Early breast updates


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  • *Early breast cancer Trialists’ Collaborative Group in 2005 metanalysis for the effect of tamthe effect in women whose tumors were foundto be ER-positive is clear and definite. For the trials of 1 or2 years of tamoxifen, both recurrence (ratio of annualrecurrence rates: 0.74 SE 0.02) and deaths due to breast cancer(ratio of annual death rates: 0.82 SE 0.03) were significantlyreduced among the 14 000 ER-positive women randomized.The effects were even larger among the 8000 ER-positive womenin the trials of five years of the drug. Comparing womenallocated to take five years of tamoxifen with those allocatednot to receive tamoxifen after their surgery, the annual rate ofrecurrence was reduced by about 40% (ratio of annualrecurrence rates: 0.59 SE 0.03). Deaths due to breast cancerwere 34% lower (ratio of annual death rates: 0.66 SE 0.04). By15 years after initial treatment for breast cancer, these benefitstranslate into average absolute reductions in recurrence of11.8% (SE 1.3, logrank 2p< 0.00001) and in breast cancermortality of 9.2% (SE 1.2, logrank 2p< 0.00001). Thus, for every11 women allocated to 5 years of tamoxifen there was one fewerdeath from breast cancer by year 15, because of tamoxifen.* Among women under 50 years of age when diagnosed withbreast cancer, the use of prolonged polychemotherapy wasshown to change the average proportion of women who hada recurrence by 15 years in these trials from 53.5% in the controlgroup to 41.1% in the chemotherapy group. The effect onbreast cancer mortality was such that the absolute risk by15 years was reduced by 10.0% (SE 1.6, logrank 2p< 0.00001).The effect in women aged 50–69 years was smaller but stillstatistically significant. By year 15, the reduction in recurrencewas 4.1% (SE 1.2, logrank 2p< 0.00001) and the reduction inbreast cancer mortality was 3.0% (SE 1.3, logrank 2p< 0.00001)
  • Our data evolved in risk classfication of br cancer from staging ( node +ve/ -ve) into more new approach utlizing the TNM + ER/PR status + Her2
  • Main point: The final gene set used for the Oncotype DX® assay includes the 16 cancer genes identified in the clinical trials.5 genes are in the proliferation group, 2 in the HER2 group, 4 in the estrogen-receptor group, 2 in the invasion group, and 3 are unaligned. Some of the genes are well known in the breast cancer literature; others are relatively new.The 5 reference genes are used for normalizing the expression of the cancer-related genes., it is important to note that there are other genes linked to breast cancer (eg, the 250 candidate genes from which the 16 genes were selected). The 16 genes presented in this slide were selected for the Oncotype DX assay based on the 3 clinical trials, which demonstrated a consistent statistical link between these genes and distant breast cancer recurrence and the most robust predictive power across the 3 studies.Additional information on some of the 16 cancer related genes:MYBL2: The protein encoded by this gene, a member of the MYB family of transcription factor genes, is a nuclear protein involved in cell cycle progression. The encoded protein is phosphorylated by cyclin A/cyclin-dependent kinase 2 during the S-phase of the cell cycle and possesses both activator and repressor activities. It has been shown to activate the cell division cycle 2, cyclin D1, and insulin-like growth factor-binding protein 5 genes. Transcript variants may exist for this gene, but their full-length natures have not been determined.STK15: The protein encoded by this gene is a cell cycle-regulated kinase that appears to be involved in microtubule formation and/or stabilization at the spindle pole during chromosome segregation. The encoded protein is found at the centrosome in interphase cells and at the spindle poles in mitosis. This gene may play a role in tumor development and progression. A processed pseudogene of this gene has been found on chromosome 1, and an unprocessed pseudogene has been found on chromosome 10. Multiple transcript variants encoding the same protein have been found for this gene.Scube2 can modulate the long-range action of Bmp-dependent Hedgehog signaling in the neural tube and somites.STMY3 (MMP11): Proteins of the matrix metalloproteinase (MMP) family are involved in the breakdown of extracellular matrix in normal physiological processes, such as embryonic development, reproduction, and tissue remodeling, as well as in disease processes, such as arthritis and metastasis. Most MMP's are secreted as inactive proproteins which are activated when cleaved by extracellular proteinases. However, the enzyme encoded by this gene is activated intracellularly by furin within the constitutive secretory pathway. Also in contrast to other MMP's, this enzyme cleaves alpha 1-proteinase inhibitor but weakly degrades structural proteins of the extracellular matrix CL2: The protein encoded by this gene, a member of the peptidase C1 family, is a lysosomalcysteineproteinase that may play an important role in corneal physiology. This gene is expressed in colorectal and breast carcinomas but not in normal colon, mammary gland, or peritumoral tissues, suggesting a possible role for this gene in tumor processes.GSTM1: Cytosolic and membrane-bound forms of glutathione S-transferase are encoded by two distinct supergene families. At present, eight distinct classes of the soluble cytoplasmic mammalian glutathione S-transferases have been identified: alpha, kappa, mu, omega, pi, sigma, theta and zeta. This gene encodes a glutathione S-transferase that belongs to the mu class. The mu class of enzymes functions in the detoxification of electrophilic compounds, including carcinogens, therapeutic drugs, environmental toxins and products of oxidative stress, by conjugation with glutathione. The genes encoding the mu class of enzymes are organized in a gene cluster on chromosome 1p13.3 and are known to be highly polymorphic. These genetic variations can change an individual's susceptibility to carcinogens and toxins as well as affect the toxicity and efficacy of certain drugs. Null mutations of this class mu gene have been linked with an increase in a number of cancers, likely due to an increased susceptibility to environmental toxins and carcinogens. Multiple protein isoforms are encoded by transcript variants of this gene.BAG1: The oncogene BCL2 is a membrane protein that blocks a step in a pathway leading to apoptosis or programmed cell death. The protein encoded by this gene binds to BCL2 and is referred to as BCL2-associated athanogene. It enhances the anti-apoptotic effects of BCL2 and represents a link between growth factor receptors and anti-apoptotic mechanisms. At least three protein isoforms are encoded by this mRNA through the use of alternative translation initiation sites, including a non-AUG siteThe Recurrence Score result ranges from 0 to 100. Expression for each individual gene is measured on a scale from 0 to 15, where an increase of 1 unit generally reflects a 2-fold increase in RNA quantity.Although the coefficients for each gene or gene group influence the Recurrence Score result, the quantitative expression for each gene can have a dominant effect. For example, there is a 200-fold range of expression of ER in the quantitative RT-PCR assay. For individual tumors, the expression of any one gene can affect the Recurrence Score result to a large degree.Recurrence Score =+ 0.47 × HER2 Group Score– 0.34 × Estrogen Group Score+ 1.04 × Proliferation Group Score + 0.10 × Invasion Group Score+ 0.05 × CD68– 0.08 × GSTM1– 0.07 × BAG1Paik et al. N Engl J Med. 2004;351:2817-2826.
  • age (finding significant benefit even at ages 55-69 years; few were older, but their results suggest favourable effects of taxanes even in old age), nodal status before chemotherapy (4000 had node negative disease), and ER status. Results are also given for subsets of ER-positive disease by HER2 status (generally by immunohistochemistry, classified where possible by standard criteria for definite positivity8), age, and differentiation (with a trend towards greater taxane benefit in well differentiated [RR 0·68, SE 0·16, 2p=0·04, n=3000] or moderately differentiated [RR 0·77, SE 0·07, 2p=0·001, n=11,000] ER-positive tumours than in poorly differentiated ER-positive tumours).
  • In ER +ve, 5 years TAM reduce the annual reccurence rate by the half, recurrence rate ratio 0.59The effect of tam on survival cont to increase till it reach greater by 3 times in after 15 years than after 5 years
  • BMD, bone mineral density; DFS, disease-free survival; EBC, early breast cancer; ZOL, zoledronic acid. Joyce O’Shaughnessy, MD: When considering the clinical applicability of these data, I am reminded that the National Comprehensive Cancer Network guidelines recommend that bone-directed therapy should be initiated in patients with a T-score < -2.0.[1] Based on these data from ZO-FAST, it is certainly reasonable to give patients zoledronic acid, particularly if they are at a higher risk of disease recurrence or fracture. With that said, I do not think these data are practice changing as the DFS data were a secondary endpoint in this study. I likely will not start all ER-positive patients on anastrozole combined with zoledronic acid every 6 months, particularly if they have normal BMD and are node negative. Peter Ravdin, MD, PhD: In addition,the World Health Organization Fracture Risk Assessment Tool (FRAX) can help determine need for bone-targeted treatment. FRAX accounts for secondary osteoporosis factors, such as aromatase inhibitor therapy. The guidelines recommend bone therapy for patients with a 10-year risk of major fracture that is > 20% or risk of hip fracture that is > 3% according to FRAX, but the absolute cutoff is a T-score of < -2.0 or a FRAX score > 3%. The guidelines also suggest a T-score cutoff of -1.5 to -2.0 to consider bone therapy. Reference1. Gralow JR, Biermann JS, Farooki A, et al. NCCN Task Force Report: Bone Health in Cancer Care. J Natl Compr Canc Netw. 2009;7(suppl 3):S1-S32.
  • Joyce O’Shaughnessy, MD: The GeparTrio Trial was a randomized phase III trial in women with operable or locally advanced breast cancer. Response was assessed after 2 cycles of docetaxel/doxorubicin/cyclophosphamide (TAC). Patients who responded to 2 cycles of TAC were randomized to receive 4 vs 6 additional cycles (ie, a total of 6 vs 8 cycles of TAC). Those with < 50% reduction in tumor size were randomized to receive 4 cycles of TAC plus vinorelbine/capecitabine (TAC-NX) vs 4 additional cycles of TAC.  The pathologic complete response data had previously been reported.[1] It was initially disappointing that this trial looked negative in that the nonresponders, regardless of whether they received 6 cycles of TAC or TAC-NX, had pathologic complete response (ypT0 ypN0) rates of 5% to 6%. Among patients who were responding to TAC, the pathologic complete response rate was still only approximately 21%.  In this report, von Minckwitz and colleagues presented an interesting 5-year follow-up analysis of systemic outcomes in secondary survival endpoints (DFS and OS). It is a little difficult to interpret the results of this report as the data for the 2 TAC x 6 (conventional chemotherapy) arms and the TAC x 8 and TAC-NX (response-guided chemotherapy) were combined. Peter Ravdin, MD, PhD: It is important to point out that the difference in the pathologic complete response rates between early responding and nonresponding patients were significantly different. However, there was no statistical difference in pathologic complete response between 6 and 8 cycles of TAC and nodifference between TAC and TAC-NX. Response-guided therapy did not seem to affect the short-term efficacy at surgery and the authors sought to determine if this strategy would influence long-term efficacy (ie, DFS, OS). Reference1. Huober J, von Minckwitz G, Denkert C, et al. Effect of neoadjuvant anthracycline-taxane-based chemotherapy in different biological breast cancer phenotypes: overall results from the GeparTrio study. Breast Cancer Res Treat. 2010;124:133-140.
  • CI, confidence interval; DFS, disease-free survival; HR, hazard ratio; OS, overall survival. Joyce O’Shaughnessy, MD: Professor von Minckwitz and colleagues showed that the patients given response-guided therapy (TAC x 8 or TAC-NX) had improved DFS and OS vs conventional chemotherapy (TAC x 6), even though switching mid-stream did not affect pathological complete response rates.  As I mentioned on the previous slide, the analysis was complex because it combined the vinorelbine/capecitabine group, which had an unfavorable prognosis, with the group that received 8 cycles of TAC, which had a favorable prognosis, as part of the response-guided therapy analysis.  However, von Minckwitz and colleagues then separated them and compared results of patients with favorable and unfavorable responses. This analysis showed an improvement in DFS in responding patients given TAC x 8 vs TAC x 6, which is interesting because these patients had a heavy enough tumor burden to warrant preoperative therapy and suggests that longer duration therapy may benefit these responding patients. In the nonresponding patients—and this is perhaps the most interesting finding—switching to vinorelbine and capecitabine was associated with significantly improved DFS vs finishing TAC x 6. Despite improvements in DFS in response-guided vs convention therapy as well as TAC x 8 and TAC-NX vs TAC x 6, there were not corresponding differences in pathologic complete response rates.
  • CI, confidence interval; HR, hazard ratio. Joyce O’Shaughnessy, MD: The investigators looked at results by the biological subtypes of breast cancer. It is notable, that the HER2-positive patients entered on this trial did not have the advantage of trastuzumab, as the trial was initiated prior to its availability. Results show that the longer-duration TAC or switching over to vinorelbine/capecitabine (ie, response-guided therapy) had the greatest benefit in the ER-positive population. However, response-guided therapy, whether it was longer TAC or whether it was vinorelbine/capecitabine, made no significant difference in patients with triple-negative disease. These data are in keeping with my clinical experience. But in ER-positive patients, switching over to vinorelbine/capecitabine or giving longer duration therapy was associated with longer DFS. Interestingly, results also showed that in the slower-growing ER-positive group—luminal A, defined as Ki67 below 14%—a pathologic complete response did not predict for DFS. However, in the faster-growing ER-positive group—luminal B with Ki67 over 14%—a pathologic complete response did predict for improved DFS.
  • pCR, pathologic complete response. Joyce O’Shaughnessy, MD: In general, lower rates of complete pathologic response were observed in luminal vs nonluminal tumors with the lowest proportion being those with luminal A and HER-positive, luminal B tumors.
  • DFS, disease-free survival; OS, overall survival; pCR, pathologic complete response. Joyce O’Shaughnessy, MD: In summary, these data suggest that switching a ER-positive patient who is not responding well to preoperative TAC to a non–cross-resistant regimen is a reasonable approach. Both the luminal A and the luminal B groups benefited by switching over to vinorelbine/capecitabine. Of note, patients who received longer-duration TAC were included in the response-guided treatment category, so it is difficult to tease out the contribution of vinorelbine/capecitabine and to say that ER-positive patients who do not respond to 2 cycles of TAC should absolutely be switched over to vinorelbine/capecitabine.  Peter Ravdin, MD, PhD: I agree that combining the groups confounded the interpretation of these data. Moreover, if a patient is doing great, I will not give more than 6 cycles of TAC, which is what these data suggest is optimal as 6 cycles is already challenging for patients to complete.  Joyce O’Shaughnessy, MD: If I were giving TAC to an ER-positive patient and she did not respond after 2 or 3 cycles, I would consider switching her to vinorelbine and capecitabine based on these data. We conducted a study with a subset analysis that suggested a benefit with capecitabine in the adjuvant setting in ER-positive tumors that were more highly proliferative (Ki67 cutoff of 10%). As this was a subset analysis, it would be important to see a confirmatory trial, but I think these data are nevertheless interesting and provide us with another avenue to potentially improve systemic outcomes in the neoadjuvant setting. These data are probably not practice changing. This analysis is based on a secondary endpoint, and the study includes patients with HER2-positive tumors not treated with anti-HER2 therapy. I do think, though, that physicians could consider switching to vinorelbine/capecitabine in more highly proliferative ER-positive patients who are not responding well to TAC.  Peter Ravdin, MD, PhD: I basically agree and also think physicians should consider switching patients to TAC-NX who are not achieving a good response after 2-4 cycles of TAC. I remember when the investigators published their data about pathologic complete response, which were tremendously discouraging because they did not show an improved pathologic complete response rate by switching. Many of us assumed that it meant there was just general chemotherapy insensitivity and, therefore, few options in terms of chemotherapy modifications. Now, I am revisiting that because, in my opinion, these data convincingly show that for patients who are not headed for a good response, it makes sense to switch therapy. Of note, the investigators used ultrasound instead of a physical examination to assess whether or not patients were responding; I find it very difficult to assess response with ultrasound, particularly after only 2 cycles.
  • Early breast updates

    1. 1. Early Breast Cancer Updates
    2. 2. WhyEffect of adjuvant therapy : adjuvant hormonal with Tam. (ER +ve)• 40% decrease in risk of recurrence by 5 years.• 34% decrease in br. cancer mortality by 5 years. adjuvant polychemotherapy .• < 50 years old: 10% decrease in br. cancermortality by 15 years.• 50-69 years old: 3% decrease in risk of br.cancer mortality by 15 yearsMeta-analyses of adjuvant therapies for women with early breast cancer: the Early Breast Cancer Trialists’ Collaborative Group overview Annals of Oncology17 (Supplement 10): x59–x62, 2006.
    3. 3. Outline• Molecular Classification.• Adjuvant Chemotherapy.• Adjuvant Hormonal.• Adjuvant Targeted Therapy.• Neoadjuvant therapy.
    4. 4. Molecular Classification:• Early EBC was 2 groups only• Now we reached to more recent approachutilizing both TNM staging Plus ER/PR statusand Her2 status. Dividing EBC into 4 maingroupsNode –ve Node +veLuminal AER ++ Luminal BER +Her 2 +veTriple –veBasal likevirulent
    5. 5. Disease outcome in subgroups
    6. 6. What are the lessons we achievedfrom molecular classification• Lumina A: more benefit in hormonal and lessin chemo.• Luminal B: grey zone: chemo, hormonaland/or Her 2 blockade (Luminal B2)• Her 2 +ve: benefit from single and morerecently dual Her 2 blockade + chemo• Triple negative: the hidden mystery, rapidresponse to chemo, but still survive poor.
    7. 7. Prognostic and Predictive markers:are we there yet?• In the last decade, advances in gene expression profilingdramatically changed our understanding of genomic andtranscriptomic landscape of breast cancer, withimproved our ability to prognosticate behavior andresponse to treatment.• Traditional prognostic factors: Tumor size, Nodalstatus, Histological grade ER/PR status , Her 2 statusand age. Multiparametric tools have been developed toimprove the predictive value of those factors TNM stagingNottingham Prognostic indexAdjuvant online ( http://www.adjuvantonline.com)
    8. 8. • Prognostic multigene classifiers in routineclinical practice: among the them, the top 3 assays incurrent clinical decision making are Oncotype Dx, the 21 gene assay.Mammaprint the 70 gene signature of Van’t veer.PAM50 clinically updated version of intrinsic subtypes.→Why Oncotype Dx in EBC:• Use paraffin embaded fixed materials• Prognostic• Predictive value for the value of chemo in those of HR+ve. Her 2-ve, -ve Node• Validated in randomized trail : NSABP B14, B20
    9. 9. The Oncotype DX• 16 BREAST CANCER RELATED GENESEstrogenERPRBcl2SCUBE2ProliferationKi-67STK15SurvivinCyclin B1MYBL2HER2GRB7HER2InvasionStromelysin 3Cathepsin L2OthersCD68GSTM1BAG1• 5 REFERENCE GENESBeta-actin GAPDH RPLPO GUS TFRCPaik S, et al. N Engl J Med. 2004;351:2817-2826.
    10. 10. • The Oncotype DX Recurrence Score is correlated withdistant recurrence rate at 10 years, hormone therapybenefit, and chemotherapy benefit.▫ Low risk is up to 17▫ Intermediate risk 18-30▫ High risk > 30• Validation: a study was performed to clinically validate theprespecified 21-gene RT-PCR assay and Recurrence Scorealgorithm as a predictor of the prospectively definedprimary endpoint of distant recurrence-free survival innode-negative, estrogen receptor–positive patients treatedwith tamoxifen from the large multicenter study NSABP -B14.
    11. 11. Distant recurrence over time10-Year rate of recurrence =6.8%*95% CI: 4.0%, 9.6%0 2 4 6 8 10 12 14 160%10%20%30%40%50%60%70%80%90%100%ProportionwithoutdistantrecurrenceRS < 18, n = 338RS 18-30, n = 149RS ≥ 31, n = 181All Patients, n = 668P < 0.00110-Year rate of recurrence =14.3%95% CI: 8.3%, 20.3%10-Year rate of recurrence =30.5%*95% CI: 23.6%, 37.4%Oncotype DX Clinical Validation: NSABP B-14, Distant RecurrencePaik S, et al. N Engl J Med. 2004;351:2817-2826.
    12. 12. Oncotype DX Clinical Validation: NSABPB-20• Objective: Prospectively determine therelationship between Recurrence Score resultand chemotherapy benefit in node-negative,ER+ patientsRandomizedTam + MFTam + CMFTamPaik S, et al. J Clin Oncol. 2006;24:3726-3734.
    13. 13. absolute benefitfrom tamoxifen +chemotherapyN EventsAll patientsTamoxifen + chemotherapyTamoxifen4242273331 P = 0.02RS 18-30Tamoxifen + chemotherapyTamoxifen894594 P = 0.39RS < 18Tamoxifen + chemotherapyTamoxifen21813584 P = 0.61N EventsRS 18-30Tamoxifen + chemotherapyTamoxifen894594 P = 0.39PATIENTS WITH HIGH RS28% absolute benefit fromtamoxifen +chemotherapyRS ≥ 31Tamoxifen + chemotherapyTamoxifen117471318 P < 0.0012 4 6 8 10 12YearsProportionwithoutdistantrecurrencePaik S, et al. J Clin Oncol. 2006;24:3726-3734.
    14. 14. Adjuvant Chemotherapy
    15. 15. The Oxford OverviewEarly Breast Cancer Trialists’Collaborative Group(EBCTCG)• The most comprehensive analysis of the adjuvantsettings• 1984, 1990, 1995, 2000, 2005/6, 2010• 2010: cover more than 100,000 patients among 123randomised trails, published 2012, postulating 3questions to be answered in meta-analysis▫ Benefit of polychemotherapy Vs non.▫ Benefit of anthracycline (A) vs CMF.▫ Benefit of Taxane + (A) vs (A) alone.
    16. 16. Polychemotherapy versusNo chemotherapy10y results in 23500 women
    17. 17. • RRs were 0·69 (SE 0·04) for distant recurrence• RRs were 0·73 (SE 0·03, χ²1=70·3) for any recurrence.• RRs 0·79 (SE 0·04, χ²1=33·7) for breast cancer mortality.• the proportional effects of anthracycline based regimens onbreast cancer outcomes did not depend much on age, nodalstatus, ER status, or, if ER-positive, on endocrine therapy,age, nodal status, tumor differentiation, or ER level
    18. 18. Anthracycline regimensvsstandard CMF10y results in 22000 women
    19. 19. • Almost equal 4 AC, vs CMF.
    20. 20. • shows results from the trials with anthracycline dose per cycle atleast 60 mg/m2 doxorubicin or 90 mg/m2 epirubicin and withcumulative anthracycline dosage more than 240 mg/m2doxorubicin or 360 mg/m2 epirubicin.• RRs were 0·89 for recurrence.• RRs were 0·80 for breast cancer mortalityANTHRACYCLINEMORE
    21. 21. Taxane + Anthracycline regimens vsAnthracycline regimens5y results in 44000 women
    22. 22. • Recurrence RRs were 0.85.• Mortality RRs were 0.87.T+AVssameA5 y results
    23. 23. 5 years results• Recurrence RRs were 0.83.• Mortality RRs were 0.86.T+AVsmoreA
    24. 24. Adjuvant Hormonal
    25. 25. Estrogen and Breast CancerEstrogenCellGrowthandDivisionEstrogenReceptorSERMS, SERDSAromataseinhibitors, ovariansuppression
    26. 26. Endocrine Therapy in Breast Cancer• Selective Estrogen Receptor Modulators▫ tamoxifen▫ toremifene▫ raloxifene• Aromatase inhibitors (postmenopausal)▫ anastrozole▫ letrozole▫ exemestane• Medical or surgical oophorectomy (premenopausal)• Selective Estrogen Receptor Downregulators▫ fulvestrant• Others: Progestins, Estrogens, Androgens
    27. 27. Selective Estrogen Receptor ModulatorsEBCTCG 2000 (Oxford Overview)Tamoxifen vs. Nil: Disease-free SurvivalER Negative ER Positive5 years of adjuvanttamoxifen becamestandard in ER+ patientstamoxifennilER status matters!!5 yrs15 yrs
    28. 28. Aromatase InhibitorsAdrenal HormonesCortisol Androstenedione AldosteroneEstradiolTestosteroneEstroneAromatase inhibitors blockpost-menopausal estrogenproductionAnastrozoleLetrozoleExemestane
    29. 29. Adjuvant Aromatase InhibitorsAIs asInitial TherapyAIs After2-3 Yrs of TAMAIs After5 Years of TAMTAM X 5 YrsAI X 5 Yrs TAM X 2-3 AI X 2-3TAM X 5 YrsTAM X 5 YrsPLAC X 5 YrsAI X 5 YrsThree StrategiesSurvival benefit for AIarmATAC and BIG1-98 studiesReduction in recurrences
    30. 30. Upfront Use of Aromatase Inhibitors vs. TamoxifenATAC Trial: Anastrozole vs. TamoxifenHowell A et al, Lancet 365:60-62, 2005BIG 1-98 Trial: Letrozole vs. TamoxifenThurlimann B et al, NEJM 353: 2747-57, 200568 months follow-up:17% relative reduction in events for A vs T(3% absolute difference)26 months follow-up:19% relative reduction in events for L vs. T(3% absolute difference)
    31. 31. Extended Adjuvant Hormonal Therapy TrialsMA17 Trial: Letrozole vs. Placebo After Completing 5Years of TamoxifenGoss P et al, J Natl Cancer Inst 97: 1262-71, 200530 months of follow-up:42% decrease in breast cancer eventsNode positive patients show statistically significantimprovement in survival
    32. 32. Letrozole +Zoledronic Acid 4 mgq6mLetrozole + Delayed*Zoledronic Acid 4 mgq6mStage I-IIIa breast cancer Postmenopausal oramenorrheic due tocancer treatment ER+ and/or PgR+ T-score ≥ -2 SD N = 1065Treatment duration 5 yrsDe Boer R, et al. SABCS 2011. Abstract S1-3.ZO-FAST: 5-Yr Final AnalysisTreatment duration 5 yrs
    33. 33. ZO-FAST: Conclusions• Immediate initiation of ZOL at start of letrozolesignificantly prolonged DFS vs delayed initiationof ZOL in postmenopausal women withendocrine-responsive EBC▫ Continued to improve BMD after 5 yrs of follow-up▫ 34% improvement in DFS
    34. 34. Adjuvant TargetedTherapy
    35. 35. 37HER-2 as a Target for Therapycell divisionHER-2nucleuscancer cellTrastuzumab (Herceptin)Anti-HER-2 AntibodyHER-2 Oncogene: amplified andoverexpressed in 20-25% of breastcancerLapatinib (Tykerb)Dual HER-1/HER-2Tyrosine Kinase Inhibitor
    36. 36. Adjuvant trastuzumab trials: >13,000 patientsNCCTG N9831 (USA)HERA (ex-USA) BCIRG 006 (global)NSABP B-31 (USA)Piccart-Gebhart et al 2005;Romond et al 2005;Slamon et al 2006IHC orFISH(n=5090)2 years HerceptinObservationStandardchemotherapy1 year HerceptinIHC orFISH(n=2030)Herceptin 1 yearIHC orFISH(n=3505)Herceptin 1 yearFISH(n=3222)Herceptin 1 yearIHC orFISH(n=5090)Docetaxel Docetaxel + carboplatin Doxorubicin + cyclophosphamide PaclitaxelFISH(n=3222)IHC orFISH(n=3505)IHC orFISH(n=2030)Herceptin1 yrHerceptin1 yrHerceptin1 yrHerceptin1 yrHerceptin2 yrObservation
    37. 37. aBased on small subgroups of patients with HER2-positivebreast cancer; brelapse-free survival; V, vinorelbineCEF, cyclophosphamide, epirubicin, 5-fluorouracilDFS benefit across 5 out of 6 trials4234Joensuu et al 2006; Slamon et al 2006Perez et al 2007; Smith et al 2007Spielmann et al 200733Median follow-up, years0 1 2FavoursHerceptinFavours noHerceptinHRDFS benefitB-31 / N9831 ACPHHERA CTxH 1 yearFinHera VH / DHCEFbPACS-04a CTxH 1 yearBCIRG 006 ACDHBCIRG 006 DCarboH
    38. 38. 0 1 2FavoursHerceptinFavours noHerceptinHRAdjuvant Trastuzumab trials: proven OS benefitB-31 / N9831 ACPHBCIRG 006 ACDHHERA H 1 yearBCIRG 006 DCarboHFinHer VH / DHa432Median follow-up,years3Joensuu et al 2006; Perez et al 2007;Slamon et al 2006; Smith et al 20063
    39. 39. Cumulative incidence of cardiac events: N9831/NSABPB31 updated analysis• Longer follow-up showed no additional concerns regarding thecardiac safety profile Cardiac events occurred early No evidence of increased toxicity or late toxicity• In NSABP B 31 the following factors were shown to be predictive forCHF: Age (p=0.03) Hypertensive medications (p=0.02) Baseline LVEF (p=0.0003)• The incidence of cardiac events reach a plateau at around 1 year• Cardiac effects of trastuzumab were largely reversiblePerez et al Abs 512 ASCO 2007Perez et al Abs 512 ASCO 2007
    40. 40. Slamon et al 2006Rastogi et al 2007Suter et al 2007Perez et al 2008Incidence of trastuzumab-relatedcardiac events in EBC trials3.0NRNR18.08.6AsymptomaticLVEF decline, %aH 1 yearACPHACPHACDHDCarboHArmHERANSABP B-31NCCTG N9831BCIRG 0061,6789475701,0681,056nSevere CHF,%0.63.8cum (5 yr)3.3cum (3 yr)1.90.4Cardiacdeath, n00000
    41. 41. Surgery& ChemoCompleteRandomizeTrastuzumab 1Lapatinib 2Lapatinib + Trastuzumab 4Lapatinib 3TrastuzumabTaxaneTaxaneTaxaneTaxaneWashout52 WeeksAll Patients: Radiotherapy, if indicatedHormone receptor-positive patients:Endocrine therapy for at least 5 yrs34 Weeks6 Weeks12 WeeksConsent &Send Blocks forCentral Path Review
    42. 42. Neoadjuvant Therapy
    43. 43. Goals of Neoadjuvant Theapy in Early Breast Cancer• Make tumours more operable, increase the rate of breast conservingsurgeries• Improve prognosis of certain disease subtypes (i.e. HER2+)• Have a better idea of prognosis based on response to neoadjuvanttreatment• Allow patients to start treatment earlier• Reduce the extent of surgery required in breast and axilla• Improve DFS and OS using pathological response rate for selectionof subsequent treatment in individual patients
    44. 44. Definition of pCR Different definition of pCR are in use:- Absence of invasive cancer in the breast- Absence of invasive cancer in the breast and in the axillarylymph nodes.- Absence of invasive and in situ cancer cells in the breast andin the axillary nodes There is high degree of concordance between thedifferent definition With very definition pCR identifies cases withfavorable diseaseMarchiò C. & Sapino A. JNCI Monogr 2011;43:86–90
    45. 45. There was no significant difference in overall survival (OS) betweenthe treatment arms (data not shown).Pathologic complete response, which was doubled by addition of preoperative T, was asignificant predictor of OS regardless of treatment (HR 0.33; P .0001).Bear HD, et al. J ClinOncol. 2006;24(13):2019-2027.Disease free-survivalOverall SurvivalpCR to Neoadjuvant Chemotherapy is correlatedwith improved DFS & OS (NSABP B-27)
    46. 46. Intrinsic sub-types have different prognosis anddifferent response to Neoadjuvant therapy.
    47. 47. Impact of treatment characteristicson the pCRUntch M. et al J Nat Cancer Inst Monogr 2011.
    48. 48. Pre and Post-operative Chemotherapyplus Trastuzumab Improve DSF
    49. 49. Women withoperable or locallyadvancedbreast cancer(N = 2072)TAC-NX*(4 cycles NX)(n = 301)TAC x 6(4 additional cycles TAC)(n = 321)TAC x 6(4 additional cycles TAC)(n = 704)TAC x 8(6 additional cycles TAC)(n = 686)TAC*(2 cycles)Assessresponse†Minimalresponse‡(n = 622)CR or PR(n = 1390)*TAC regimen: docetaxel 75 mg/m2, doxorubicin 50mg/m2, cyclophosphamide 500 mg/m2 all on Day 1 q21d.NX regimen: vinorelbine 25 mg/m2 on Days 1 and 8,capecitabine 1000 mg/m2 on Days 1-14 q21d.†Response assessed by ultrasound/palpation.‡< 50% tumor reduction.Von Minckwitz G, et al. SABCS 2011. Abstract S3-2.GeparTrio Trial: Study DesignNot working?Try another typeof chemotherapyWorking?Give more of the samechemotherapy
    50. 50. GeparTrio Trial: DFS and OS• Median follow-up: 62 mos• DFS benefit in early responding and nonresponding patients whoreceived response-guided vs conventional chemotherapyVon Minckwitz G, et al. SABCS 2011. Abstract S3-2.Endpoint HR for Response-Guided vsConventional Chemotherapy (95% CI)P ValueDFS 0.71 (0.60-0.85) < .001OS 0.79 (0.63-0.99) .048PatientSubgroupTreatmentComparisonHR for DFS(95% CI)P ValueResponders TAC x 8 vs TAC x 6 0.78 (0.62-0.97) .026Nonresponders TAC-NX vs TAC x 6 0.59 (0.49-0.82) .001
    51. 51. GeparTrio Trial: DFS by Patient SubgroupResponse-guided treatments better Conventional treatments better0.2 0.4 0.6 0.8 1.0 1.2 1.4SubgroupOverallAge (yrs)<40≥ 40cT-stagecT1-3cT4cT-size< 40 mm≥ 40 mmcN statusNegativePositiveHistological typeDuctal or otherLobularGrade1 or 23Hormone receptor statusNegativePositiveHER2 statusNegativePositiveBreast cancer phenotypeLuminal ALuminal B (HER2-)Luminal B (HER2+)HER2+ (nonluminal)Triple negativeN patients2012353165917372677751212894NR1571270117672571712951145486572211281178362Test forInteraction0.670.660.220.190.710.250.0080.540.12-0.01HR (95% CI)0.74 (0.60-0.85)0.66 (0.42-1.03)0.73 (0.60-0.88)0.70 (0.56-0.85)0.79 (0.54-1.17)0.62 (0.44-0.85)0.79 (0.63-0.98)0.84 (0.61-1.14)0.66 (0.53-0.82)0.73 (0.60-0.88)0.61 (0.37-1.03)0.79 (0.61-1.01)0.65 (0.49-0.85)0.94 (0.73-1.22)0.56 (0.44-0.73)0.63 (0.49-0.81)0.72 (0.51-1.04)0.55 (0.37-0.82)0.40 (0.20-0.79)0.56 (0.33-0.96)1.01 (0.61-1.67)0.87 (0.61-1.25)Von Minckwitz G, et al. SABCS 2011. Abstract S3-2.
    52. 52. GeparTrio Trial: pCR by Breast Cancer SubtypeVon Minckwitz G, et al. SABCS 2011. Abstract S3-2.pCR(%)4035302520151050Luminal A(n = 572)Luminal B(HER2-)(n = 211)Luminal B(HER2+)(n = 281)HER2+(Nonluminal)(n = 178)Triple Negative(n = 362)
    53. 53. GeparTrio Trial: Conclusions• Adapting neoadjuvant chemotherapy based onearly response significantly improved DFS andOS vs conventional chemotherapy• Response-guided chemotherapy most effectivein patients with luminal A or luminal B tumors▫ Low pCR rates in these tumors▫ pCR not prognostic• No DFS benefit with response-guidedchemotherapy in patients with HER2-positive ortriple-negative tumorsVon Minckwitz G, et al. SABCS 2011. Abstract S3-2.
    54. 54. Baselga J et al. Lancet 2012
    55. 55. • pCR rate was significantly higher in the group given lapatinib and trastuzumab (78of 152 patients [51·3%; 95% CI 43·1—59·5]) than in the group given trastuzumabalone (44 of 149 patients [29·5%; 22·4—37·5]; difference 21·1%, 9·1—34·2,p=0·0001).•no significant difference in pCR between the lapatinib (38 of 154 patients [24·7%,18·1—32·3]) and the trastuzumab (difference −4·8%, −17·6 to 8·2, p=0·34) groups.Baselga J et al. Lancet 2012