event. There were no treatment-related deaths in the placebo arm.

The most common events were those typically associated with chemotherapy, including anemia, neutropenia, nausea, alopecia, fatigue, decreased neutrophil counts, and elevated liver transaminases. Immune-mediated adverse events of any grade occurred in 25.6% of patients in the pembrolizumab arm versus 6% of controls; none of these events were fatal.

“What is clear in this study is that again we’re seeing efficacy of pembrolizumab in combination with chemotherapy increases with increases in CPS,” according to the invited discussant Catherine M. Kelly, MB, BCh, from University College Dublin and Mater Misericordiae University Hospital in Dublin.

“The results from today’s KEYNOTE-355 appear consistent in terms of progression-free survival. However, it is ‘watch this space’ until we get overall survival data before we can make any further comparisons,” she added.

Questions that still need to be answered include which is the best test for measuring PD-L1, whether patients with CPS of 1 or more but less than 10 benefit from the treatment, which of the available chemotherapy regimens is the best partner for pembrolizumab, how to treat patients who don’t respond to the combination, and what are the implications for PD-1/PD-L1 inhibitors in late-stage disease if they are approved in the neoadjuvant or adjuvant setting, Dr. Kelly said.

The study was funded by Merck. Dr. Cortes disclosed honoraria from, a consulting/advisory role for, and institutional research funding from Merck and others. Dr. Kelly disclosed honoraria from MSD Oncology and others, and travel expenses from Pfizer and Roche.

SOURCE: Cortes J et al. ASCO 2020, Abstract 1000.

Adding pembrolizumab to standard chemotherapy significantly improved progression-free survival for patients with metastatic triple-negative breast cancer, but only if their tumors were enriched with comparatively high levels of the target programmed death ligand-1 (PD-L1), results of the KEYNOTE 355 trial showed.

Among 843 patients with triple-negative breast cancer (TNBC) randomized to receive either investigator’s choice of chemotherapy plus pembrolizumab (Keytruda) or placebo, patients whose tumors had a PD-L1 combined positive score (CPS) of 10 or higher had a median progression-free survival (PFS) of 9.7 months when treated with pembrolizumab and chemotherapy, compared with 5.6 months among patients treated with chemotherapy and placebo, reported Javier Cortes, MD, PhD, from the Vall d´Hebron Institute of Oncology in Madrid and Barcelona.

However, among patients with CPS between 1 and 10, there was no significant difference in PFS between the treatment arms, he said in a presentation made as a part of the 2020 American Society of Clinical Oncology virtual scientific program.

“The inclusion of taxanes and a known taxane/platinum–based regimen permits assessment of the clinical benefit of pembro in combination with several routinely used chemo partners. A trend toward improved efficacy with PD-L1 enrichment was observed in patients treated with pembro plus chemo. The improvement in progression-free survival with chemotherapy and pembrolizumab was observed across patient subgroups,” said Dr. Cortes.

In the KEYNOTE-522 study, adding pembrolizumab to chemotherapy in the neoadjuvant setting increased the likelihood that women with stage III or early node-positive TNBC would have a pathologic complete response and sustained clinical benefit.

KEYNOTE-355 examined whether pembrolizumab in combination with chemotherapy could provide additional benefit over chemotherapy alone in patients with previously untreated locally recurrent inoperable or metastatic TNBC.

Patients with previously untreated metastatic triple-negative breast cancer who had at least 6 months between definite surgery or last dose of adjuvant chemotherapy (whichever came last) and first disease recurrence were stratified by study chemotherapy received, tumor PD-L1 expression at baseline, and prior treatment with the same class of chemotherapy in the neoadjuvant and/or adjuvant setting.

The patients were then randomized in a 2:1 ratio to pembrolizumab plus chemotherapy based on the investigator’s choice of nab-paclitaxel, paclitaxel, or carboplatin-gemcitabine (562 patients) or to chemotherapy alone (281).

Pembrolizumab and placebo were administered in a double-blind fashion for up to 35 doses. Chemotherapy was given at the investigator’s discretion according to local guidelines. This trial was not powered or designed to compare differential efficacy of the various chemotherapy regimens, Dr. Cortes noted.

The trial had dual primary endpoints of PFS in patients with PD-L1–positive tumors (CPS > 10 and > 1) and in the intention-to-treat population, and overall survival both in PD-L1-positive patients and the ITT population. Overall survival results will be reported at a later date.

As noted before, the primary endpoint was met in the population of patients with CPS higher than 10, with median PFS of 9.7 among those receiving pembrolizumab versus 5.6 months among those receiving placebo, and an estimated 1 year PFS of 39.1% versus 23% for controls, translating into a hazard ratio for progression on pembrolizumab of 0.65 (P = .0012).

In the patients with CPS higher than 1, however, the median PFS was 7.6 months with pembrolizumab compared with 5.6 months with placebo, translating into a hazard ratio of 0.74. However, the results did not meet the prespecified boundary for significance. Because of this, the statistical significance in the ITT population was not tested.

“In patients with PD-L1 CPS 10 or higher tumors, the benefit of pembro/chemo on progression-free survival was generally consistent across most predefined subgroups, including eight geographic regions, ECOG performance status, on-study chemo, and prior treatment with the same class of chemo,” Dr. Cortes said.

Treatment-related adverse events occurred in 96.3% of the patients on pembrolizumab and 95% of patients on placebo. Grade 3 or greater adverse events occurred in 68.1% versus 66.9%, respectively. Two patients in the pembrolizumab arm died from a treatment-related event. There were no treatment-related deaths in the placebo arm.

The most common events were those typically associated with chemotherapy, including anemia, neutropenia, nausea, alopecia, fatigue, decreased neutrophil counts, and elevated liver transaminases. Immune-mediated adverse events of any grade occurred in 25.6% of patients in the pembrolizumab arm versus 6% of controls; none of these events were fatal.

“What is clear in this study is that again we’re seeing efficacy of pembrolizumab in combination with chemotherapy increases with increases in CPS,” according to the invited discussant Catherine M. Kelly, MB, BCh, from University College Dublin and Mater Misericordiae University Hospital in Dublin.

“The results from today’s KEYNOTE-355 appear consistent in terms of progression-free survival. However, it is ‘watch this space’ until we get overall survival data before we can make any further comparisons,” she added.

Questions that still need to be answered include which is the best test for measuring PD-L1, whether patients with CPS of 1 or more but less than 10 benefit from the treatment, which of the available chemotherapy regimens is the best partner for pembrolizumab, how to treat patients who don’t respond to the combination, and what are the implications for PD-1/PD-L1 inhibitors in late-stage disease if they are approved in the neoadjuvant or adjuvant setting, Dr. Kelly said.

The study was funded by Merck. Dr. Cortes disclosed honoraria from, a consulting/advisory role for, and institutional research funding from Merck and others. Dr. Kelly disclosed honoraria from MSD Oncology and others, and travel expenses from Pfizer and Roche.

SOURCE: Cortes J et al. ASCO 2020, Abstract 1000.

Adding pembrolizumab to standard chemotherapy significantly improved progression-free survival for patients with metastatic triple-negative breast cancer, but only if their tumors were enriched with comparatively high levels of the target programmed death ligand-1 (PD-L1), results of the KEYNOTE 355 trial showed.

Among 843 patients with triple-negative breast cancer (TNBC) randomized to receive either investigator’s choice of chemotherapy plus pembrolizumab (Keytruda) or placebo, patients whose tumors had a PD-L1 combined positive score (CPS) of 10 or higher had a median progression-free survival (PFS) of 9.7 months when treated with pembrolizumab and chemotherapy, compared with 5.6 months among patients treated with chemotherapy and placebo, reported Javier Cortes, MD, PhD, from the Vall d´Hebron Institute of Oncology in Madrid and Barcelona.

However, among patients with CPS between 1 and 10, there was no significant difference in PFS between the treatment arms, he said in a presentation made as a part of the 2020 American Society of Clinical Oncology virtual scientific program.

“The inclusion of taxanes and a known taxane/platinum–based regimen permits assessment of the clinical benefit of pembro in combination with several routinely used chemo partners. A trend toward improved efficacy with PD-L1 enrichment was observed in patients treated with pembro plus chemo. The improvement in progression-free survival with chemotherapy and pembrolizumab was observed across patient subgroups,” said Dr. Cortes.

In the KEYNOTE-522 study, adding pembrolizumab to chemotherapy in the neoadjuvant setting increased the likelihood that women with stage III or early node-positive TNBC would have a pathologic complete response and sustained clinical benefit.

KEYNOTE-355 examined whether pembrolizumab in combination with chemotherapy could provide additional benefit over chemotherapy alone in patients with previously untreated locally recurrent inoperable or metastatic TNBC.

Patients with previously untreated metastatic triple-negative breast cancer who had at least 6 months between definite surgery or last dose of adjuvant chemotherapy (whichever came last) and first disease recurrence were stratified by study chemotherapy received, tumor PD-L1 expression at baseline, and prior treatment with the same class of chemotherapy in the neoadjuvant and/or adjuvant setting.

The patients were then randomized in a 2:1 ratio to pembrolizumab plus chemotherapy based on the investigator’s choice of nab-paclitaxel, paclitaxel, or carboplatin-gemcitabine (562 patients) or to chemotherapy alone (281).

Pembrolizumab and placebo were administered in a double-blind fashion for up to 35 doses. Chemotherapy was given at the investigator’s discretion according to local guidelines. This trial was not powered or designed to compare differential efficacy of the various chemotherapy regimens, Dr. Cortes noted.

The trial had dual primary endpoints of PFS in patients with PD-L1–positive tumors (CPS > 10 and > 1) and in the intention-to-treat population, and overall survival both in PD-L1-positive patients and the ITT population. Overall survival results will be reported at a later date.

As noted before, the primary endpoint was met in the population of patients with CPS higher than 10, with median PFS of 9.7 among those receiving pembrolizumab versus 5.6 months among those receiving placebo, and an estimated 1 year PFS of 39.1% versus 23% for controls, translating into a hazard ratio for progression on pembrolizumab of 0.65 (P = .0012).

In the patients with CPS higher than 1, however, the median PFS was 7.6 months with pembrolizumab compared with 5.6 months with placebo, translating into a hazard ratio of 0.74. However, the results did not meet the prespecified boundary for significance. Because of this, the statistical significance in the ITT population was not tested.

“In patients with PD-L1 CPS 10 or higher tumors, the benefit of pembro/chemo on progression-free survival was generally consistent across most predefined subgroups, including eight geographic regions, ECOG performance status, on-study chemo, and prior treatment with the same class of chemo,” Dr. Cortes said.

Treatment-related adverse events occurred in 96.3% of the patients on pembrolizumab and 95% of patients on placebo. Grade 3 or greater adverse events occurred in 68.1% versus 66.9%, respectively. Two patients in the pembrolizumab arm died from a treatment-related event. There were no treatment-related deaths in the placebo arm.

The most common events were those typically associated with chemotherapy, including anemia, neutropenia, nausea, alopecia, fatigue, decreased neutrophil counts, and elevated liver transaminases. Immune-mediated adverse events of any grade occurred in 25.6% of patients in the pembrolizumab arm versus 6% of controls; none of these events were fatal.

“What is clear in this study is that again we’re seeing efficacy of pembrolizumab in combination with chemotherapy increases with increases in CPS,” according to the invited discussant Catherine M. Kelly, MB, BCh, from University College Dublin and Mater Misericordiae University Hospital in Dublin.

“The results from today’s KEYNOTE-355 appear consistent in terms of progression-free survival. However, it is ‘watch this space’ until we get overall survival data before we can make any further comparisons,” she added.

Questions that still need to be answered include which is the best test for measuring PD-L1, whether patients with CPS of 1 or more but less than 10 benefit from the treatment, which of the available chemotherapy regimens is the best partner for pembrolizumab, how to treat patients who don’t respond to the combination, and what are the implications for PD-1/PD-L1 inhibitors in late-stage disease if they are approved in the neoadjuvant or adjuvant setting, Dr. Kelly said.

The study was funded by Merck. Dr. Cortes disclosed honoraria from, a consulting/advisory role for, and institutional research funding from Merck and others. Dr. Kelly disclosed honoraria from MSD Oncology and others, and travel expenses from Pfizer and Roche.

SOURCE: Cortes J et al. ASCO 2020, Abstract 1000.

Adding the AKT inhibitor ipatasertib to paclitaxel may provide an overall survival (OS) benefit for inoperable locally advanced/metastatic triple-negative breast cancer (TNBC), according to final results of the phase 2 LOTUS trial.

The median OS was 25.8 months in patients who received ipatasertib plus paclitaxel and 16.9 months in patients who received paclitaxel plus placebo. Although this difference was not statistically significant, it was “clinically meaningful,” according to Rebecca Dent, MD, of the National Cancer Center Singapore. Dr. Dent presented OS data from the LOTUS trial at the European Society of Medical Oncology: Breast Cancer virtual meeting.

Previously reported data showed a progression-free survival benefit in the ipatasertib arm, compared with the placebo arm – 6.2 months and 4.9 months, respectively (Lancet Oncol. 2017 Oct;18[10]:1360-72). An enhanced effect was noted in patients with PIK3CA/AKT1/PTEN–altered tumors, but the OS data were not mature at the time of that primary analysis.
 

Patients, treatment, and safety

LOTUS participants had measurable locally advanced/metastatic TNBC that was previously untreated with systemic therapy, and they were stratified by prior adjuvant therapy, chemotherapy-free interval, and tumor immunohistochemistry PTEN status.

Patients were randomized 1:1 to receive paclitaxel at a dose of 80 mg/m² on days 1, 8, and 15 of each 28-day cycle plus either placebo (n = 62) or ipatasertib at a dose of 400 mg on days 1-21 (n = 62).

The safety results didn’t differ between the primary and updated results, Dr. Dent noted.

“What we can say is that the combination is extremely well tolerated, especially when we compare it to other targeted agents targeting this pathway,” she said. “What we do see is noticeable diarrhea ... [and] an increase in sensory neuropathy, which is not entirely unexpected.”

Subsequent systemic anticancer therapy was required in 77% of patients in the ipatasertib arm and 90% of patients in the placebo arm.
 

OS results

The final OS data show a numerical advantage for patients in the ipatasertib arm compared with the placebo arm. The 1-year OS was 83% in the ipatasertib arm and 68% in the placebo arm. The median OS was 25.8 months and 16.9 months, respectively (stratified hazard ratio, 0.80).

“This is a clinically meaningful improvement of 9 months in overall survival, which is indeed not too dissimilar to what we have seen in patients with PD-L1-positive TNBC who are receiving immune checkpoint inhibition in combination with chemotherapy,” Dr. Dent said.

However, the 95% confidence interval for the stratified OS hazard ratio crossed 1 (0.50-1.28). Therefore, the findings require confirmatory phase 3 trial results, Dr. Dent said.

The OS improvements with ipatasertib were seen “in all biomarker-defined subgroups – PTEN normal or low, PIK3CA/AKT1/PTEN altered or non-altered,” she said. OS benefits were more pronounced in patients with altered PIK3C/AKT1/PTEN status, but the numbers are too small to make definitive conclusions, according to Dr. Dent.
 

‘Promising’ results, confirmation needed

Invited discussant Suzette Delaloge, MD, head of the breast cancer department at Gustave Roussy, Paris, said the OS findings from LOTUS are “quite promising,” and the safety data are “reassuring.”

The findings are comparable to those of the recently published PAKT trial (J Clin Oncol. 2020 Feb 10;38[5]:423-33), she said, noting that “AKT inhibition in combination with paclitaxel deserves phase 3 development, and this is ongoing in major phase 3 trials.”

Dr. Delaloge also noted that the efficacy may not be limited to PIK3CA/AKT–altered tumors, and given the heterogeneity of TNBC – which may explain the differences seen among various studies – “it is very important that such phase 3 trials ideally involve extensive genomical definitions of tumors so that we understand what it is we are talking about and what is the real effect of the drug.”

“The adequate positioning of AKT inhibition in competition/complementation with other ongoing strategies remains to be defined,” she said. “I think these drugs are ready for translation to early phases.”

Dr. Dent said the results of LOTUS warrant confirmation in the ongoing, randomized phase 3 IPATunity130 trial , in which researchers are evaluating first-line ipatasertib plus paclitaxel for metastatic TNBC. She noted that the small sample sizes and heterogeneity of TNBC among LOTUS participants limited the interpretation of the findings.

In another trial, IPATunity170, researchers are evaluating the first-line role of ipatasertib plus paclitaxel and atezolizumab in locally advanced or metastatic TNBC.

“This is an exciting triplet combination that’s been evaluated already in the phase 1 setting, and now we have a phase 3 study evaluating the triplet,” Dr. Dent said.

The LOTUS trial was funded by Roche/Genentech. Dr. Dent reported receiving honoraria from Roche, Novartis, Lilly, Pfizer, Eisai, Merck, and AstraZeneca. Dr. Delaloge reported personal financial interests in AstraZeneca until 2018 and travel and accommodation support from AstraZeneca, Pfizer, Roche, and Pierre Fabre.

sworcester@mdedge.com

SOURCE: Dent R et al. ESMO Breast Cancer 2020, Abstract 139O

Adding the AKT inhibitor ipatasertib to paclitaxel may provide an overall survival (OS) benefit for inoperable locally advanced/metastatic triple-negative breast cancer (TNBC), according to final results of the phase 2 LOTUS trial.

The median OS was 25.8 months in patients who received ipatasertib plus paclitaxel and 16.9 months in patients who received paclitaxel plus placebo. Although this difference was not statistically significant, it was “clinically meaningful,” according to Rebecca Dent, MD, of the National Cancer Center Singapore. Dr. Dent presented OS data from the LOTUS trial at the European Society of Medical Oncology: Breast Cancer virtual meeting.

Previously reported data showed a progression-free survival benefit in the ipatasertib arm, compared with the placebo arm – 6.2 months and 4.9 months, respectively (Lancet Oncol. 2017 Oct;18[10]:1360-72). An enhanced effect was noted in patients with PIK3CA/AKT1/PTEN–altered tumors, but the OS data were not mature at the time of that primary analysis.
 

Patients, treatment, and safety

LOTUS participants had measurable locally advanced/metastatic TNBC that was previously untreated with systemic therapy, and they were stratified by prior adjuvant therapy, chemotherapy-free interval, and tumor immunohistochemistry PTEN status.

Patients were randomized 1:1 to receive paclitaxel at a dose of 80 mg/m² on days 1, 8, and 15 of each 28-day cycle plus either placebo (n = 62) or ipatasertib at a dose of 400 mg on days 1-21 (n = 62).

The safety results didn’t differ between the primary and updated results, Dr. Dent noted.

“What we can say is that the combination is extremely well tolerated, especially when we compare it to other targeted agents targeting this pathway,” she said. “What we do see is noticeable diarrhea ... [and] an increase in sensory neuropathy, which is not entirely unexpected.”

Subsequent systemic anticancer therapy was required in 77% of patients in the ipatasertib arm and 90% of patients in the placebo arm.
 

OS results

The final OS data show a numerical advantage for patients in the ipatasertib arm compared with the placebo arm. The 1-year OS was 83% in the ipatasertib arm and 68% in the placebo arm. The median OS was 25.8 months and 16.9 months, respectively (stratified hazard ratio, 0.80).

“This is a clinically meaningful improvement of 9 months in overall survival, which is indeed not too dissimilar to what we have seen in patients with PD-L1-positive TNBC who are receiving immune checkpoint inhibition in combination with chemotherapy,” Dr. Dent said.

However, the 95% confidence interval for the stratified OS hazard ratio crossed 1 (0.50-1.28). Therefore, the findings require confirmatory phase 3 trial results, Dr. Dent said.

The OS improvements with ipatasertib were seen “in all biomarker-defined subgroups – PTEN normal or low, PIK3CA/AKT1/PTEN altered or non-altered,” she said. OS benefits were more pronounced in patients with altered PIK3C/AKT1/PTEN status, but the numbers are too small to make definitive conclusions, according to Dr. Dent.
 

‘Promising’ results, confirmation needed

Invited discussant Suzette Delaloge, MD, head of the breast cancer department at Gustave Roussy, Paris, said the OS findings from LOTUS are “quite promising,” and the safety data are “reassuring.”

The findings are comparable to those of the recently published PAKT trial (J Clin Oncol. 2020 Feb 10;38[5]:423-33), she said, noting that “AKT inhibition in combination with paclitaxel deserves phase 3 development, and this is ongoing in major phase 3 trials.”

Dr. Delaloge also noted that the efficacy may not be limited to PIK3CA/AKT–altered tumors, and given the heterogeneity of TNBC – which may explain the differences seen among various studies – “it is very important that such phase 3 trials ideally involve extensive genomical definitions of tumors so that we understand what it is we are talking about and what is the real effect of the drug.”

“The adequate positioning of AKT inhibition in competition/complementation with other ongoing strategies remains to be defined,” she said. “I think these drugs are ready for translation to early phases.”

Dr. Dent said the results of LOTUS warrant confirmation in the ongoing, randomized phase 3 IPATunity130 trial , in which researchers are evaluating first-line ipatasertib plus paclitaxel for metastatic TNBC. She noted that the small sample sizes and heterogeneity of TNBC among LOTUS participants limited the interpretation of the findings.

In another trial, IPATunity170, researchers are evaluating the first-line role of ipatasertib plus paclitaxel and atezolizumab in locally advanced or metastatic TNBC.

“This is an exciting triplet combination that’s been evaluated already in the phase 1 setting, and now we have a phase 3 study evaluating the triplet,” Dr. Dent said.

The LOTUS trial was funded by Roche/Genentech. Dr. Dent reported receiving honoraria from Roche, Novartis, Lilly, Pfizer, Eisai, Merck, and AstraZeneca. Dr. Delaloge reported personal financial interests in AstraZeneca until 2018 and travel and accommodation support from AstraZeneca, Pfizer, Roche, and Pierre Fabre.

sworcester@mdedge.com

SOURCE: Dent R et al. ESMO Breast Cancer 2020, Abstract 139O

Adding the AKT inhibitor ipatasertib to paclitaxel may provide an overall survival (OS) benefit for inoperable locally advanced/metastatic triple-negative breast cancer (TNBC), according to final results of the phase 2 LOTUS trial.

The median OS was 25.8 months in patients who received ipatasertib plus paclitaxel and 16.9 months in patients who received paclitaxel plus placebo. Although this difference was not statistically significant, it was “clinically meaningful,” according to Rebecca Dent, MD, of the National Cancer Center Singapore. Dr. Dent presented OS data from the LOTUS trial at the European Society of Medical Oncology: Breast Cancer virtual meeting.

Previously reported data showed a progression-free survival benefit in the ipatasertib arm, compared with the placebo arm – 6.2 months and 4.9 months, respectively (Lancet Oncol. 2017 Oct;18[10]:1360-72). An enhanced effect was noted in patients with PIK3CA/AKT1/PTEN–altered tumors, but the OS data were not mature at the time of that primary analysis.
 

Patients, treatment, and safety

LOTUS participants had measurable locally advanced/metastatic TNBC that was previously untreated with systemic therapy, and they were stratified by prior adjuvant therapy, chemotherapy-free interval, and tumor immunohistochemistry PTEN status.

Patients were randomized 1:1 to receive paclitaxel at a dose of 80 mg/m² on days 1, 8, and 15 of each 28-day cycle plus either placebo (n = 62) or ipatasertib at a dose of 400 mg on days 1-21 (n = 62).

The safety results didn’t differ between the primary and updated results, Dr. Dent noted.

“What we can say is that the combination is extremely well tolerated, especially when we compare it to other targeted agents targeting this pathway,” she said. “What we do see is noticeable diarrhea ... [and] an increase in sensory neuropathy, which is not entirely unexpected.”

Subsequent systemic anticancer therapy was required in 77% of patients in the ipatasertib arm and 90% of patients in the placebo arm.
 

OS results

The final OS data show a numerical advantage for patients in the ipatasertib arm compared with the placebo arm. The 1-year OS was 83% in the ipatasertib arm and 68% in the placebo arm. The median OS was 25.8 months and 16.9 months, respectively (stratified hazard ratio, 0.80).

“This is a clinically meaningful improvement of 9 months in overall survival, which is indeed not too dissimilar to what we have seen in patients with PD-L1-positive TNBC who are receiving immune checkpoint inhibition in combination with chemotherapy,” Dr. Dent said.

However, the 95% confidence interval for the stratified OS hazard ratio crossed 1 (0.50-1.28). Therefore, the findings require confirmatory phase 3 trial results, Dr. Dent said.

The OS improvements with ipatasertib were seen “in all biomarker-defined subgroups – PTEN normal or low, PIK3CA/AKT1/PTEN altered or non-altered,” she said. OS benefits were more pronounced in patients with altered PIK3C/AKT1/PTEN status, but the numbers are too small to make definitive conclusions, according to Dr. Dent.
 

‘Promising’ results, confirmation needed

Invited discussant Suzette Delaloge, MD, head of the breast cancer department at Gustave Roussy, Paris, said the OS findings from LOTUS are “quite promising,” and the safety data are “reassuring.”

The findings are comparable to those of the recently published PAKT trial (J Clin Oncol. 2020 Feb 10;38[5]:423-33), she said, noting that “AKT inhibition in combination with paclitaxel deserves phase 3 development, and this is ongoing in major phase 3 trials.”

Dr. Delaloge also noted that the efficacy may not be limited to PIK3CA/AKT–altered tumors, and given the heterogeneity of TNBC – which may explain the differences seen among various studies – “it is very important that such phase 3 trials ideally involve extensive genomical definitions of tumors so that we understand what it is we are talking about and what is the real effect of the drug.”

“The adequate positioning of AKT inhibition in competition/complementation with other ongoing strategies remains to be defined,” she said. “I think these drugs are ready for translation to early phases.”

Dr. Dent said the results of LOTUS warrant confirmation in the ongoing, randomized phase 3 IPATunity130 trial , in which researchers are evaluating first-line ipatasertib plus paclitaxel for metastatic TNBC. She noted that the small sample sizes and heterogeneity of TNBC among LOTUS participants limited the interpretation of the findings.

In another trial, IPATunity170, researchers are evaluating the first-line role of ipatasertib plus paclitaxel and atezolizumab in locally advanced or metastatic TNBC.

“This is an exciting triplet combination that’s been evaluated already in the phase 1 setting, and now we have a phase 3 study evaluating the triplet,” Dr. Dent said.

The LOTUS trial was funded by Roche/Genentech. Dr. Dent reported receiving honoraria from Roche, Novartis, Lilly, Pfizer, Eisai, Merck, and AstraZeneca. Dr. Delaloge reported personal financial interests in AstraZeneca until 2018 and travel and accommodation support from AstraZeneca, Pfizer, Roche, and Pierre Fabre.

sworcester@mdedge.com

SOURCE: Dent R et al. ESMO Breast Cancer 2020, Abstract 139O

New data from a large Swedish study show that mammography screening for breast cancer reduces the rate of both advanced and fatal breast cancer.

Three experts who were approached by Medscape Medical News say this is further evidence that regular screening mammography significantly reduces the risk of dying from breast cancer, but one expert questioned the methodology used in the study.

The primary goal of cancer screening is to detect tumors at an early stage, when they are most treatable. The hope is that this will reduce the number of advanced cancers associated with poor prognosis and hence the risk of dying from that cancer.

So far, for mammography, the data have been somewhat conflicting. For example, some evidence suggests that widespread breast cancer screening may catch more small, slow-growing tumors that are unlikely to be fatal but will not curb the number of cancers that are diagnosed at a late stage.

The new study, published online in Cancer, refutes this view.

It followed a Swedish cohort of 549,091 women (covering approximately 30% of the Swedish screening-eligible population) who underwent regular mammography.

For the women in this cohort, there was a statistically significant 41% reduction in the risk of dying of breast cancer within 10 years and a 25% reduction in the incidence of advanced disease, compared to women who did not undergo screening. “Even in this age of effective treatments, early detection confers a substantial and significant additional reduction in risk of dying from breast cancer,” said lead author Stephen W. Duffy, MSc, from the Center for Cancer Prevention at Queen Mary University, London, United Kingdom.

The current study confirms the findings of a smaller earlier study (Cancer. 2019;125:515-23) from the same investigators. “It finds the same result with an extremely large evidence base, with more than half a million women, and it also adds further to the evidence that screening achieves this reduction in the context of routine healthcare, not only in the research context,” Duffy commented. “The results are generalizable to other populations, particularly in North America, Western Europe, and Australasia, where the epidemiology and demographics of breast cancer are similar,” said Duffy. “Clearly, more intensive screening is likely to achieve a greater benefit, but a trade-off between costs, both financial and human, and benefits always has to be made specific to each societal and healthcare environment.”

In Sweden, the policy regarding breast cancer screening is to screen women aged 40 to 54 years every 18 months. For those aged 55 to 69 years, screening is recommended every 24 months.

“The use of the incidence-based endpoints means that there is accurate classification of both the breast cancer cases and the whole study population in terms of exposure to screening and avoids a number of biases seen in other studies of service screening,” Duffy told Medscape Medical News.

“I have never seen persuasive evidence for the assertion that breast cancer screening does not reduce deaths from metastatic disease – indeed, the randomized trials seem to show the opposite,” said Duffy. “This may have arisen from a misunderstanding about the mechanism whereby screening works. It primarily works by diagnosing cancer early so that treatment is successful and recurrence with distant metastases, followed by death, does not occur some years later. I suspect some colleagues have confused this with distant metastases at initial diagnosis,” he added.
 

One expert questions methodology

One of the experts who was approached by Medscape Medical News to comment on the new study, Philippe Autier, MD, MPH, PhD, University of Strathclyde Institute of Global Public Health at the International Prevention Research Institute, Dardilly, France, questioned the methodology of the study. “This method is incorrect simply because women attending screening are different from women not attending screening,” he said. “The former are more health aware and have healthier behaviors than the latter, and this is a well-known fact and supported by the literature.”

Autier emphasized that it is practically impossible to control for that bias, which is known as confounding by indication.

“The statistical methods used for attenuating the so-called self-selection are very approximate and based on unverified assumptions,” he said. “For this reason, the Handbook on Breast Cancer Screening produced by the International Agency for Research on Cancer [IARC] clearly stated that ‘observational studies based on individual screening history, no matter how well designed and conducted, should not be regarded as providing evidence for an effect of screening,’ and the methodology in this paper has never been recommended by the IARC.”

A better way of conducting this type of study would have been to show the incidence trends of advanced-stage breast cancer in Sweden for the entire female population aged 40 years and older, he asserts. Autier used that methodology in his own study in the Netherlands, as previously reported by Medscape Medical News. That study found that in the Netherlands, screening mammography over a period of 24 years among women aged 50 to 74 years had little effect on reducing rates of advanced breast cancer or mortality from the disease.
 

Experts applaud the new findings

Three of the experts who were approached by Medscape Medical News to comment on the new findings applauded the efforts of Duffy and colleagues in providing evidence that mammography can reduce breast cancer–related mortality.

Marie Quinn, MD, director of diagnostic radiology at Roswell Park Comprehensive Cancer Center, Buffalo, New York, said this study adds to the growing body of scientific evidence that confirms that women who undergo regular screening mammography significantly reduce their risk of dying from breast cancer.

“Women who underwent regular screening also had a 25% reduction in the incidence of advanced-stage breast cancer,” she said. “This is important, because breast cancers are less fatal and often require less treatment when picked up at an earlier stage. We know the risk reduction benefit detected in this well-designed study can be attributed to screening mammography and not advances in cancer treatment, due to the long-term follow-up and outcome of cancer death within 10 years.”

The findings from this study support the guidelines recommending routine screening mammography in the United States, Quinn continued, but she pointed out that some aspects of screening (e.g., the age at which to begin screening and how often to screen) can vary. “This can be confusing for patients and providers,” she said. “Overall, research has shown us that women who undergo regular screening mammograms reduce their risk of dying from breast cancer. For women of average risk, the benefit of mammography is maximized with annual screening beginning at age 40,” she said.

Jay A. Baker, MD, FACR, FSBI, chief of the Division of Breast Imaging at Duke University Medical Center, Durham, North Carolina, emphasized that this is yet another study that confirms that the improvement in breast cancer mortality is not the result of improved treatments alone, as some have speculated. “Others have tried to model the benefit of screening vs treatment, but this study is a more direct measurement,” he said. “This conclusion is important for both patients and physicians to hear.”

Although the study strongly supports regular screening for all women, it does not specifically address which set of screening guidelines is optimal, Baker commented. “Fortunately, even though some organizations in the US curiously suggest a delayed start to screening, all organizations and professional societies agree that the most lives and the most years of life are saved by yearly screening beginning at age 40,” he added. “This new study tells us that new treatments alone aren’t enough and confirms that screening saves at least one-third more lives.”

Another expert, Bonnie N. Joe, MD, PhD, professor in residence and chief of breast imaging in the Department of Radiology and Biomedical Imaging at the University of California, San Francisco, agreed that the study shows the mortality benefits of regular screening mammography. “Notably, these benefits were related to participation in mammography screening and independent of any advances in treatment,” she said, “And these findings in this study support regular screening mammography to reduce advanced-stage breast cancers and to reduce a woman’s risk of dying from breast cancer.”

Joe noted that overall, this was a “well-done, large-scale screening study with long-term outcomes and should be applicable to other populations. In the US, we know that peak cancer incidence is in the 40s for minority women, and the results of this study support regular screening starting at 40.”

The study was supported by the American Cancer Society through a gift from the Longaberger Company’s Horizon of Hope Campaign. Additional financial support was provided by Brostcancerförbundet, Sweden. Duffy, Autier, Quinn, Joe, and Baker have disclosed no relevant financial relationships. One coauthor of the study has disclosed relationships with industry, as noted in the original article.

This article first appeared on Medscape.com.

New data from a large Swedish study show that mammography screening for breast cancer reduces the rate of both advanced and fatal breast cancer.

Three experts who were approached by Medscape Medical News say this is further evidence that regular screening mammography significantly reduces the risk of dying from breast cancer, but one expert questioned the methodology used in the study.

The primary goal of cancer screening is to detect tumors at an early stage, when they are most treatable. The hope is that this will reduce the number of advanced cancers associated with poor prognosis and hence the risk of dying from that cancer.

So far, for mammography, the data have been somewhat conflicting. For example, some evidence suggests that widespread breast cancer screening may catch more small, slow-growing tumors that are unlikely to be fatal but will not curb the number of cancers that are diagnosed at a late stage.

The new study, published online in Cancer, refutes this view.

It followed a Swedish cohort of 549,091 women (covering approximately 30% of the Swedish screening-eligible population) who underwent regular mammography.

For the women in this cohort, there was a statistically significant 41% reduction in the risk of dying of breast cancer within 10 years and a 25% reduction in the incidence of advanced disease, compared to women who did not undergo screening. “Even in this age of effective treatments, early detection confers a substantial and significant additional reduction in risk of dying from breast cancer,” said lead author Stephen W. Duffy, MSc, from the Center for Cancer Prevention at Queen Mary University, London, United Kingdom.

The current study confirms the findings of a smaller earlier study (Cancer. 2019;125:515-23) from the same investigators. “It finds the same result with an extremely large evidence base, with more than half a million women, and it also adds further to the evidence that screening achieves this reduction in the context of routine healthcare, not only in the research context,” Duffy commented. “The results are generalizable to other populations, particularly in North America, Western Europe, and Australasia, where the epidemiology and demographics of breast cancer are similar,” said Duffy. “Clearly, more intensive screening is likely to achieve a greater benefit, but a trade-off between costs, both financial and human, and benefits always has to be made specific to each societal and healthcare environment.”

In Sweden, the policy regarding breast cancer screening is to screen women aged 40 to 54 years every 18 months. For those aged 55 to 69 years, screening is recommended every 24 months.

“The use of the incidence-based endpoints means that there is accurate classification of both the breast cancer cases and the whole study population in terms of exposure to screening and avoids a number of biases seen in other studies of service screening,” Duffy told Medscape Medical News.

“I have never seen persuasive evidence for the assertion that breast cancer screening does not reduce deaths from metastatic disease – indeed, the randomized trials seem to show the opposite,” said Duffy. “This may have arisen from a misunderstanding about the mechanism whereby screening works. It primarily works by diagnosing cancer early so that treatment is successful and recurrence with distant metastases, followed by death, does not occur some years later. I suspect some colleagues have confused this with distant metastases at initial diagnosis,” he added.
 

One expert questions methodology

One of the experts who was approached by Medscape Medical News to comment on the new study, Philippe Autier, MD, MPH, PhD, University of Strathclyde Institute of Global Public Health at the International Prevention Research Institute, Dardilly, France, questioned the methodology of the study. “This method is incorrect simply because women attending screening are different from women not attending screening,” he said. “The former are more health aware and have healthier behaviors than the latter, and this is a well-known fact and supported by the literature.”

Autier emphasized that it is practically impossible to control for that bias, which is known as confounding by indication.

“The statistical methods used for attenuating the so-called self-selection are very approximate and based on unverified assumptions,” he said. “For this reason, the Handbook on Breast Cancer Screening produced by the International Agency for Research on Cancer [IARC] clearly stated that ‘observational studies based on individual screening history, no matter how well designed and conducted, should not be regarded as providing evidence for an effect of screening,’ and the methodology in this paper has never been recommended by the IARC.”

A better way of conducting this type of study would have been to show the incidence trends of advanced-stage breast cancer in Sweden for the entire female population aged 40 years and older, he asserts. Autier used that methodology in his own study in the Netherlands, as previously reported by Medscape Medical News. That study found that in the Netherlands, screening mammography over a period of 24 years among women aged 50 to 74 years had little effect on reducing rates of advanced breast cancer or mortality from the disease.
 

Experts applaud the new findings

Three of the experts who were approached by Medscape Medical News to comment on the new findings applauded the efforts of Duffy and colleagues in providing evidence that mammography can reduce breast cancer–related mortality.

Marie Quinn, MD, director of diagnostic radiology at Roswell Park Comprehensive Cancer Center, Buffalo, New York, said this study adds to the growing body of scientific evidence that confirms that women who undergo regular screening mammography significantly reduce their risk of dying from breast cancer.

“Women who underwent regular screening also had a 25% reduction in the incidence of advanced-stage breast cancer,” she said. “This is important, because breast cancers are less fatal and often require less treatment when picked up at an earlier stage. We know the risk reduction benefit detected in this well-designed study can be attributed to screening mammography and not advances in cancer treatment, due to the long-term follow-up and outcome of cancer death within 10 years.”

The findings from this study support the guidelines recommending routine screening mammography in the United States, Quinn continued, but she pointed out that some aspects of screening (e.g., the age at which to begin screening and how often to screen) can vary. “This can be confusing for patients and providers,” she said. “Overall, research has shown us that women who undergo regular screening mammograms reduce their risk of dying from breast cancer. For women of average risk, the benefit of mammography is maximized with annual screening beginning at age 40,” she said.

Jay A. Baker, MD, FACR, FSBI, chief of the Division of Breast Imaging at Duke University Medical Center, Durham, North Carolina, emphasized that this is yet another study that confirms that the improvement in breast cancer mortality is not the result of improved treatments alone, as some have speculated. “Others have tried to model the benefit of screening vs treatment, but this study is a more direct measurement,” he said. “This conclusion is important for both patients and physicians to hear.”

Although the study strongly supports regular screening for all women, it does not specifically address which set of screening guidelines is optimal, Baker commented. “Fortunately, even though some organizations in the US curiously suggest a delayed start to screening, all organizations and professional societies agree that the most lives and the most years of life are saved by yearly screening beginning at age 40,” he added. “This new study tells us that new treatments alone aren’t enough and confirms that screening saves at least one-third more lives.”

Another expert, Bonnie N. Joe, MD, PhD, professor in residence and chief of breast imaging in the Department of Radiology and Biomedical Imaging at the University of California, San Francisco, agreed that the study shows the mortality benefits of regular screening mammography. “Notably, these benefits were related to participation in mammography screening and independent of any advances in treatment,” she said, “And these findings in this study support regular screening mammography to reduce advanced-stage breast cancers and to reduce a woman’s risk of dying from breast cancer.”

Joe noted that overall, this was a “well-done, large-scale screening study with long-term outcomes and should be applicable to other populations. In the US, we know that peak cancer incidence is in the 40s for minority women, and the results of this study support regular screening starting at 40.”

The study was supported by the American Cancer Society through a gift from the Longaberger Company’s Horizon of Hope Campaign. Additional financial support was provided by Brostcancerförbundet, Sweden. Duffy, Autier, Quinn, Joe, and Baker have disclosed no relevant financial relationships. One coauthor of the study has disclosed relationships with industry, as noted in the original article.

This article first appeared on Medscape.com.

New data from a large Swedish study show that mammography screening for breast cancer reduces the rate of both advanced and fatal breast cancer.

Three experts who were approached by Medscape Medical News say this is further evidence that regular screening mammography significantly reduces the risk of dying from breast cancer, but one expert questioned the methodology used in the study.

The primary goal of cancer screening is to detect tumors at an early stage, when they are most treatable. The hope is that this will reduce the number of advanced cancers associated with poor prognosis and hence the risk of dying from that cancer.

So far, for mammography, the data have been somewhat conflicting. For example, some evidence suggests that widespread breast cancer screening may catch more small, slow-growing tumors that are unlikely to be fatal but will not curb the number of cancers that are diagnosed at a late stage.

The new study, published online in Cancer, refutes this view.

It followed a Swedish cohort of 549,091 women (covering approximately 30% of the Swedish screening-eligible population) who underwent regular mammography.

For the women in this cohort, there was a statistically significant 41% reduction in the risk of dying of breast cancer within 10 years and a 25% reduction in the incidence of advanced disease, compared to women who did not undergo screening. “Even in this age of effective treatments, early detection confers a substantial and significant additional reduction in risk of dying from breast cancer,” said lead author Stephen W. Duffy, MSc, from the Center for Cancer Prevention at Queen Mary University, London, United Kingdom.

The current study confirms the findings of a smaller earlier study (Cancer. 2019;125:515-23) from the same investigators. “It finds the same result with an extremely large evidence base, with more than half a million women, and it also adds further to the evidence that screening achieves this reduction in the context of routine healthcare, not only in the research context,” Duffy commented. “The results are generalizable to other populations, particularly in North America, Western Europe, and Australasia, where the epidemiology and demographics of breast cancer are similar,” said Duffy. “Clearly, more intensive screening is likely to achieve a greater benefit, but a trade-off between costs, both financial and human, and benefits always has to be made specific to each societal and healthcare environment.”

In Sweden, the policy regarding breast cancer screening is to screen women aged 40 to 54 years every 18 months. For those aged 55 to 69 years, screening is recommended every 24 months.

“The use of the incidence-based endpoints means that there is accurate classification of both the breast cancer cases and the whole study population in terms of exposure to screening and avoids a number of biases seen in other studies of service screening,” Duffy told Medscape Medical News.

“I have never seen persuasive evidence for the assertion that breast cancer screening does not reduce deaths from metastatic disease – indeed, the randomized trials seem to show the opposite,” said Duffy. “This may have arisen from a misunderstanding about the mechanism whereby screening works. It primarily works by diagnosing cancer early so that treatment is successful and recurrence with distant metastases, followed by death, does not occur some years later. I suspect some colleagues have confused this with distant metastases at initial diagnosis,” he added.
 

One expert questions methodology

One of the experts who was approached by Medscape Medical News to comment on the new study, Philippe Autier, MD, MPH, PhD, University of Strathclyde Institute of Global Public Health at the International Prevention Research Institute, Dardilly, France, questioned the methodology of the study. “This method is incorrect simply because women attending screening are different from women not attending screening,” he said. “The former are more health aware and have healthier behaviors than the latter, and this is a well-known fact and supported by the literature.”

Autier emphasized that it is practically impossible to control for that bias, which is known as confounding by indication.

“The statistical methods used for attenuating the so-called self-selection are very approximate and based on unverified assumptions,” he said. “For this reason, the Handbook on Breast Cancer Screening produced by the International Agency for Research on Cancer [IARC] clearly stated that ‘observational studies based on individual screening history, no matter how well designed and conducted, should not be regarded as providing evidence for an effect of screening,’ and the methodology in this paper has never been recommended by the IARC.”

A better way of conducting this type of study would have been to show the incidence trends of advanced-stage breast cancer in Sweden for the entire female population aged 40 years and older, he asserts. Autier used that methodology in his own study in the Netherlands, as previously reported by Medscape Medical News. That study found that in the Netherlands, screening mammography over a period of 24 years among women aged 50 to 74 years had little effect on reducing rates of advanced breast cancer or mortality from the disease.
 

Experts applaud the new findings

Three of the experts who were approached by Medscape Medical News to comment on the new findings applauded the efforts of Duffy and colleagues in providing evidence that mammography can reduce breast cancer–related mortality.

Marie Quinn, MD, director of diagnostic radiology at Roswell Park Comprehensive Cancer Center, Buffalo, New York, said this study adds to the growing body of scientific evidence that confirms that women who undergo regular screening mammography significantly reduce their risk of dying from breast cancer.

“Women who underwent regular screening also had a 25% reduction in the incidence of advanced-stage breast cancer,” she said. “This is important, because breast cancers are less fatal and often require less treatment when picked up at an earlier stage. We know the risk reduction benefit detected in this well-designed study can be attributed to screening mammography and not advances in cancer treatment, due to the long-term follow-up and outcome of cancer death within 10 years.”

The findings from this study support the guidelines recommending routine screening mammography in the United States, Quinn continued, but she pointed out that some aspects of screening (e.g., the age at which to begin screening and how often to screen) can vary. “This can be confusing for patients and providers,” she said. “Overall, research has shown us that women who undergo regular screening mammograms reduce their risk of dying from breast cancer. For women of average risk, the benefit of mammography is maximized with annual screening beginning at age 40,” she said.

Jay A. Baker, MD, FACR, FSBI, chief of the Division of Breast Imaging at Duke University Medical Center, Durham, North Carolina, emphasized that this is yet another study that confirms that the improvement in breast cancer mortality is not the result of improved treatments alone, as some have speculated. “Others have tried to model the benefit of screening vs treatment, but this study is a more direct measurement,” he said. “This conclusion is important for both patients and physicians to hear.”

Although the study strongly supports regular screening for all women, it does not specifically address which set of screening guidelines is optimal, Baker commented. “Fortunately, even though some organizations in the US curiously suggest a delayed start to screening, all organizations and professional societies agree that the most lives and the most years of life are saved by yearly screening beginning at age 40,” he added. “This new study tells us that new treatments alone aren’t enough and confirms that screening saves at least one-third more lives.”

Another expert, Bonnie N. Joe, MD, PhD, professor in residence and chief of breast imaging in the Department of Radiology and Biomedical Imaging at the University of California, San Francisco, agreed that the study shows the mortality benefits of regular screening mammography. “Notably, these benefits were related to participation in mammography screening and independent of any advances in treatment,” she said, “And these findings in this study support regular screening mammography to reduce advanced-stage breast cancers and to reduce a woman’s risk of dying from breast cancer.”

Joe noted that overall, this was a “well-done, large-scale screening study with long-term outcomes and should be applicable to other populations. In the US, we know that peak cancer incidence is in the 40s for minority women, and the results of this study support regular screening starting at 40.”

The study was supported by the American Cancer Society through a gift from the Longaberger Company’s Horizon of Hope Campaign. Additional financial support was provided by Brostcancerförbundet, Sweden. Duffy, Autier, Quinn, Joe, and Baker have disclosed no relevant financial relationships. One coauthor of the study has disclosed relationships with industry, as noted in the original article.

This article first appeared on Medscape.com.

Triple-negative breast cancer (TNBC) is a particularly aggressive form of this disease, with a poor prognosis, so there is great interest in any new treatment approach. Immunotherapy has raised hopes in TNBC, but more recently, studies have produced conflicting results.

New results show that adding a novel immune activator, Imprime PGG (Biothera), to immunotherapy with pembrolizumab (Keytruda, Merck) appears to improve the clinical benefit. The overall survival seen with the combination was twice that seen in a separate trial with pembrolizumab alone.

The new results were presented during the American Association for Cancer Research (AACR) virtual annual meeting I.

They come from the IMPRIME 1 trial, conducted in 44 women with metastatic TNBC who had anti-glucan antibodies.

“These were patients who had had prior chemotherapy and had extensive disease, including the majority with visceral disease and even liver metastasis,” said investigator Steven O’Day, MD, from the John Wayne Cancer Institute in Santa Monica, California.

All patients were treated with the combination. “We see encouraging clinical benefit evidence across all of our clinical measurements: response, durable response, and median and overall survival compared to historical single-agent [anti] PD-1 in a similar metastatic triple-negative breast cancer population,” he said.

At a median follow-up of 22.5 months, median overall survival with the combination among the 44 patients treated was 16.4 months.

In contrast, in the Keynote-086 trial of pembrolizumab monotherapy in patients with TNBC, median overall survival was 9 months, O’Day said.

He emphasized, however, that the IMPRIME 1 trial was not designed or powered to directly compare the combination therapy with pembrolizumab monotherapy.

Clinical benefit with the combination was particularly pronounced for patients who were so-called TNBC “converters” — that is, they originally had estrogen receptor (ER)-positive tumors that had progressed on endocrine therapy and, prior to starting treatment with Imprime PGG and pembrolizumab, they had biopsy results confirming TNBC, O’Day said.

The overall response rate (ORR) for all 44 patients included in the efficacy analysis was 15.9%. But among the 12 patients whose disease converted from ER-positive to TNBC after endocrine therapy, six had a response, for an ORR of 50% and a median overall survival of 17.1 months.

“It is not clear whether hormone resistance may have led to the increased responses versus secondary triple-negative status, but it is of great interest to us,” O’Day said.
 

Why This Special Benefit?

Invited discussant Ben Ho Park, MD, PhD, from Vanderbilt University Medical Center in Nashville, Tennessee, commented that the finding of special benefit among TNBC converters raises the question of biomarkers to determine which patients might most benefit from the combination.

“We already know that anti-beta-glucan antibodies were required to be actually eligible for this study, but is it that, in combination with immune activation, or prior ER-positive disease?” he said. “What about the role of PD-L1 staining? Can we actually combine all this data to come up with some sort of predictive score for whether or not a patient is more or less likely to respond, and more or less likely to have toxicities?”

Yeast-Derived Compound

Imprime PGG is a novel beta-glucan isolated from the cell walls of saccharomyces yeast that binds to endogenous anti-beta-glucan antibodies to form an immune complex.

The immune complex, which is the active drug, binds to a receptor known as dectin-1 to activate innate immunity and reprogram the immunosuppressive tumor microenvironment, enhance antigen presentation, and trigger T-cell activation to improve the efficacy of immune checkpoint inhibitor therapy, O’Day explained.

The complex has been administered to date to approximately 600 healthy volunteers and patients. In these studies, it was administered intravenously at doses of 2 mg/kg to 6 mg/kg weekly as monotherapy or in combination with anti-angiogenic antibodies or tumor-targeting antibodies, with or without chemotherapy.

Studies in volunteers showed that the complex activated innate immunity. Patients have tolerated it well, with no significant safety signals in either monotherapy or combination, with grade 1 or 2 infusion-related reactions being the most common adverse events to date, O’Day reported.

Study Details

Imprime 1 was a single-arm phase 2 trial enrolling 44 women with TNBC who had received at least one prior line of treatment, but not with an immune checkpoint inhibitor. They were all required to have anti-beta-glucan antibody levels of at least 20 mcg/mL.

All patients received the combination, which comprised Imprime PGG 4 mg/kg weekly plus pembrolizumab 200 mg IV every 3 weeks.

Twenty one patients were under age 50 years, and 23 were 50 years old and older. Seventeen patients were premenopausal, and 27 were postmenopausal. In all, 15 patients had more than three prior lines of therapy for metastatic disease, 30 had visceral disease, and 12 had liver metastases; only four had metastases confined to lymph nodes.

As noted above, median overall survival for all patients was 16.4 months. The ORR was 15.9%, and the disease control rate (a combination of complete and partial responses plus stable disease) was 25%. The median progression-free survival was 2.7 months (vs 2 months in Keynote-086).

In all, 39 of the 44 patients had treatment-related adverse events, with the most common being nausea, back pain, chills, fatigue, diarrhea, arthralgia, and headache. Four patients had grade 3 or 4 events, which included an infusion-related reaction, hyperglycemia, pericarditis, and pancreatitis.

Infusion-related reactions were seen in 27 patients, but only one of these reactions was grade 3 or 4.

The most common immune-mediated events were grade 1 or 2 thyroid dysfunction, which is commonly seen with PD-1 inhibitors, and there were single low-grade events of pancreatitis, pneumonitis, and pericarditis “most likely related to PD-1 inhibitor therapy,” O’Day said.

Translational data showed that innate and adaptive immunity in peripheral blood correlates with clinical benefit, with longer overall survival among patients with either monocyte activation (P = .0045) or T-cell activation (P = .012) compared with patients without activation of those components.

Taken together, the findings suggest that larger controlled studies of the combination are warranted, O’Day said.

The study was sponsored by Biothera and Merck. O’Day disclosed advisory board activities and research funding from both companies and others, and consulting for Biothera. Park disclosed royalties and consulting activities from several companies, not including the Imprime 1 sponsors.
 

This article first appeared on Medscape.com.

Triple-negative breast cancer (TNBC) is a particularly aggressive form of this disease, with a poor prognosis, so there is great interest in any new treatment approach. Immunotherapy has raised hopes in TNBC, but more recently, studies have produced conflicting results.

New results show that adding a novel immune activator, Imprime PGG (Biothera), to immunotherapy with pembrolizumab (Keytruda, Merck) appears to improve the clinical benefit. The overall survival seen with the combination was twice that seen in a separate trial with pembrolizumab alone.

The new results were presented during the American Association for Cancer Research (AACR) virtual annual meeting I.

They come from the IMPRIME 1 trial, conducted in 44 women with metastatic TNBC who had anti-glucan antibodies.

“These were patients who had had prior chemotherapy and had extensive disease, including the majority with visceral disease and even liver metastasis,” said investigator Steven O’Day, MD, from the John Wayne Cancer Institute in Santa Monica, California.

All patients were treated with the combination. “We see encouraging clinical benefit evidence across all of our clinical measurements: response, durable response, and median and overall survival compared to historical single-agent [anti] PD-1 in a similar metastatic triple-negative breast cancer population,” he said.

At a median follow-up of 22.5 months, median overall survival with the combination among the 44 patients treated was 16.4 months.

In contrast, in the Keynote-086 trial of pembrolizumab monotherapy in patients with TNBC, median overall survival was 9 months, O’Day said.

He emphasized, however, that the IMPRIME 1 trial was not designed or powered to directly compare the combination therapy with pembrolizumab monotherapy.

Clinical benefit with the combination was particularly pronounced for patients who were so-called TNBC “converters” — that is, they originally had estrogen receptor (ER)-positive tumors that had progressed on endocrine therapy and, prior to starting treatment with Imprime PGG and pembrolizumab, they had biopsy results confirming TNBC, O’Day said.

The overall response rate (ORR) for all 44 patients included in the efficacy analysis was 15.9%. But among the 12 patients whose disease converted from ER-positive to TNBC after endocrine therapy, six had a response, for an ORR of 50% and a median overall survival of 17.1 months.

“It is not clear whether hormone resistance may have led to the increased responses versus secondary triple-negative status, but it is of great interest to us,” O’Day said.
 

Why This Special Benefit?

Invited discussant Ben Ho Park, MD, PhD, from Vanderbilt University Medical Center in Nashville, Tennessee, commented that the finding of special benefit among TNBC converters raises the question of biomarkers to determine which patients might most benefit from the combination.

“We already know that anti-beta-glucan antibodies were required to be actually eligible for this study, but is it that, in combination with immune activation, or prior ER-positive disease?” he said. “What about the role of PD-L1 staining? Can we actually combine all this data to come up with some sort of predictive score for whether or not a patient is more or less likely to respond, and more or less likely to have toxicities?”

Yeast-Derived Compound

Imprime PGG is a novel beta-glucan isolated from the cell walls of saccharomyces yeast that binds to endogenous anti-beta-glucan antibodies to form an immune complex.

The immune complex, which is the active drug, binds to a receptor known as dectin-1 to activate innate immunity and reprogram the immunosuppressive tumor microenvironment, enhance antigen presentation, and trigger T-cell activation to improve the efficacy of immune checkpoint inhibitor therapy, O’Day explained.

The complex has been administered to date to approximately 600 healthy volunteers and patients. In these studies, it was administered intravenously at doses of 2 mg/kg to 6 mg/kg weekly as monotherapy or in combination with anti-angiogenic antibodies or tumor-targeting antibodies, with or without chemotherapy.

Studies in volunteers showed that the complex activated innate immunity. Patients have tolerated it well, with no significant safety signals in either monotherapy or combination, with grade 1 or 2 infusion-related reactions being the most common adverse events to date, O’Day reported.

Study Details

Imprime 1 was a single-arm phase 2 trial enrolling 44 women with TNBC who had received at least one prior line of treatment, but not with an immune checkpoint inhibitor. They were all required to have anti-beta-glucan antibody levels of at least 20 mcg/mL.

All patients received the combination, which comprised Imprime PGG 4 mg/kg weekly plus pembrolizumab 200 mg IV every 3 weeks.

Twenty one patients were under age 50 years, and 23 were 50 years old and older. Seventeen patients were premenopausal, and 27 were postmenopausal. In all, 15 patients had more than three prior lines of therapy for metastatic disease, 30 had visceral disease, and 12 had liver metastases; only four had metastases confined to lymph nodes.

As noted above, median overall survival for all patients was 16.4 months. The ORR was 15.9%, and the disease control rate (a combination of complete and partial responses plus stable disease) was 25%. The median progression-free survival was 2.7 months (vs 2 months in Keynote-086).

In all, 39 of the 44 patients had treatment-related adverse events, with the most common being nausea, back pain, chills, fatigue, diarrhea, arthralgia, and headache. Four patients had grade 3 or 4 events, which included an infusion-related reaction, hyperglycemia, pericarditis, and pancreatitis.

Infusion-related reactions were seen in 27 patients, but only one of these reactions was grade 3 or 4.

The most common immune-mediated events were grade 1 or 2 thyroid dysfunction, which is commonly seen with PD-1 inhibitors, and there were single low-grade events of pancreatitis, pneumonitis, and pericarditis “most likely related to PD-1 inhibitor therapy,” O’Day said.

Translational data showed that innate and adaptive immunity in peripheral blood correlates with clinical benefit, with longer overall survival among patients with either monocyte activation (P = .0045) or T-cell activation (P = .012) compared with patients without activation of those components.

Taken together, the findings suggest that larger controlled studies of the combination are warranted, O’Day said.

The study was sponsored by Biothera and Merck. O’Day disclosed advisory board activities and research funding from both companies and others, and consulting for Biothera. Park disclosed royalties and consulting activities from several companies, not including the Imprime 1 sponsors.
 

This article first appeared on Medscape.com.

Triple-negative breast cancer (TNBC) is a particularly aggressive form of this disease, with a poor prognosis, so there is great interest in any new treatment approach. Immunotherapy has raised hopes in TNBC, but more recently, studies have produced conflicting results.

New results show that adding a novel immune activator, Imprime PGG (Biothera), to immunotherapy with pembrolizumab (Keytruda, Merck) appears to improve the clinical benefit. The overall survival seen with the combination was twice that seen in a separate trial with pembrolizumab alone.

The new results were presented during the American Association for Cancer Research (AACR) virtual annual meeting I.

They come from the IMPRIME 1 trial, conducted in 44 women with metastatic TNBC who had anti-glucan antibodies.

“These were patients who had had prior chemotherapy and had extensive disease, including the majority with visceral disease and even liver metastasis,” said investigator Steven O’Day, MD, from the John Wayne Cancer Institute in Santa Monica, California.

All patients were treated with the combination. “We see encouraging clinical benefit evidence across all of our clinical measurements: response, durable response, and median and overall survival compared to historical single-agent [anti] PD-1 in a similar metastatic triple-negative breast cancer population,” he said.

At a median follow-up of 22.5 months, median overall survival with the combination among the 44 patients treated was 16.4 months.

In contrast, in the Keynote-086 trial of pembrolizumab monotherapy in patients with TNBC, median overall survival was 9 months, O’Day said.

He emphasized, however, that the IMPRIME 1 trial was not designed or powered to directly compare the combination therapy with pembrolizumab monotherapy.

Clinical benefit with the combination was particularly pronounced for patients who were so-called TNBC “converters” — that is, they originally had estrogen receptor (ER)-positive tumors that had progressed on endocrine therapy and, prior to starting treatment with Imprime PGG and pembrolizumab, they had biopsy results confirming TNBC, O’Day said.

The overall response rate (ORR) for all 44 patients included in the efficacy analysis was 15.9%. But among the 12 patients whose disease converted from ER-positive to TNBC after endocrine therapy, six had a response, for an ORR of 50% and a median overall survival of 17.1 months.

“It is not clear whether hormone resistance may have led to the increased responses versus secondary triple-negative status, but it is of great interest to us,” O’Day said.
 

Why This Special Benefit?

Invited discussant Ben Ho Park, MD, PhD, from Vanderbilt University Medical Center in Nashville, Tennessee, commented that the finding of special benefit among TNBC converters raises the question of biomarkers to determine which patients might most benefit from the combination.

“We already know that anti-beta-glucan antibodies were required to be actually eligible for this study, but is it that, in combination with immune activation, or prior ER-positive disease?” he said. “What about the role of PD-L1 staining? Can we actually combine all this data to come up with some sort of predictive score for whether or not a patient is more or less likely to respond, and more or less likely to have toxicities?”

Yeast-Derived Compound

Imprime PGG is a novel beta-glucan isolated from the cell walls of saccharomyces yeast that binds to endogenous anti-beta-glucan antibodies to form an immune complex.

The immune complex, which is the active drug, binds to a receptor known as dectin-1 to activate innate immunity and reprogram the immunosuppressive tumor microenvironment, enhance antigen presentation, and trigger T-cell activation to improve the efficacy of immune checkpoint inhibitor therapy, O’Day explained.

The complex has been administered to date to approximately 600 healthy volunteers and patients. In these studies, it was administered intravenously at doses of 2 mg/kg to 6 mg/kg weekly as monotherapy or in combination with anti-angiogenic antibodies or tumor-targeting antibodies, with or without chemotherapy.

Studies in volunteers showed that the complex activated innate immunity. Patients have tolerated it well, with no significant safety signals in either monotherapy or combination, with grade 1 or 2 infusion-related reactions being the most common adverse events to date, O’Day reported.

Study Details

Imprime 1 was a single-arm phase 2 trial enrolling 44 women with TNBC who had received at least one prior line of treatment, but not with an immune checkpoint inhibitor. They were all required to have anti-beta-glucan antibody levels of at least 20 mcg/mL.

All patients received the combination, which comprised Imprime PGG 4 mg/kg weekly plus pembrolizumab 200 mg IV every 3 weeks.

Twenty one patients were under age 50 years, and 23 were 50 years old and older. Seventeen patients were premenopausal, and 27 were postmenopausal. In all, 15 patients had more than three prior lines of therapy for metastatic disease, 30 had visceral disease, and 12 had liver metastases; only four had metastases confined to lymph nodes.

As noted above, median overall survival for all patients was 16.4 months. The ORR was 15.9%, and the disease control rate (a combination of complete and partial responses plus stable disease) was 25%. The median progression-free survival was 2.7 months (vs 2 months in Keynote-086).

In all, 39 of the 44 patients had treatment-related adverse events, with the most common being nausea, back pain, chills, fatigue, diarrhea, arthralgia, and headache. Four patients had grade 3 or 4 events, which included an infusion-related reaction, hyperglycemia, pericarditis, and pancreatitis.

Infusion-related reactions were seen in 27 patients, but only one of these reactions was grade 3 or 4.

The most common immune-mediated events were grade 1 or 2 thyroid dysfunction, which is commonly seen with PD-1 inhibitors, and there were single low-grade events of pancreatitis, pneumonitis, and pericarditis “most likely related to PD-1 inhibitor therapy,” O’Day said.

Translational data showed that innate and adaptive immunity in peripheral blood correlates with clinical benefit, with longer overall survival among patients with either monocyte activation (P = .0045) or T-cell activation (P = .012) compared with patients without activation of those components.

Taken together, the findings suggest that larger controlled studies of the combination are warranted, O’Day said.

The study was sponsored by Biothera and Merck. O’Day disclosed advisory board activities and research funding from both companies and others, and consulting for Biothera. Park disclosed royalties and consulting activities from several companies, not including the Imprime 1 sponsors.
 

This article first appeared on Medscape.com.

Talazoparib did not confer an overall survival benefit over chemotherapy in patients with germline BRCA1/2-mutated HER2-negative advanced breast cancer, according to a final analysis of the phase 3 EMBRACA trial.

The progression-free survival benefit previously seen with talazoparib did not translate to an overall survival benefit. However, patient-reported quality of life continued to favor talazoparib in the final analysis, Jennifer K. Litton, MD, of the University of Texas MD Anderson Cancer Center in Houston, reported at the AACR virtual meeting I.

The EMBRACA trial enrolled adults with HER2-negative locally advanced or metastatic breast cancer and a deleterious or suspected deleterious germline BRCA mutation. They were randomized to talazoparib at 1 mg daily (n = 287) or to physician’s choice of single-agent chemotherapy (n = 144).

In the primary analysis, talazoparib was associated with significantly improved progression-free survival. The median progression-free survival was 8.6 months in the talazoparib arm and 5.6 months in the chemotherapy arm (hazard ratio, 0.54).

“At the time of the primary analysis, the overall survival data were immature, and the hazard ratio for the interim overall survival was 0.761, which was not statistically significant,” Dr. Litton said.

However, patient-reported outcomes favored talazoparib in the primary analysis, with patients in that arm showing “significant overall improvements with a significant delay in time to clinically meaningful deterioration in multiple cancer-related and breast cancer–specific symptoms, functions, quality of life, and global health,” Dr. Litton said.
 

Final overall survival

At the final analysis, the median follow-up was 44.9 months for the talazoparib arm and 36.8 months for the chemotherapy arm.

The median overall survival was 19.3 months in the talazoparib arm and 19.5 months in the chemotherapy arm (HR, 0.848; P = .17)

The results were “generally consistent” across patient subgroups,” Dr. Litton said, adding that “the effect of treatment with talazoparib was also similar irrespective of BRCA status, as well as triple-negative or hormone-receptor-positive subtypes.”

Of note, most patients received poststudy therapies. These included PARP inhibitors in 4.5% of patients in the talazoparib arm and 32.6% of patients in the chemotherapy arm, and platinum drugs in 46.3% and 41.7%, respectively.

Patients who received chemotherapy on study but did not receive a subsequent PARP inhibitor or platinum therapy had both shorter total treatment duration and shorter overall survival, compared with patients who did receive subsequent treatment.

In the talazoparib arm, outcomes were similar whether or not patients received a subsequent PARP inhibitor or platinum therapy.

“Interpretation of the overall survival results may have been confounded by subsequent treatment, so two sensitivity analyses accounting for subsequent PARP inhibition or platinum therapy were carried out,” Dr. Litton said.

She noted that adjustment for poststudy treatment lowered the hazard ratio, but there was still no significant difference between the talazoparib and chemotherapy arms. These results suggest “the primary overall survival analysis underestimated the treatment benefit of talazoparib,” Dr. Litton said. She also noted that a longer platinum-free interval prior to study entry was generally associated with a longer duration of survival, particularly in the talazoparib arm.
 

Quality of life and safety

Patient-reported outcomes continued to favor talazoparib with extended follow-up and were consistent with the initial analysis, Dr. Litton noted.

The updated analysis revealed “a significant improvement in estimated overall change from baseline in the global health quality of life scores for those patients receiving talazoparib, while a significant deterioration was observed in patients receiving chemotherapy,” she said.

The estimated overall change in score was a 2.1-point increase in the talazoparib arm and a 5.7-point decrease in the chemotherapy arm (P = .001). The median time to clinically meaningful deterioration in global health quality of life scores was 26.3 months in the talazoparib arm and 6.7 months in the chemotherapy arm (HR, 0.385).

At the final analysis, the overall safety profile was consistent with that reported previously. Talazoparib was generally well tolerated, and no new safety signals were identified.

Grade 3/4 serious adverse events occurred in 28.3% of patients in the talazoparib arm and 27% of those in the chemotherapy arm. Adverse events led to treatment discontinuation in 7.7% and 9.5% of patients, respectively.

Most grade 3/4 adverse events were hematologic, and most were successfully managed by supportive care, including transfusions and dose modifications, Dr. Litton said.

She noted that one patient in the chemotherapy arm assigned to receive capecitabine had been diagnosed with acute myeloid leukemia at the time of the first analysis. “And now we report an additional case of [acute myeloid leukemia] in a patient who was randomized to the talazoparib arm,” Dr. Litton said.
 

Jury’s still out

Based on existing data, including from EMBRACA, the jury is still out on whether PARP inhibition is associated with an overall survival benefit in this setting, said invited discussant Susan Domcheck, MD, of the University of Pennsylvania in Philadelphia.

She suggested that could change with ongoing efforts to identify biomarkers for treatment response and new approaches to treatment, such as earlier lines of therapy and combinations.

“At this time, germline BRCA 1 and 2 pathogenic variants are the best predictor of PARP inhibitor sensitivity in breast cancer,” Dr. Domcheck said. “Not all the tumors are sensitive, but this is true of [estrogen receptor–positive] breast cancer and hormonal therapy, and HER2-positive breast cancer as well.”

Studies investigating approaches to improve survival are “incredibly important, because the progression-free survival is not as long as we would like it to be and there’s not an overwhelming overall survival benefit, for sure,” she said.

The EMBRACA trial was funded by Medivation (Pfizer). Dr. Litton and colleagues disclosed numerous relationships with pharmaceutical companies and other organizations. Dr. Domcheck disclosed relationships with AstraZeneca, Clovis, and Bristol Myers Squibb.

sworcester@mdedge.com

SOURCE: Litton J et al., AACR 20, Abstract CT071.

Talazoparib did not confer an overall survival benefit over chemotherapy in patients with germline BRCA1/2-mutated HER2-negative advanced breast cancer, according to a final analysis of the phase 3 EMBRACA trial.

The progression-free survival benefit previously seen with talazoparib did not translate to an overall survival benefit. However, patient-reported quality of life continued to favor talazoparib in the final analysis, Jennifer K. Litton, MD, of the University of Texas MD Anderson Cancer Center in Houston, reported at the AACR virtual meeting I.

The EMBRACA trial enrolled adults with HER2-negative locally advanced or metastatic breast cancer and a deleterious or suspected deleterious germline BRCA mutation. They were randomized to talazoparib at 1 mg daily (n = 287) or to physician’s choice of single-agent chemotherapy (n = 144).

In the primary analysis, talazoparib was associated with significantly improved progression-free survival. The median progression-free survival was 8.6 months in the talazoparib arm and 5.6 months in the chemotherapy arm (hazard ratio, 0.54).

“At the time of the primary analysis, the overall survival data were immature, and the hazard ratio for the interim overall survival was 0.761, which was not statistically significant,” Dr. Litton said.

However, patient-reported outcomes favored talazoparib in the primary analysis, with patients in that arm showing “significant overall improvements with a significant delay in time to clinically meaningful deterioration in multiple cancer-related and breast cancer–specific symptoms, functions, quality of life, and global health,” Dr. Litton said.
 

Final overall survival

At the final analysis, the median follow-up was 44.9 months for the talazoparib arm and 36.8 months for the chemotherapy arm.

The median overall survival was 19.3 months in the talazoparib arm and 19.5 months in the chemotherapy arm (HR, 0.848; P = .17)

The results were “generally consistent” across patient subgroups,” Dr. Litton said, adding that “the effect of treatment with talazoparib was also similar irrespective of BRCA status, as well as triple-negative or hormone-receptor-positive subtypes.”

Of note, most patients received poststudy therapies. These included PARP inhibitors in 4.5% of patients in the talazoparib arm and 32.6% of patients in the chemotherapy arm, and platinum drugs in 46.3% and 41.7%, respectively.

Patients who received chemotherapy on study but did not receive a subsequent PARP inhibitor or platinum therapy had both shorter total treatment duration and shorter overall survival, compared with patients who did receive subsequent treatment.

In the talazoparib arm, outcomes were similar whether or not patients received a subsequent PARP inhibitor or platinum therapy.

“Interpretation of the overall survival results may have been confounded by subsequent treatment, so two sensitivity analyses accounting for subsequent PARP inhibition or platinum therapy were carried out,” Dr. Litton said.

She noted that adjustment for poststudy treatment lowered the hazard ratio, but there was still no significant difference between the talazoparib and chemotherapy arms. These results suggest “the primary overall survival analysis underestimated the treatment benefit of talazoparib,” Dr. Litton said. She also noted that a longer platinum-free interval prior to study entry was generally associated with a longer duration of survival, particularly in the talazoparib arm.
 

Quality of life and safety

Patient-reported outcomes continued to favor talazoparib with extended follow-up and were consistent with the initial analysis, Dr. Litton noted.

The updated analysis revealed “a significant improvement in estimated overall change from baseline in the global health quality of life scores for those patients receiving talazoparib, while a significant deterioration was observed in patients receiving chemotherapy,” she said.

The estimated overall change in score was a 2.1-point increase in the talazoparib arm and a 5.7-point decrease in the chemotherapy arm (P = .001). The median time to clinically meaningful deterioration in global health quality of life scores was 26.3 months in the talazoparib arm and 6.7 months in the chemotherapy arm (HR, 0.385).

At the final analysis, the overall safety profile was consistent with that reported previously. Talazoparib was generally well tolerated, and no new safety signals were identified.

Grade 3/4 serious adverse events occurred in 28.3% of patients in the talazoparib arm and 27% of those in the chemotherapy arm. Adverse events led to treatment discontinuation in 7.7% and 9.5% of patients, respectively.

Most grade 3/4 adverse events were hematologic, and most were successfully managed by supportive care, including transfusions and dose modifications, Dr. Litton said.

She noted that one patient in the chemotherapy arm assigned to receive capecitabine had been diagnosed with acute myeloid leukemia at the time of the first analysis. “And now we report an additional case of [acute myeloid leukemia] in a patient who was randomized to the talazoparib arm,” Dr. Litton said.
 

Jury’s still out

Based on existing data, including from EMBRACA, the jury is still out on whether PARP inhibition is associated with an overall survival benefit in this setting, said invited discussant Susan Domcheck, MD, of the University of Pennsylvania in Philadelphia.

She suggested that could change with ongoing efforts to identify biomarkers for treatment response and new approaches to treatment, such as earlier lines of therapy and combinations.

“At this time, germline BRCA 1 and 2 pathogenic variants are the best predictor of PARP inhibitor sensitivity in breast cancer,” Dr. Domcheck said. “Not all the tumors are sensitive, but this is true of [estrogen receptor–positive] breast cancer and hormonal therapy, and HER2-positive breast cancer as well.”

Studies investigating approaches to improve survival are “incredibly important, because the progression-free survival is not as long as we would like it to be and there’s not an overwhelming overall survival benefit, for sure,” she said.

The EMBRACA trial was funded by Medivation (Pfizer). Dr. Litton and colleagues disclosed numerous relationships with pharmaceutical companies and other organizations. Dr. Domcheck disclosed relationships with AstraZeneca, Clovis, and Bristol Myers Squibb.

sworcester@mdedge.com

SOURCE: Litton J et al., AACR 20, Abstract CT071.

Talazoparib did not confer an overall survival benefit over chemotherapy in patients with germline BRCA1/2-mutated HER2-negative advanced breast cancer, according to a final analysis of the phase 3 EMBRACA trial.

The progression-free survival benefit previously seen with talazoparib did not translate to an overall survival benefit. However, patient-reported quality of life continued to favor talazoparib in the final analysis, Jennifer K. Litton, MD, of the University of Texas MD Anderson Cancer Center in Houston, reported at the AACR virtual meeting I.

The EMBRACA trial enrolled adults with HER2-negative locally advanced or metastatic breast cancer and a deleterious or suspected deleterious germline BRCA mutation. They were randomized to talazoparib at 1 mg daily (n = 287) or to physician’s choice of single-agent chemotherapy (n = 144).

In the primary analysis, talazoparib was associated with significantly improved progression-free survival. The median progression-free survival was 8.6 months in the talazoparib arm and 5.6 months in the chemotherapy arm (hazard ratio, 0.54).

“At the time of the primary analysis, the overall survival data were immature, and the hazard ratio for the interim overall survival was 0.761, which was not statistically significant,” Dr. Litton said.

However, patient-reported outcomes favored talazoparib in the primary analysis, with patients in that arm showing “significant overall improvements with a significant delay in time to clinically meaningful deterioration in multiple cancer-related and breast cancer–specific symptoms, functions, quality of life, and global health,” Dr. Litton said.
 

Final overall survival

At the final analysis, the median follow-up was 44.9 months for the talazoparib arm and 36.8 months for the chemotherapy arm.

The median overall survival was 19.3 months in the talazoparib arm and 19.5 months in the chemotherapy arm (HR, 0.848; P = .17)

The results were “generally consistent” across patient subgroups,” Dr. Litton said, adding that “the effect of treatment with talazoparib was also similar irrespective of BRCA status, as well as triple-negative or hormone-receptor-positive subtypes.”

Of note, most patients received poststudy therapies. These included PARP inhibitors in 4.5% of patients in the talazoparib arm and 32.6% of patients in the chemotherapy arm, and platinum drugs in 46.3% and 41.7%, respectively.

Patients who received chemotherapy on study but did not receive a subsequent PARP inhibitor or platinum therapy had both shorter total treatment duration and shorter overall survival, compared with patients who did receive subsequent treatment.

In the talazoparib arm, outcomes were similar whether or not patients received a subsequent PARP inhibitor or platinum therapy.

“Interpretation of the overall survival results may have been confounded by subsequent treatment, so two sensitivity analyses accounting for subsequent PARP inhibition or platinum therapy were carried out,” Dr. Litton said.

She noted that adjustment for poststudy treatment lowered the hazard ratio, but there was still no significant difference between the talazoparib and chemotherapy arms. These results suggest “the primary overall survival analysis underestimated the treatment benefit of talazoparib,” Dr. Litton said. She also noted that a longer platinum-free interval prior to study entry was generally associated with a longer duration of survival, particularly in the talazoparib arm.
 

Quality of life and safety

Patient-reported outcomes continued to favor talazoparib with extended follow-up and were consistent with the initial analysis, Dr. Litton noted.

The updated analysis revealed “a significant improvement in estimated overall change from baseline in the global health quality of life scores for those patients receiving talazoparib, while a significant deterioration was observed in patients receiving chemotherapy,” she said.

The estimated overall change in score was a 2.1-point increase in the talazoparib arm and a 5.7-point decrease in the chemotherapy arm (P = .001). The median time to clinically meaningful deterioration in global health quality of life scores was 26.3 months in the talazoparib arm and 6.7 months in the chemotherapy arm (HR, 0.385).

At the final analysis, the overall safety profile was consistent with that reported previously. Talazoparib was generally well tolerated, and no new safety signals were identified.

Grade 3/4 serious adverse events occurred in 28.3% of patients in the talazoparib arm and 27% of those in the chemotherapy arm. Adverse events led to treatment discontinuation in 7.7% and 9.5% of patients, respectively.

Most grade 3/4 adverse events were hematologic, and most were successfully managed by supportive care, including transfusions and dose modifications, Dr. Litton said.

She noted that one patient in the chemotherapy arm assigned to receive capecitabine had been diagnosed with acute myeloid leukemia at the time of the first analysis. “And now we report an additional case of [acute myeloid leukemia] in a patient who was randomized to the talazoparib arm,” Dr. Litton said.
 

Jury’s still out

Based on existing data, including from EMBRACA, the jury is still out on whether PARP inhibition is associated with an overall survival benefit in this setting, said invited discussant Susan Domcheck, MD, of the University of Pennsylvania in Philadelphia.

She suggested that could change with ongoing efforts to identify biomarkers for treatment response and new approaches to treatment, such as earlier lines of therapy and combinations.

“At this time, germline BRCA 1 and 2 pathogenic variants are the best predictor of PARP inhibitor sensitivity in breast cancer,” Dr. Domcheck said. “Not all the tumors are sensitive, but this is true of [estrogen receptor–positive] breast cancer and hormonal therapy, and HER2-positive breast cancer as well.”

Studies investigating approaches to improve survival are “incredibly important, because the progression-free survival is not as long as we would like it to be and there’s not an overwhelming overall survival benefit, for sure,” she said.

The EMBRACA trial was funded by Medivation (Pfizer). Dr. Litton and colleagues disclosed numerous relationships with pharmaceutical companies and other organizations. Dr. Domcheck disclosed relationships with AstraZeneca, Clovis, and Bristol Myers Squibb.

sworcester@mdedge.com

SOURCE: Litton J et al., AACR 20, Abstract CT071.

Cancer type, stage, and recent treatment may affect outcomes of COVID-19 in cancer patients, according to a study of patients from China.

The data showed that patients with hematologic malignancies and those with metastatic cancers had higher risks of developing severe or critical COVID-19 symptoms, being admitted to the ICU, requiring ventilation, and dying.

On the other hand, patients with nonmetastatic cancer had outcomes comparable to those of noncancer patients with COVID-19.

Similarly, cancer patients who had recently undergone surgery or received immunotherapy were more likely to have poor outcomes, whereas cancer patients treated with radiotherapy had outcomes similar to those of noncancer COVID-19 patients.

Hongbing Cai, MD, of Zhongnan Hospital of Wuhan University in China, presented these results at the AACR virtual meeting I. The results also were published in Cancer Discovery.
 

Cancer vs. noncancer patients

The study included 105 cancer patients with COVID-19 who were treated from Jan. 1 to Feb. 24, 2020, at 14 hospitals in Wuhan, China. Patients had lung (20.95%), gastrointestinal (12.38%), breast (10.48%), and thyroid cancers (10.48%) as well as hematologic malignancies (8.57%). Dr. Cai and colleagues matched the COVID-19 cancer patients to 536 COVID-19 patients without cancer. Patients were matched by hospital, duration of hospitalization, and age.

“COVID-19 patients with cancer had higher risks of all severe outcomes,” Dr. Cai noted.

Compared with noncancer patients, the cancer patients had a higher risk of:

• Severe or critical COVID-19 symptoms – odds ratio, 2.79 (P < .01).
• Being admitted to the ICU – OR, 2.84 (P < .01).
• Requiring invasive mechanical ventilation – OR, 14 (P < .01).
• Death – OR, 2.34 (P = .03).

Cancer type and stage

Dr. Cai noted that outcomes were the worst among patients with hematologic malignancies and those with metastatic cancer (stage IV).

Compared with patients without cancer, those with hematologic malignancies had a higher risk of:

• Severe/critical symptoms – OR, 10.61 (P < .01).
• ICU admission – OR, 9.66 (P < .01).
• Invasive mechanical ventilation – OR, 38 (P < .01).
• Death – OR, 9.07 (P = .01).

Compared with patients without cancer, those with metastatic cancer had a higher risk of:

• Severe/critical symptoms – OR, 5.97 (P < .01).
• ICU admission – OR, 6.59 (P < 0.01).
• Invasive mechanical ventilation – OR, 55.42 (P < .01).
• Death – OR, 5.58 (P = .01).

On the other hand, outcomes in patients with nonmetastatic cancer were not significantly different from outcomes in patients without cancer (P > .05 for all outcomes).
 

Cancer treatment

The treatments cancer patients received within 40 days before the onset of COVID-19 symptoms were radiotherapy (12.26%), chemotherapy (14.15%), surgery (7.62%), targeted therapies (3.81%), and immunotherapy (5.71%).

Compared with patients without cancer, those who received immunotherapy had a higher risk of:

• Severe/critical symptoms – OR, 10.61 (P < .01).
• Death – OR, 9.07 (P = .04).

Patients who underwent surgery had a higher risk of:

• Severe/critical symptoms – OR, 8.84 (P < .01).
• ICU admission – OR, 7.24 (P = .02).
• Invasive mechanical ventilation – OR, 44.33 (P < .01).

Conversely, outcomes in cancer patients who received radiotherapy were not significantly different from outcomes in patients without cancer (P > .10 for all).

These results suggest that “postponing surgery should be considered in outbreak areas,” Dr. Cai said, adding that scheduled radiotherapy can go ahead but with “intensive protection and surveillance.”

Dr. Cai said it remains to be seen whether patients with early-stage cancer need to postpone their treatments during the COVID-19 pandemic or whether immunotherapy aggravates severe outcomes in cancer patients with COVID-19. For now, she said, cancer patients should have individualized treatment plans based on their tumor type and stage.

Dr. Cai disclosed no conflicts of interest. This study was supported by the National Natural Science Foundation of China, the Singapore Ministry of Health’s National Medical Research Council, the National Institutes of Health/National Heart, Lung, and Blood Institute, and the Xiu Research Fund.

jensmith@mdedge.com

SOURCE: Cai H. AACR 2020. Patients with cancer appear more vulnerable to SARS-COV-2: A multicenter study during the COVID-19 outbreak; Dai M et al. Cancer Discov. 2020 Apr 28. doi: 10.1158/2159-8290.CD-20-0422.

Cancer type, stage, and recent treatment may affect outcomes of COVID-19 in cancer patients, according to a study of patients from China.

The data showed that patients with hematologic malignancies and those with metastatic cancers had higher risks of developing severe or critical COVID-19 symptoms, being admitted to the ICU, requiring ventilation, and dying.

On the other hand, patients with nonmetastatic cancer had outcomes comparable to those of noncancer patients with COVID-19.

Similarly, cancer patients who had recently undergone surgery or received immunotherapy were more likely to have poor outcomes, whereas cancer patients treated with radiotherapy had outcomes similar to those of noncancer COVID-19 patients.

Hongbing Cai, MD, of Zhongnan Hospital of Wuhan University in China, presented these results at the AACR virtual meeting I. The results also were published in Cancer Discovery.
 

Cancer vs. noncancer patients

The study included 105 cancer patients with COVID-19 who were treated from Jan. 1 to Feb. 24, 2020, at 14 hospitals in Wuhan, China. Patients had lung (20.95%), gastrointestinal (12.38%), breast (10.48%), and thyroid cancers (10.48%) as well as hematologic malignancies (8.57%). Dr. Cai and colleagues matched the COVID-19 cancer patients to 536 COVID-19 patients without cancer. Patients were matched by hospital, duration of hospitalization, and age.

“COVID-19 patients with cancer had higher risks of all severe outcomes,” Dr. Cai noted.

Compared with noncancer patients, the cancer patients had a higher risk of:

• Severe or critical COVID-19 symptoms – odds ratio, 2.79 (P < .01).
• Being admitted to the ICU – OR, 2.84 (P < .01).
• Requiring invasive mechanical ventilation – OR, 14 (P < .01).
• Death – OR, 2.34 (P = .03).

Cancer type and stage

Dr. Cai noted that outcomes were the worst among patients with hematologic malignancies and those with metastatic cancer (stage IV).

Compared with patients without cancer, those with hematologic malignancies had a higher risk of:

• Severe/critical symptoms – OR, 10.61 (P < .01).
• ICU admission – OR, 9.66 (P < .01).
• Invasive mechanical ventilation – OR, 38 (P < .01).
• Death – OR, 9.07 (P = .01).

Compared with patients without cancer, those with metastatic cancer had a higher risk of:

• Severe/critical symptoms – OR, 5.97 (P < .01).
• ICU admission – OR, 6.59 (P < 0.01).
• Invasive mechanical ventilation – OR, 55.42 (P < .01).
• Death – OR, 5.58 (P = .01).

On the other hand, outcomes in patients with nonmetastatic cancer were not significantly different from outcomes in patients without cancer (P > .05 for all outcomes).
 

Cancer treatment

The treatments cancer patients received within 40 days before the onset of COVID-19 symptoms were radiotherapy (12.26%), chemotherapy (14.15%), surgery (7.62%), targeted therapies (3.81%), and immunotherapy (5.71%).

Compared with patients without cancer, those who received immunotherapy had a higher risk of:

• Severe/critical symptoms – OR, 10.61 (P < .01).
• Death – OR, 9.07 (P = .04).

Patients who underwent surgery had a higher risk of:

• Severe/critical symptoms – OR, 8.84 (P < .01).
• ICU admission – OR, 7.24 (P = .02).
• Invasive mechanical ventilation – OR, 44.33 (P < .01).

Conversely, outcomes in cancer patients who received radiotherapy were not significantly different from outcomes in patients without cancer (P > .10 for all).

These results suggest that “postponing surgery should be considered in outbreak areas,” Dr. Cai said, adding that scheduled radiotherapy can go ahead but with “intensive protection and surveillance.”

Dr. Cai said it remains to be seen whether patients with early-stage cancer need to postpone their treatments during the COVID-19 pandemic or whether immunotherapy aggravates severe outcomes in cancer patients with COVID-19. For now, she said, cancer patients should have individualized treatment plans based on their tumor type and stage.

Dr. Cai disclosed no conflicts of interest. This study was supported by the National Natural Science Foundation of China, the Singapore Ministry of Health’s National Medical Research Council, the National Institutes of Health/National Heart, Lung, and Blood Institute, and the Xiu Research Fund.

jensmith@mdedge.com

SOURCE: Cai H. AACR 2020. Patients with cancer appear more vulnerable to SARS-COV-2: A multicenter study during the COVID-19 outbreak; Dai M et al. Cancer Discov. 2020 Apr 28. doi: 10.1158/2159-8290.CD-20-0422.

Cancer type, stage, and recent treatment may affect outcomes of COVID-19 in cancer patients, according to a study of patients from China.

The data showed that patients with hematologic malignancies and those with metastatic cancers had higher risks of developing severe or critical COVID-19 symptoms, being admitted to the ICU, requiring ventilation, and dying.

On the other hand, patients with nonmetastatic cancer had outcomes comparable to those of noncancer patients with COVID-19.

Similarly, cancer patients who had recently undergone surgery or received immunotherapy were more likely to have poor outcomes, whereas cancer patients treated with radiotherapy had outcomes similar to those of noncancer COVID-19 patients.

Hongbing Cai, MD, of Zhongnan Hospital of Wuhan University in China, presented these results at the AACR virtual meeting I. The results also were published in Cancer Discovery.
 

Cancer vs. noncancer patients

The study included 105 cancer patients with COVID-19 who were treated from Jan. 1 to Feb. 24, 2020, at 14 hospitals in Wuhan, China. Patients had lung (20.95%), gastrointestinal (12.38%), breast (10.48%), and thyroid cancers (10.48%) as well as hematologic malignancies (8.57%). Dr. Cai and colleagues matched the COVID-19 cancer patients to 536 COVID-19 patients without cancer. Patients were matched by hospital, duration of hospitalization, and age.

“COVID-19 patients with cancer had higher risks of all severe outcomes,” Dr. Cai noted.

Compared with noncancer patients, the cancer patients had a higher risk of:

• Severe or critical COVID-19 symptoms – odds ratio, 2.79 (P < .01).
• Being admitted to the ICU – OR, 2.84 (P < .01).
• Requiring invasive mechanical ventilation – OR, 14 (P < .01).
• Death – OR, 2.34 (P = .03).

Cancer type and stage

Dr. Cai noted that outcomes were the worst among patients with hematologic malignancies and those with metastatic cancer (stage IV).

Compared with patients without cancer, those with hematologic malignancies had a higher risk of:

• Severe/critical symptoms – OR, 10.61 (P < .01).
• ICU admission – OR, 9.66 (P < .01).
• Invasive mechanical ventilation – OR, 38 (P < .01).
• Death – OR, 9.07 (P = .01).

Compared with patients without cancer, those with metastatic cancer had a higher risk of:

• Severe/critical symptoms – OR, 5.97 (P < .01).
• ICU admission – OR, 6.59 (P < 0.01).
• Invasive mechanical ventilation – OR, 55.42 (P < .01).
• Death – OR, 5.58 (P = .01).

On the other hand, outcomes in patients with nonmetastatic cancer were not significantly different from outcomes in patients without cancer (P > .05 for all outcomes).
 

Cancer treatment

The treatments cancer patients received within 40 days before the onset of COVID-19 symptoms were radiotherapy (12.26%), chemotherapy (14.15%), surgery (7.62%), targeted therapies (3.81%), and immunotherapy (5.71%).

Compared with patients without cancer, those who received immunotherapy had a higher risk of:

• Severe/critical symptoms – OR, 10.61 (P < .01).
• Death – OR, 9.07 (P = .04).

Patients who underwent surgery had a higher risk of:

• Severe/critical symptoms – OR, 8.84 (P < .01).
• ICU admission – OR, 7.24 (P = .02).
• Invasive mechanical ventilation – OR, 44.33 (P < .01).

Conversely, outcomes in cancer patients who received radiotherapy were not significantly different from outcomes in patients without cancer (P > .10 for all).

These results suggest that “postponing surgery should be considered in outbreak areas,” Dr. Cai said, adding that scheduled radiotherapy can go ahead but with “intensive protection and surveillance.”

Dr. Cai said it remains to be seen whether patients with early-stage cancer need to postpone their treatments during the COVID-19 pandemic or whether immunotherapy aggravates severe outcomes in cancer patients with COVID-19. For now, she said, cancer patients should have individualized treatment plans based on their tumor type and stage.

Dr. Cai disclosed no conflicts of interest. This study was supported by the National Natural Science Foundation of China, the Singapore Ministry of Health’s National Medical Research Council, the National Institutes of Health/National Heart, Lung, and Blood Institute, and the Xiu Research Fund.

jensmith@mdedge.com

SOURCE: Cai H. AACR 2020. Patients with cancer appear more vulnerable to SARS-COV-2: A multicenter study during the COVID-19 outbreak; Dai M et al. Cancer Discov. 2020 Apr 28. doi: 10.1158/2159-8290.CD-20-0422.

Like other agencies, the European Society for Medical Oncology has developed guidelines for managing breast cancer patients during the COVID-19 pandemic, recommending when care should be prioritized, delayed, or modified.

ESMO’s breast cancer guidelines expand upon guidelines issued by other groups, addressing a broad spectrum of patient profiles and providing a creative array of treatment options in COVID-19–era clinical practice.

As with ESMO’s other disease-focused COVID-19 guidelines, the breast cancer guidelines are organized by priority levels – high, medium, and low – which are applied to several domains of diagnosis and treatment.

High-priority recommendations apply to patients whose condition is either clinically unstable or whose cancer burden is immediately life-threatening.

Medium-priority recommendations apply to patients for whom delaying care beyond 6 weeks would probably lower the likelihood of a significant benefit from the intervention.

Low-priority recommendations apply to patients for whom services can be delayed for the duration of the COVID-19 pandemic.
 

Personalized care and high-priority situations

ESMO’s guidelines suggest that multidisciplinary tumor boards should guide decisions about the urgency of care for individual patients, given the complexity of breast cancer biology, the multiplicity of evidence-based treatments, and the possibility of cure or durable high-quality remissions.

The guidelines deliver a clear message that prepandemic discussions about delivering personalized care are even more important now.

ESMO prioritizes investigating high-risk screening mammography results (i.e., BIRADS 5), lumps noted on breast self-examination, clinical evidence of local-regional recurrence, and breast cancer in pregnant women.

Making these scenarios “high priority” will facilitate the best long-term outcomes in time-sensitive scenarios and improve patient satisfaction with care.

Modifications to consider

ESMO provides explicit options for treatment of common breast cancer profiles in which short-term modifications of standard management strategies can safely be considered. Given the generally long natural history of most breast cancer subtypes, these temporary modifications are unlikely to compromise long-term outcomes.

For patients with a new diagnosis of localized breast cancer, the guidelines recommend neoadjuvant chemotherapy, targeted therapy, or hormonal therapy to achieve optimal breast cancer outcomes and safely delay surgery or radiotherapy.

In the metastatic setting, ESMO advises providers to consider:

• Symptom-oriented testing, recognizing the arguable benefit of frequent imaging or serum tumor marker measurement (J Clin Oncol. 2016 Aug 20;34[24]:2820-6).
• Drug holidays, de-escalated maintenance therapy, and protracted schedules of bone-modifying agents.
• Avoiding mTOR and PI3KCA inhibitors as an addition to standard hormonal therapy because of pneumonitis, hyperglycemia, and immunosuppression risks. The guidelines suggest careful thought about adding CDK4/6 inhibitors to standard hormonal therapy because of the added burden of remote safety monitoring with the biologic agents.

ESMO makes suggestions about trimming the duration of adjuvant trastuzumab to 6 months, as in the PERSEPHONE study (Lancet. 2019 Jun 29;393[10191]:2599-612), and modifying the schedule of luteinizing hormone–releasing hormone agonist administration, in an effort to reduce patient exposure to health care personnel (and vice versa).

The guidelines recommend continuing clinical trials if benefits to patients outweigh risks and trials can be modified to enhance patient safety while preserving study endpoint evaluations.
 

Lower-priority situations

ESMO pointedly assigns a low priority to follow-up of patients who are at high risk of relapse but lack signs or symptoms of relapse.

Like other groups, ESMO recommends that patients with equivocal (i.e., BIRADS 3) screening mammograms should have 6-month follow-up imaging in preference to immediate core needle biopsy of the area(s) of concern.

ESMO uses age to assign priority for postponing adjuvant breast radiation in patients with low- to moderate-risk lesions. However, the guidelines stop surprisingly short of recommending that adjuvant radiation be withheld for older patients with low-risk, stage I, hormonally sensitive, HER2-negative breast cancers who receive endocrine therapy.
 

Bottom line

The pragmatic adjustments ESMO suggests address the challenges of evaluating and treating breast cancer patients during the COVID-19 pandemic. The guidelines protect each patient’s right to care and safety as well as protecting the safety of caregivers.

The guidelines will likely heighten patients’ satisfaction with care and decrease concern about adequacy of timely evaluation and treatment.
 

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

Like other agencies, the European Society for Medical Oncology has developed guidelines for managing breast cancer patients during the COVID-19 pandemic, recommending when care should be prioritized, delayed, or modified.

ESMO’s breast cancer guidelines expand upon guidelines issued by other groups, addressing a broad spectrum of patient profiles and providing a creative array of treatment options in COVID-19–era clinical practice.

As with ESMO’s other disease-focused COVID-19 guidelines, the breast cancer guidelines are organized by priority levels – high, medium, and low – which are applied to several domains of diagnosis and treatment.

High-priority recommendations apply to patients whose condition is either clinically unstable or whose cancer burden is immediately life-threatening.

Medium-priority recommendations apply to patients for whom delaying care beyond 6 weeks would probably lower the likelihood of a significant benefit from the intervention.

Low-priority recommendations apply to patients for whom services can be delayed for the duration of the COVID-19 pandemic.
 

Personalized care and high-priority situations

ESMO’s guidelines suggest that multidisciplinary tumor boards should guide decisions about the urgency of care for individual patients, given the complexity of breast cancer biology, the multiplicity of evidence-based treatments, and the possibility of cure or durable high-quality remissions.

The guidelines deliver a clear message that prepandemic discussions about delivering personalized care are even more important now.

ESMO prioritizes investigating high-risk screening mammography results (i.e., BIRADS 5), lumps noted on breast self-examination, clinical evidence of local-regional recurrence, and breast cancer in pregnant women.

Making these scenarios “high priority” will facilitate the best long-term outcomes in time-sensitive scenarios and improve patient satisfaction with care.

Modifications to consider

ESMO provides explicit options for treatment of common breast cancer profiles in which short-term modifications of standard management strategies can safely be considered. Given the generally long natural history of most breast cancer subtypes, these temporary modifications are unlikely to compromise long-term outcomes.

For patients with a new diagnosis of localized breast cancer, the guidelines recommend neoadjuvant chemotherapy, targeted therapy, or hormonal therapy to achieve optimal breast cancer outcomes and safely delay surgery or radiotherapy.

In the metastatic setting, ESMO advises providers to consider:

• Symptom-oriented testing, recognizing the arguable benefit of frequent imaging or serum tumor marker measurement (J Clin Oncol. 2016 Aug 20;34[24]:2820-6).
• Drug holidays, de-escalated maintenance therapy, and protracted schedules of bone-modifying agents.
• Avoiding mTOR and PI3KCA inhibitors as an addition to standard hormonal therapy because of pneumonitis, hyperglycemia, and immunosuppression risks. The guidelines suggest careful thought about adding CDK4/6 inhibitors to standard hormonal therapy because of the added burden of remote safety monitoring with the biologic agents.

ESMO makes suggestions about trimming the duration of adjuvant trastuzumab to 6 months, as in the PERSEPHONE study (Lancet. 2019 Jun 29;393[10191]:2599-612), and modifying the schedule of luteinizing hormone–releasing hormone agonist administration, in an effort to reduce patient exposure to health care personnel (and vice versa).

The guidelines recommend continuing clinical trials if benefits to patients outweigh risks and trials can be modified to enhance patient safety while preserving study endpoint evaluations.
 

Lower-priority situations

ESMO pointedly assigns a low priority to follow-up of patients who are at high risk of relapse but lack signs or symptoms of relapse.

Like other groups, ESMO recommends that patients with equivocal (i.e., BIRADS 3) screening mammograms should have 6-month follow-up imaging in preference to immediate core needle biopsy of the area(s) of concern.

ESMO uses age to assign priority for postponing adjuvant breast radiation in patients with low- to moderate-risk lesions. However, the guidelines stop surprisingly short of recommending that adjuvant radiation be withheld for older patients with low-risk, stage I, hormonally sensitive, HER2-negative breast cancers who receive endocrine therapy.
 

Bottom line

The pragmatic adjustments ESMO suggests address the challenges of evaluating and treating breast cancer patients during the COVID-19 pandemic. The guidelines protect each patient’s right to care and safety as well as protecting the safety of caregivers.

The guidelines will likely heighten patients’ satisfaction with care and decrease concern about adequacy of timely evaluation and treatment.
 

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

Like other agencies, the European Society for Medical Oncology has developed guidelines for managing breast cancer patients during the COVID-19 pandemic, recommending when care should be prioritized, delayed, or modified.

ESMO’s breast cancer guidelines expand upon guidelines issued by other groups, addressing a broad spectrum of patient profiles and providing a creative array of treatment options in COVID-19–era clinical practice.

As with ESMO’s other disease-focused COVID-19 guidelines, the breast cancer guidelines are organized by priority levels – high, medium, and low – which are applied to several domains of diagnosis and treatment.

High-priority recommendations apply to patients whose condition is either clinically unstable or whose cancer burden is immediately life-threatening.

Medium-priority recommendations apply to patients for whom delaying care beyond 6 weeks would probably lower the likelihood of a significant benefit from the intervention.

Low-priority recommendations apply to patients for whom services can be delayed for the duration of the COVID-19 pandemic.
 

Personalized care and high-priority situations

ESMO’s guidelines suggest that multidisciplinary tumor boards should guide decisions about the urgency of care for individual patients, given the complexity of breast cancer biology, the multiplicity of evidence-based treatments, and the possibility of cure or durable high-quality remissions.

The guidelines deliver a clear message that prepandemic discussions about delivering personalized care are even more important now.

ESMO prioritizes investigating high-risk screening mammography results (i.e., BIRADS 5), lumps noted on breast self-examination, clinical evidence of local-regional recurrence, and breast cancer in pregnant women.

Making these scenarios “high priority” will facilitate the best long-term outcomes in time-sensitive scenarios and improve patient satisfaction with care.

Modifications to consider

ESMO provides explicit options for treatment of common breast cancer profiles in which short-term modifications of standard management strategies can safely be considered. Given the generally long natural history of most breast cancer subtypes, these temporary modifications are unlikely to compromise long-term outcomes.

For patients with a new diagnosis of localized breast cancer, the guidelines recommend neoadjuvant chemotherapy, targeted therapy, or hormonal therapy to achieve optimal breast cancer outcomes and safely delay surgery or radiotherapy.

In the metastatic setting, ESMO advises providers to consider:

• Symptom-oriented testing, recognizing the arguable benefit of frequent imaging or serum tumor marker measurement (J Clin Oncol. 2016 Aug 20;34[24]:2820-6).
• Drug holidays, de-escalated maintenance therapy, and protracted schedules of bone-modifying agents.
• Avoiding mTOR and PI3KCA inhibitors as an addition to standard hormonal therapy because of pneumonitis, hyperglycemia, and immunosuppression risks. The guidelines suggest careful thought about adding CDK4/6 inhibitors to standard hormonal therapy because of the added burden of remote safety monitoring with the biologic agents.

ESMO makes suggestions about trimming the duration of adjuvant trastuzumab to 6 months, as in the PERSEPHONE study (Lancet. 2019 Jun 29;393[10191]:2599-612), and modifying the schedule of luteinizing hormone–releasing hormone agonist administration, in an effort to reduce patient exposure to health care personnel (and vice versa).

The guidelines recommend continuing clinical trials if benefits to patients outweigh risks and trials can be modified to enhance patient safety while preserving study endpoint evaluations.
 

Lower-priority situations

ESMO pointedly assigns a low priority to follow-up of patients who are at high risk of relapse but lack signs or symptoms of relapse.

Like other groups, ESMO recommends that patients with equivocal (i.e., BIRADS 3) screening mammograms should have 6-month follow-up imaging in preference to immediate core needle biopsy of the area(s) of concern.

ESMO uses age to assign priority for postponing adjuvant breast radiation in patients with low- to moderate-risk lesions. However, the guidelines stop surprisingly short of recommending that adjuvant radiation be withheld for older patients with low-risk, stage I, hormonally sensitive, HER2-negative breast cancers who receive endocrine therapy.
 

Bottom line

The pragmatic adjustments ESMO suggests address the challenges of evaluating and treating breast cancer patients during the COVID-19 pandemic. The guidelines protect each patient’s right to care and safety as well as protecting the safety of caregivers.

The guidelines will likely heighten patients’ satisfaction with care and decrease concern about adequacy of timely evaluation and treatment.
 

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

The US Food and Drug Administration (FDA) granted accelerated approval to sacituzumab govitecan (Trodelvy, Immunomedics) for the treatment of metastatic triple-negative breast cancer (TNBC).

Eligible patients must have received at least two prior therapies.

TNBC is so-called because it lacks the three cellular targets present in more common forms of breast cancer. It is usually treated with chemotherapy.

Sacituzumab govitecan offers a new approach – and it has a target.

Given intravenously, the new drug is an antibody-drug conjugate in which SN-38, an active metabolite of the chemotherapy drug irinotecan (multiple brands), is coupled to a monoclonal antibody that targets an antigen that has high expression in TNBC and induces cancer cell growth.

“Metastatic triple-negative breast cancer is an aggressive form of breast cancer with limited treatment options,” observed Richard Pazdur, MD, director of the FDA’s Oncology Center of Excellence and acting director of the Office of Oncologic Diseases in the FDA’s Center for Drug Evaluation and Research in a press statement. “There is intense interest in finding new medications” for this patient population, he added.

The new approval is based on safety and efficacy results from a phase 1/2 clinical trial of 108 patients (median age, 56 years) who had received at least two prior treatments for metastatic disease.

The overall response rate was 33% (n = 36), including three complete responses. Median duration of response was 7.7 months. Of responders, 55.6% maintained their response for at least 6 months and 16.7% for at least 12 months.

Median progression-free survival was 5.5 months, and median overall survival was 13.0 months.

The study data were published last year in the New England Journal of Medicine.

“It’s not every day that we see this sort of clinical activity in this aggressive subtype of breast cancer,” said senior study author Kevin Kalinsky, MD, in an interview at that time. He is a medical oncologist at New York–Presbyterian Hospital and Columbia University Medical Center in New York City.

The most common side effects of the new therapy were nausea, neutropenia, diarrhea, fatigue, anemia, vomiting, alopecia, constipation, decreased appetite, rash, and abdominal pain.

No peripheral neuropathy of grade 3 or higher was reported.

In the study, patients received sacituzumab govitecan intravenously (10 mg/kg body weight) on days 1 and 8 of each 21-day cycle until disease progression or unacceptable toxicity.

The 108 participants received a mean 18.7 doses of sacituzumab govitecan, or 9.6 cycles. The median duration of exposure was 5.1 months.

Three patients discontinued treatment because of adverse events, and two patients discontinued because of drug-related events.

The prescribing information includes a boxed warning regarding the risks of severe neutropenia and severe diarrhea. Blood cell counts should be monitored during treatment and granulocyte-colony stimulating factor (G-CSF) therapy should be considered. Anti-infective treatment should be initiated in the event of febrile neutropenia. Patients with reduced uridine diphosphate-glucuronosyltransferase 1A1 (UGT1A1) activity are at increased risk for neutropenia following initiation of treatment.

The new drug can also cause hypersensitivity reactions including severe anaphylactic reactions.

Women who are pregnant should not take sacituzumab govitecan.

This article first appeared on Medscape.com.

The US Food and Drug Administration (FDA) granted accelerated approval to sacituzumab govitecan (Trodelvy, Immunomedics) for the treatment of metastatic triple-negative breast cancer (TNBC).

Eligible patients must have received at least two prior therapies.

TNBC is so-called because it lacks the three cellular targets present in more common forms of breast cancer. It is usually treated with chemotherapy.

Sacituzumab govitecan offers a new approach – and it has a target.

Given intravenously, the new drug is an antibody-drug conjugate in which SN-38, an active metabolite of the chemotherapy drug irinotecan (multiple brands), is coupled to a monoclonal antibody that targets an antigen that has high expression in TNBC and induces cancer cell growth.

“Metastatic triple-negative breast cancer is an aggressive form of breast cancer with limited treatment options,” observed Richard Pazdur, MD, director of the FDA’s Oncology Center of Excellence and acting director of the Office of Oncologic Diseases in the FDA’s Center for Drug Evaluation and Research in a press statement. “There is intense interest in finding new medications” for this patient population, he added.

The new approval is based on safety and efficacy results from a phase 1/2 clinical trial of 108 patients (median age, 56 years) who had received at least two prior treatments for metastatic disease.

The overall response rate was 33% (n = 36), including three complete responses. Median duration of response was 7.7 months. Of responders, 55.6% maintained their response for at least 6 months and 16.7% for at least 12 months.

Median progression-free survival was 5.5 months, and median overall survival was 13.0 months.

The study data were published last year in the New England Journal of Medicine.

“It’s not every day that we see this sort of clinical activity in this aggressive subtype of breast cancer,” said senior study author Kevin Kalinsky, MD, in an interview at that time. He is a medical oncologist at New York–Presbyterian Hospital and Columbia University Medical Center in New York City.

The most common side effects of the new therapy were nausea, neutropenia, diarrhea, fatigue, anemia, vomiting, alopecia, constipation, decreased appetite, rash, and abdominal pain.

No peripheral neuropathy of grade 3 or higher was reported.

In the study, patients received sacituzumab govitecan intravenously (10 mg/kg body weight) on days 1 and 8 of each 21-day cycle until disease progression or unacceptable toxicity.

The 108 participants received a mean 18.7 doses of sacituzumab govitecan, or 9.6 cycles. The median duration of exposure was 5.1 months.

Three patients discontinued treatment because of adverse events, and two patients discontinued because of drug-related events.

The prescribing information includes a boxed warning regarding the risks of severe neutropenia and severe diarrhea. Blood cell counts should be monitored during treatment and granulocyte-colony stimulating factor (G-CSF) therapy should be considered. Anti-infective treatment should be initiated in the event of febrile neutropenia. Patients with reduced uridine diphosphate-glucuronosyltransferase 1A1 (UGT1A1) activity are at increased risk for neutropenia following initiation of treatment.

The new drug can also cause hypersensitivity reactions including severe anaphylactic reactions.

Women who are pregnant should not take sacituzumab govitecan.

This article first appeared on Medscape.com.

The US Food and Drug Administration (FDA) granted accelerated approval to sacituzumab govitecan (Trodelvy, Immunomedics) for the treatment of metastatic triple-negative breast cancer (TNBC).

Eligible patients must have received at least two prior therapies.

TNBC is so-called because it lacks the three cellular targets present in more common forms of breast cancer. It is usually treated with chemotherapy.

Sacituzumab govitecan offers a new approach – and it has a target.

Given intravenously, the new drug is an antibody-drug conjugate in which SN-38, an active metabolite of the chemotherapy drug irinotecan (multiple brands), is coupled to a monoclonal antibody that targets an antigen that has high expression in TNBC and induces cancer cell growth.

“Metastatic triple-negative breast cancer is an aggressive form of breast cancer with limited treatment options,” observed Richard Pazdur, MD, director of the FDA’s Oncology Center of Excellence and acting director of the Office of Oncologic Diseases in the FDA’s Center for Drug Evaluation and Research in a press statement. “There is intense interest in finding new medications” for this patient population, he added.

The new approval is based on safety and efficacy results from a phase 1/2 clinical trial of 108 patients (median age, 56 years) who had received at least two prior treatments for metastatic disease.

The overall response rate was 33% (n = 36), including three complete responses. Median duration of response was 7.7 months. Of responders, 55.6% maintained their response for at least 6 months and 16.7% for at least 12 months.

Median progression-free survival was 5.5 months, and median overall survival was 13.0 months.

The study data were published last year in the New England Journal of Medicine.

“It’s not every day that we see this sort of clinical activity in this aggressive subtype of breast cancer,” said senior study author Kevin Kalinsky, MD, in an interview at that time. He is a medical oncologist at New York–Presbyterian Hospital and Columbia University Medical Center in New York City.

The most common side effects of the new therapy were nausea, neutropenia, diarrhea, fatigue, anemia, vomiting, alopecia, constipation, decreased appetite, rash, and abdominal pain.

No peripheral neuropathy of grade 3 or higher was reported.

In the study, patients received sacituzumab govitecan intravenously (10 mg/kg body weight) on days 1 and 8 of each 21-day cycle until disease progression or unacceptable toxicity.

The 108 participants received a mean 18.7 doses of sacituzumab govitecan, or 9.6 cycles. The median duration of exposure was 5.1 months.

Three patients discontinued treatment because of adverse events, and two patients discontinued because of drug-related events.

The prescribing information includes a boxed warning regarding the risks of severe neutropenia and severe diarrhea. Blood cell counts should be monitored during treatment and granulocyte-colony stimulating factor (G-CSF) therapy should be considered. Anti-infective treatment should be initiated in the event of febrile neutropenia. Patients with reduced uridine diphosphate-glucuronosyltransferase 1A1 (UGT1A1) activity are at increased risk for neutropenia following initiation of treatment.

The new drug can also cause hypersensitivity reactions including severe anaphylactic reactions.

Women who are pregnant should not take sacituzumab govitecan.

This article first appeared on Medscape.com.

The U.S. Food and Drug Administration has approved the oral therapy tucatinib (Tukysa, Seattle Genetics) for the treatment of advanced HER2-positive breast cancer. This is the first new drug approved under Project Orbis, an international collaboration.

Tucatinib, which is a small-molecule tyrosine kinase inhibitor, is approved in combination with trastuzumab and capecitabine to treat patients who have received one or more prior treatments for advanced disease.

The FDA collaborated with the regulatory authorities of Australia, Canada, Singapore, and Switzerland on this review. However, only the FDA has approved tucatinib; the application is still under review at the other agencies.

While working with Project Orbis in 2019, the FDA granted an accelerated, conditional approval to a drug combination that included previously approved agents.

“The FDA’s Project Orbis provides a framework for concurrent submission and review of oncology drug applications among the FDA’s international collaborators,” said Richard Pazdur, MD, acting director of the Office of Oncologic Diseases in the FDA’s Center for Drug Evaluation and Research, in a statement.

Collaboration among regulators may allow patients with cancer to receive earlier access to products in other countries where there may be significant delays in regulatory submissions, according to the FDA.

The new drug is a “valuable addition” to the roster of treatments for advanced HER2-positive breast cancer, said study investigator Eric Winer, MD, Dana-Farber Cancer Institute, Boston, Massachusetts, in a company press statement.

“With highly significant and clinically important results for overall and progression-free survival, the addition of [tucatinib] to trastuzumab and capecitabine has the potential to become a standard of care for people with HER2-positive metastatic breast cancer after having received one or more previous anti-HER2 therapies in the metastatic setting,” he said.

The new approval is based on safety and efficacy results from the phase 2 HER2CLIMB trial that enrolled 612 patients with HER2-positive unresectable locally advanced or metastatic breast cancer who had previously received, either separately or in combination, trastuzumab, pertuzumab, and ado-trastuzumab emtansine.

Nearly half (48%) of patients in the study had brain metastases at the start of the trial. The primary outcome measure was progression-free survival (PFS). All patients received trastuzumab and capecitabine and were randomly assigned to either tucatinib or placebo.

Median PFS in the tucatinib patient group was 7.8 months, compared with 5.6 months in the placebo group. The PFS results in the subgroup of patients with brain metastases were nearly the same.

Median overall survival in the tucatinib patient group was 21.9 months versus 17.4 months in the placebo group.

The new drug is a rare success in the treatment of breast cancer brain metastases, said Jawad Fares, MD, of Northwestern University, Chicago, Illinois, who spoke to Medscape Medical News when the phase 3 trial data were first presented at the 2019 San Antonio Breast Cancer Symposium.

“Outcomes in the field have been pretty dismal,” summarized Fares, who was not involved in the study.

The results of the HER2CLIMB study, which was funded by Seattle Genetics, were published in the New England Journal of Medicine last year.

According to the FDA, common side effects with tucatinib were diarrhea, palmar-plantar erythrodysesthesia syndrome, nausea, fatigue, hepatotoxicity, vomiting, stomatitis, decreased appetite, abdominal pain, headache, anemia, and rash.

Tucatinib can cause serious side effects, including diarrhea associated with dehydration, acute kidney injury, and death. Health care professionals should start antidiarrheals as clinically indicated if diarrhea occurs and should interrupt treatment or reduce the dosage. Tucatinib can also cause severe hepatotoxicity; patients should be monitored with liver tests.

This article first appeared on Medscape.com.

The U.S. Food and Drug Administration has approved the oral therapy tucatinib (Tukysa, Seattle Genetics) for the treatment of advanced HER2-positive breast cancer. This is the first new drug approved under Project Orbis, an international collaboration.

Tucatinib, which is a small-molecule tyrosine kinase inhibitor, is approved in combination with trastuzumab and capecitabine to treat patients who have received one or more prior treatments for advanced disease.

The FDA collaborated with the regulatory authorities of Australia, Canada, Singapore, and Switzerland on this review. However, only the FDA has approved tucatinib; the application is still under review at the other agencies.

While working with Project Orbis in 2019, the FDA granted an accelerated, conditional approval to a drug combination that included previously approved agents.

“The FDA’s Project Orbis provides a framework for concurrent submission and review of oncology drug applications among the FDA’s international collaborators,” said Richard Pazdur, MD, acting director of the Office of Oncologic Diseases in the FDA’s Center for Drug Evaluation and Research, in a statement.

Collaboration among regulators may allow patients with cancer to receive earlier access to products in other countries where there may be significant delays in regulatory submissions, according to the FDA.

The new drug is a “valuable addition” to the roster of treatments for advanced HER2-positive breast cancer, said study investigator Eric Winer, MD, Dana-Farber Cancer Institute, Boston, Massachusetts, in a company press statement.

“With highly significant and clinically important results for overall and progression-free survival, the addition of [tucatinib] to trastuzumab and capecitabine has the potential to become a standard of care for people with HER2-positive metastatic breast cancer after having received one or more previous anti-HER2 therapies in the metastatic setting,” he said.

The new approval is based on safety and efficacy results from the phase 2 HER2CLIMB trial that enrolled 612 patients with HER2-positive unresectable locally advanced or metastatic breast cancer who had previously received, either separately or in combination, trastuzumab, pertuzumab, and ado-trastuzumab emtansine.

Nearly half (48%) of patients in the study had brain metastases at the start of the trial. The primary outcome measure was progression-free survival (PFS). All patients received trastuzumab and capecitabine and were randomly assigned to either tucatinib or placebo.

Median PFS in the tucatinib patient group was 7.8 months, compared with 5.6 months in the placebo group. The PFS results in the subgroup of patients with brain metastases were nearly the same.

Median overall survival in the tucatinib patient group was 21.9 months versus 17.4 months in the placebo group.

The new drug is a rare success in the treatment of breast cancer brain metastases, said Jawad Fares, MD, of Northwestern University, Chicago, Illinois, who spoke to Medscape Medical News when the phase 3 trial data were first presented at the 2019 San Antonio Breast Cancer Symposium.

“Outcomes in the field have been pretty dismal,” summarized Fares, who was not involved in the study.

The results of the HER2CLIMB study, which was funded by Seattle Genetics, were published in the New England Journal of Medicine last year.

According to the FDA, common side effects with tucatinib were diarrhea, palmar-plantar erythrodysesthesia syndrome, nausea, fatigue, hepatotoxicity, vomiting, stomatitis, decreased appetite, abdominal pain, headache, anemia, and rash.

Tucatinib can cause serious side effects, including diarrhea associated with dehydration, acute kidney injury, and death. Health care professionals should start antidiarrheals as clinically indicated if diarrhea occurs and should interrupt treatment or reduce the dosage. Tucatinib can also cause severe hepatotoxicity; patients should be monitored with liver tests.

This article first appeared on Medscape.com.

The U.S. Food and Drug Administration has approved the oral therapy tucatinib (Tukysa, Seattle Genetics) for the treatment of advanced HER2-positive breast cancer. This is the first new drug approved under Project Orbis, an international collaboration.

Tucatinib, which is a small-molecule tyrosine kinase inhibitor, is approved in combination with trastuzumab and capecitabine to treat patients who have received one or more prior treatments for advanced disease.

The FDA collaborated with the regulatory authorities of Australia, Canada, Singapore, and Switzerland on this review. However, only the FDA has approved tucatinib; the application is still under review at the other agencies.

While working with Project Orbis in 2019, the FDA granted an accelerated, conditional approval to a drug combination that included previously approved agents.

“The FDA’s Project Orbis provides a framework for concurrent submission and review of oncology drug applications among the FDA’s international collaborators,” said Richard Pazdur, MD, acting director of the Office of Oncologic Diseases in the FDA’s Center for Drug Evaluation and Research, in a statement.

Collaboration among regulators may allow patients with cancer to receive earlier access to products in other countries where there may be significant delays in regulatory submissions, according to the FDA.

The new drug is a “valuable addition” to the roster of treatments for advanced HER2-positive breast cancer, said study investigator Eric Winer, MD, Dana-Farber Cancer Institute, Boston, Massachusetts, in a company press statement.

“With highly significant and clinically important results for overall and progression-free survival, the addition of [tucatinib] to trastuzumab and capecitabine has the potential to become a standard of care for people with HER2-positive metastatic breast cancer after having received one or more previous anti-HER2 therapies in the metastatic setting,” he said.

The new approval is based on safety and efficacy results from the phase 2 HER2CLIMB trial that enrolled 612 patients with HER2-positive unresectable locally advanced or metastatic breast cancer who had previously received, either separately or in combination, trastuzumab, pertuzumab, and ado-trastuzumab emtansine.

Nearly half (48%) of patients in the study had brain metastases at the start of the trial. The primary outcome measure was progression-free survival (PFS). All patients received trastuzumab and capecitabine and were randomly assigned to either tucatinib or placebo.

Median PFS in the tucatinib patient group was 7.8 months, compared with 5.6 months in the placebo group. The PFS results in the subgroup of patients with brain metastases were nearly the same.

Median overall survival in the tucatinib patient group was 21.9 months versus 17.4 months in the placebo group.

The new drug is a rare success in the treatment of breast cancer brain metastases, said Jawad Fares, MD, of Northwestern University, Chicago, Illinois, who spoke to Medscape Medical News when the phase 3 trial data were first presented at the 2019 San Antonio Breast Cancer Symposium.

“Outcomes in the field have been pretty dismal,” summarized Fares, who was not involved in the study.

The results of the HER2CLIMB study, which was funded by Seattle Genetics, were published in the New England Journal of Medicine last year.

According to the FDA, common side effects with tucatinib were diarrhea, palmar-plantar erythrodysesthesia syndrome, nausea, fatigue, hepatotoxicity, vomiting, stomatitis, decreased appetite, abdominal pain, headache, anemia, and rash.

Tucatinib can cause serious side effects, including diarrhea associated with dehydration, acute kidney injury, and death. Health care professionals should start antidiarrheals as clinically indicated if diarrhea occurs and should interrupt treatment or reduce the dosage. Tucatinib can also cause severe hepatotoxicity; patients should be monitored with liver tests.

This article first appeared on Medscape.com.