The study evaluated dual HER2 blockade with lapatinib plus trastuzumab plus an aromatase inhibitor compared to trastuzumab plus an aromatase inhibitor or lapatinib plus an aromatase inhibitor in patients with HER2-positive, hormone receptor-positive metastatic breast cancer. 355 patients were randomly assigned to one of the three treatment arms. The results showed that progression-free survival was significantly longer in the lapatinib plus trastuzumab plus aromatase inhibitor arm compared to the trastuzumab plus aromatase inhibitor arm, with overall response and clinical benefit rates also being higher. Overall survival data were immature but trended in favor of the lapatinib plus trastuzumab arm. The most common
Tried to summarise all landmark trials in carcinoma breast in radiation oncology,medical oncology as well in surgical oncology.
References taken from Devita Book,Breast Disease book from Springer,journals like NEJM,JAMA,LANCET,ANNL ONCOLOGY etc,internet,Perez book,Practical Clinical Oncology by Hanna etc textbooks.
Thanks.
Tried to summarise all landmark trials in carcinoma breast in radiation oncology,medical oncology as well in surgical oncology.
References taken from Devita Book,Breast Disease book from Springer,journals like NEJM,JAMA,LANCET,ANNL ONCOLOGY etc,internet,Perez book,Practical Clinical Oncology by Hanna etc textbooks.
Thanks.
Oncologist briefing given by Dr. Castel as Principal Investigator of the Breast Cancer Adjuvant Therapy prospective longitudinal study (NCT00954564) to communicate interim results and help oncologists identify and refer eligible breast cancer patients into the longitudinal cohort study. The goal of this presentation was to help achieve study enrollment targets.
The Trial Assigning IndividuaLized Options for Treatment (Rx) -TAILORx,TAILORx clinical trial showed that most women with hormone receptor (HR)–positive, HER2-negative, axillary node–negative early-stage breast cancer and a mid-range score on a 21-tumor gene expression assay (Oncotype DX® Breast Recurrence Score) do not need chemotherapy after surgery
Dr. Stephanie Blank and Dr. Melissa Frey update us on the latest developments in ovarian cancer research and treatment from the annual conference of the Society of Gynecologic Oncology. Dr. Blank is a gynecologic oncologist at Perlmutter Cancer Center at NYU Langone Medical Center and an associate professor at NYU School of Medicine. Dr. Frey is a Gynecological Oncology Fellow at NYU Langone Medical Center.
Dr. Maurie Markman, President of Science and Medicine at Cancer Treatment Centers of America, shares his expertise on the latest developments in immunotherapy for ovarian cancer.
Robert P. Edwards, MD, Chair of OB/GYN/RS, Co-Director of Women's Cancer Program at University of Pittsburgh, offers information about the current state of immunotherapy for recurrent ovarian cancer patients.
Topic-Driven Round Table on Low Grade Serous Ovarian Cancerbkling
A discussion about low grade serous ovarian cancer with Dr. Amanda Nickles Fader, Director of Kelly Gynecologic Oncology Service, Johns Hopkins Hospital. This type of ovarian cancer behaves differently and is treated differently than other ovarian cancers. Join the conversation to learn more and ask an expert your questions.
Oncologist briefing given by Dr. Castel as Principal Investigator of the Breast Cancer Adjuvant Therapy prospective longitudinal study (NCT00954564) to communicate interim results and help oncologists identify and refer eligible breast cancer patients into the longitudinal cohort study. The goal of this presentation was to help achieve study enrollment targets.
The Trial Assigning IndividuaLized Options for Treatment (Rx) -TAILORx,TAILORx clinical trial showed that most women with hormone receptor (HR)–positive, HER2-negative, axillary node–negative early-stage breast cancer and a mid-range score on a 21-tumor gene expression assay (Oncotype DX® Breast Recurrence Score) do not need chemotherapy after surgery
Dr. Stephanie Blank and Dr. Melissa Frey update us on the latest developments in ovarian cancer research and treatment from the annual conference of the Society of Gynecologic Oncology. Dr. Blank is a gynecologic oncologist at Perlmutter Cancer Center at NYU Langone Medical Center and an associate professor at NYU School of Medicine. Dr. Frey is a Gynecological Oncology Fellow at NYU Langone Medical Center.
Dr. Maurie Markman, President of Science and Medicine at Cancer Treatment Centers of America, shares his expertise on the latest developments in immunotherapy for ovarian cancer.
Robert P. Edwards, MD, Chair of OB/GYN/RS, Co-Director of Women's Cancer Program at University of Pittsburgh, offers information about the current state of immunotherapy for recurrent ovarian cancer patients.
Topic-Driven Round Table on Low Grade Serous Ovarian Cancerbkling
A discussion about low grade serous ovarian cancer with Dr. Amanda Nickles Fader, Director of Kelly Gynecologic Oncology Service, Johns Hopkins Hospital. This type of ovarian cancer behaves differently and is treated differently than other ovarian cancers. Join the conversation to learn more and ask an expert your questions.
Metastatic breast cancer, specifically HER2-positive subtype, represents an advanced stage of breast cancer characterized by the presence of human epidermal growth factor receptor 2 (HER2) overexpression. HER2-positive breast cancer tends to be more aggressive, but advancements in treatment options have significantly improved outcomes.
Targeted therapies play a crucial role in managing metastatic HER2-positive breast cancer. Trastuzumab (Herceptin) and pertuzumab are monoclonal antibodies that specifically target the HER2 protein, inhibiting its activity and impeding cancer cell growth. These drugs are often used in combination with chemotherapy to enhance their effectiveness.
In addition to trastuzumab and pertuzumab, other HER2-targeted therapies such as ado-trastuzumab emtansine (Kadcyla) and lapatinib may be employed in certain cases. Ado-trastuzumab emtansine is an antibody-drug conjugate that delivers chemotherapy directly to HER2-positive cancer cells, minimizing damage to healthy cells. Lapatinib, on the other hand, is a small molecule inhibitor that blocks HER2 and other related receptors.
Given the chronic nature of metastatic breast cancer, treatment plans are often individualized based on the patient's overall health, specific characteristics of the cancer, and prior treatments. Hormone therapy may also be considered if the cancer is hormone receptor-positive. Clinical trials and ongoing research continue to explore novel treatment options, providing hope for further advancements in managing HER2-positive metastatic breast cancer. Patients are encouraged to work closely with their healthcare team to determine the most appropriate and effective treatment plan tailored to their unique circumstances.
Breast cancer is the commonest cancer and leading cause of cancer death in women. Triple negative breast cancers are ER, PR and Her 2 Neu negative. These tumors have high propensity for metastatic spread. The lack of expression of ER, PR and Her 2 Neu receptors makes chemotherapy only option available to treat these aggressive tumors.
Breast Cancer is the commonest cancer and leading cause of cancer death in women. In the year 2012 approximately 1,671,149
new patients were diagnosed with breast cancer and 521,907
deaths were attributed to this menace [1]. According to SEER
Cancer Registry 95% of the patients have localized disease at
initial presentation whereas 5% of patients present with metastatic disease [2]. About 20-30% of early stage patients develop
systemic disease at some point in life [3]. In Pakistan every year
approximately 90,000 women are diagnosed with breast cancer
and most of these patients have either locally advanced or metastatic disease [4]. A study conducted by Gilani et al. [5] showed
that 25-36% of Pakistani women present with disseminated disease.
Analyzing ASCO 2016: Developments, takeaways, and implications from the confe...Pharma Intelligence
In conjunction with a Key Opinion Leader, Dr. Peter Lee MD Chair, Department of Immuno-Oncology at City of Hope Comprehensive Cancer Center, CA, several Informa analysts discuss the major developments of the conference and key take-aways via a Webinar.
Watch our recording of Biomedtracker's Robert Jeng, Ph,D., Citeline's Allison Bruce, Scrip's Mary Jo Laffler, and Datamonitor Healthcare's Zachary McLellan as they download and debrief following the always-exciting ASCO weekend.
View and listen to the full webinar here https://www.youtube.com/watch?v=7yMsCb3R5X8
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Journal alternative
1. Phase III, Randomized Study of Dual Human
Epidermal Growth Factor Receptor 2 (HER2)
Blockade With Lapatinib Plus Trastuzumab in
Combination With an Aromatase Inhibitor in
Postmenopausal Women With HER2-Positive,
Hormone Receptor–Positive Metastatic Breast Cancer:
Updated Results of ALTERNATIVE
2. Metastatic Breast Cancer (MBC)
Landscape
HER2+
Triple negative
~15%
• Dawood S, et al. Survival differences among women with de novo stage IV and relapsed breast cancer. Ann Oncol. 2010
Nov;21(11):2169-74.
• Howlader N, et al. US incidence of breast cancer subtypes defined by joint hormone receptor and HER2 status. J Natl Cancer Inst.
2014 Apr 28;106(5). pii: dju055.
Women
living with MBC
HR+
HR+/HER
2-
~61%
HR+/HER
2+
~15%
HR-
/HER2+
~9%
Roughly 30% of women who
have had early disease will
develop advanced or
metastatic disease
6% to 10% of all women with
breast cancer present with
metastatic disease at the
time of initial diagnosis3
(20-25%)
3. Endocrine therapy alone or in combination with HER2- targeted
therapy is a less toxic approach compared with HER2-targeted
therapy combined .
But due to aggressive nature of this subgroup --patients with HER2-
positive metastatic breast cancer (MBC) are usually treated with
chemotherapy-based regimens irrespective of HR status.
However, not all patients with HER2-positive/HR-positive MBC
may need or tolerate chemotherapy, and these patients could be
candidates for anti-HER2 therapies plus ET.
Her2-targeted therapy plus chemotherapy
Endocrine therapy alone +/- with her2-targeted therapy
7. Resistance:
• Preclinical evidence suggests that cross talk between HER2- and HR-
signaling pathways contributes to endocrine resistance.
8. • Furthermore, in HER2-positive and estrogen receptor (ER)–positive BC
cells, either HER2 or ER can function as the major promoter of survival.
• With effective HER2 inhibition in these cells, ER can become the primary
driver of proliferation, resulting in relative resistance to anti-HER2
therapy.
• Therefore, co-targeting HER2 and ER simultaneously may be essential
for obtaining optimal benefit in patients with HER2-positive/HR-positive
MBC.
10. TAnDEM (Trastuzumab and Anastrozole Directed Against
ER-Positive HER2-Positive Mammary Carcinoma )
Improved PFS from 4.8m to 2.4m(hazard ratio = 0.63; 95% CI, 0.47 to 0.84; log-
rank P = .0016).
In patients with centrally confirmed hormone receptor positivity (n = 150), median
PFS was 5.6 and 3.8 months in the trastuzumab plus anastrozole and anastrozole
alone arms, respectively (log-rank P = .006).
Overall survival showed no statistically significant difference.
11.
12. Median PFS in the HER2+ population was significantly increased
from 3.0 months in the letrozole group to 8.2 months in the
lapatinibletrozole group [Hazard Ratio (95% CI)=0.71(0.53,0.96),
stratified log rank p=0.019].
Overall response rate (ORR) in the HER2+ population was
significantly increased from 14.8% to 37.9% in the combination group
[Odds Ratio = 0.4 (0.2, 0.9), p=0.021], with a clinical benefit rate
(CBR) improvement from 28.7% to 48.7% [Odds Ratio = 0.4
(0.2,0.8), p=0.003].
There was no difference in ORR or CBR in the HER2 negative
population
13. Dual Her2 Blockade
The use of dual anti-HER2 blockade represents a potential strategy
to further improve the outcome for these patients.
preclinical models of her2-positive BC have shown that a
combination of TRAS and lap results in a more optimal anticancer
effect.
Dual targeting of HER2-positive tumors with TRAS and LAP is
beneficial because of differing mechanisms of action and because of
the well-characterized synergistic interaction between them in
HER2 BC models.
In the clinic ,dual Her2 blockade has shown to improve outcomes in
both the neoadjuvant and the metastatic setting compared with
single HER2 blockade
14.
15. EGF104900 Study
Combination resulted in :
An improvement in PFS (median, 11 versus 8 weeks; HR 0.74, 95% CI
0.58-0.94)
An improvement in OS (median, 14 versus 10 months; HR 0.74, 95%
CI 0.57-0.97)
16. Therefore, the current study (EGF114299) was designed to evaluate
whether dual HER2 blockade with LAP and TRAS plus aromatase
inhibitor (AI), without chemotherapy, improves outcomes compared
with TRAS plus AI in patients with HER2-positive/HR-positive
MBC who experienced disease progression after prior
neo(adjuvant)/first-line TRAS plus chemotherapy.
The study also included a third arm of LAP plus AI to explore
whether this combination results in different outcomes compared
with the other 2 arms.
17.
18. On July 30, 2018, during Food and Drug Administration (FDA) review of the primary
analysis study report, the FDA identified :
Programming error in the calculation of the hazard ratio and P value estimates of
the secondary end points of PFS and OS for LAP plus aromatase inhibitor (AI)
versus TRAS plus AIs. This error did not affect the hazard ratios for PFS and OS
for the primary end point of comparison and therefore, the interpretation of the
main objective of the study remained unchanged.
Summary of the best overall response (BOR) categories. The sum of the individual
patients in each response category (complete response [CR], partial response [PR],
stable disease [SD], progressive disease [PD], and not evaluable [NE]) did not add
up to the number of patients in the intent to-treat population because some NE
patients (ie, those with no baseline and/or postbaseline tumor assessments) were
missed as being NE.
The response assessment date was mapped incorrectly using the visit date instead
of the tumor scan date, which led to incorrect derivation of time-to-event efficacy
end points.
19.
20. MATERIALS & METHODS
Study Design :
Phase III
Open-label study
Eligible patients were randomly assigned (1:1:1) to
receive either LAP plus TRAS or TRAS or LAP, plus an
AI, hereafter referred to as the LAP plus TRAS plus AI,
TRAS plus AI, and LAP plus AI treatment arms,
respectively
21. LAP + TRAS + AI arm ----- LAP dose –1000mg/day
LAP + AI arm ------ LAP dose – 1500mg/day
TRAS was administered intravenously at a loading dose of 8 mg/kg,
followed by the maintenance dose of 6 mg/kg intravenously every 3
weeks in both TRAS arms.
Investigator’s choice of oral AIs was given among letrozole ,
anastrozole, exemestane.
It was highly recommended that patients receiving LAP initiate a
prescription of loperamide treatment at the onset of diarrhea.
22. Inclusion Criteria :
Postmenopausal women >18 years of age
Histologically or cytologically confirmed HR-positive, HER2- positive
MBC as determined in a local laboratory.
Prior treatment with ET and disease progression during or after a prior
regimen containing TRAS plus chemotherapy in the neo(adjuvant)
setting and/or in the first-line metastatic setting was required (maximum
of 1 prior regimen in the metastatic setting).
ECOG performance status 0 or 1.
Good baseline organ function-hematologic, hepatic, and renal
No active or history of cardiac disease were included.
23. Objectives :
Primary:
To evaluate the superiority of progression-free survival
(PFS; radiologic progression only as per investigator
assessment or death) with LAP plus TRAS plus AI
versus TRAS plus AI using RECIST version 1.1.
Non radiologic response was based on clinical signs and
symptoms.
PFS and response rate were based on radiologic
assessment only.
24. Secondary objectives
PFS in defined subgroups
Overall response rate (ORR)
Clinical benefit rate (CBR; either complete response or
partial response or stable disease for at least 6 months)
Duration of response
Overall survival (OS)
Safety
Change in QOL status from baseline
25.
26. Procedure
Tumor samples were collected and retrospectively analyzed for
confirmation of HR and Her 2 status according to ASCO–College of
American Pathologists clinical practice guidelines.
Tumor assessments were performed at baseline, within 28 days of
random assignment, and every 12 weeks thereafter until disease
progression or discontinuation of the study treatment, and at the end
of the study.
Efficacy assessments were performed locally using radiologic
scans, including computed tomography or magnetic resonance
imaging. Safety was monitored throughout the study
27. The severity of adverse events (AEs) was graded according to the
National Cancer Institute Common Terminology Criteria for
Adverse Events version 4.0.
Left ventricular ejection fraction (LVEF) was evaluated every 12
weeks using echocardiogram and/or multigated acquisition scan.
Patient-reported health-related QoL outcomes were evaluated using
the Functional Assessment of Cancer Therapy- Breast questionnaire
28. Statistical Analyses :
A minimum of 121 PFS events in the LAP plus TRAS plus AI and
TRAS plus AI treatment arms was required to achieve 80% power
(2-sided a 5 0.05) to detect a 67% increase (hazard ratio, 0.60) in
mPFS (from an estimated 7 months in the TRAS plus AI arm to
11.7 months in the LAP plus TRAS plus AI arm).
The intent-to-treat population, comprising all randomly assigned
patients, was used for efficacy analyses.
PFS and OS across treatment arms were estimated using the
Kaplan-Meier method .
Comparison of PFS for the primary end point was per- formed using
a 2-sided stratified log-rank test (using baseline stratification
factors).
29. The Pike estimator was used to estimate the hazard ratio, together
with the 95% CI.
Two sensitivity analyses for PFS were performed, in which
nonradiologic progressions and receipt of a subsequent anticancer
therapy were treated as events.
The effect of prespecified baseline prognostic factors (including
measurable disease, type of AI, and prior TRAS usage) on PFS was
determined using a predefined stepwise Cox regression model.
A stratified Fisher’s exact test was used for ORR comparison
between treatment arms.
31. Study enrolment till March 11, 2016
355 patients were enrolled across 112 sites in 29 countries.
Two thirds of the patients had received a prior TRAS
chemotherapy–containing regimen in the neo(adjuvant)
setting only, and one third in the metastatic setting (with or
without prior TRAS in the neo[adjuvant] setting.
Prior ET included tamoxifen (55%), ANA(29%), LET (28%),
and EXE (8%).
32. In the LAP plus TRAS plus AI, TRAS plus AI, and LAP plus AI
arms, 68%, 57%, and 65% of patients, respectively, received study
treatment in the first-line metastatic setting, and 32%, 41%, and
35% of patients, respectively, in the second-line setting (or later).
EXE (47%) was the most common AI received by patients in the
study, followed by LET (42%) and ANA (11%).
Prior therapy in the metastatic setting included fulvestrant (n=2),
PTZ (n=17), and T-DM1 (n=1).
33.
34.
35.
36. The overall median duration of treatment across all
treatment arms was 53.6 weeks.
The median duration of LAP treatment was 35.8 weeks
in the LAP plus TRAS plus AI arm and 24.7 weeks in
the LAP plus AI arm.
The median duration of TRAS treatment was 36 weeks
in the LAP plus TRAS plus AI arm and 18 weeks in the
TRAS plus AI arm.
38. A similar magnitude of benefit favoring the LAP plus TRAS plus AI
arm was observed in the following 2 sensitivity analyses of PFS:
(1) Not censoring patients receiving alternative anticancer therapies
before a PFS event (hazard ratio, 0.65 [95% ci, 0.47 to 0.91])
(2) Inclusion of nonradiologic progressions (1 and 2 additional events,
respectively) as events (hazard ratio, 0.64 [95% CI, 0.46 to 0.89] .
A consistent PFS benefit with LAP plus TRAS plus AI was observed in
predefined subgroups: patients with measurable disease, patients treated
with AIs (steroidal/nonsteroidal), and patients who had already received
TRAS in a neo(adjuvant) or metastatic setting
39.
40. Cox regression analysis including all factors that had a significant
effect on PFS in addition to treatment showed that the PFS benefit
with LAP plus TRAS plus AI was consistent with the primary
analysis (hazard ratio, 0.56 [95% CI, 0.396 to 0.796]).
A consistent PFS benefit with LAP plus TRAS plus AI was
observed in the centrally confirmed HER2-positive subpopulation
(by FISH or IHC: hazard ratio, 0.63 [95% CI, 0.40 to 1.01], and by
FISH only: hazard ratio, 0.57 [95% CI, 0.35 to 0.94]).
Similarly, in the centrally confirmed HER2-positive/HR-positive
subpopulation, the benefit of LAP plus TRAS plus AI was
confirmed (hazard ratio, 0.72 [95% CI, 0.43 to 1.23]).
41. Overall Response Rate
The ORR with LAP plus TRAS plus AI, TRAS plus AI, and LAP
plus AI was 31.7%, 13.7%, and 18.6%, respectively
42. Duration of Response
The median duration of response was 14.0
months, 8.4 months, and 11.1 months,
respectively.
The Clinical Benefit Rate was 40%, 30%, and
34%, respectively.
43. Overall Survival :
OS data for LAP plus TRAS plus AI versus TRAS plus AI were
immature at the time of the current analysis (median OS, 46.0 v 40.0
months; hazard ratio, 0.60 [95% CI, 0.35 to 1.04] but trended in favor
of the LAP plus TRAS plus AI versus the TRAS plus AI arm, in line
with the primary PFS analysis.
45. The incidence of serious adverse events (SAEs) irrespective of
causality the LAP plus TRAS plus AI, TRAS plus AI, and LAP plus
AI arms was 14%, 10%, and 17%, respectively, and treatment-
related SAEs were 5%, 2%, and 4%, respectively.
On-treatment deaths were reported in 3 (3%), 5 (4%), and 6 patients
(5%), respectively.
All deaths were a result of disease progression, with the exception
of 1 death as a result of cardiogenic shock and 1 death as a result of
organ failure in the LAP plus AI arm and 1 death as a result of
cardiopulmonary arrest in the TRAS plus AI arm.
46. Cardiac events :
One, 3, and 2 patients in the LAP plus TRAS plus AI,
TRAS plus AI, and LAP plus AI arms, respectively,
discontinued treatment as the result of LVEF
decrease/cardiogenic shock.
LAP+ T + AI T + AI LAP + AI
Cardiac safety events 7% 3% 2%
Any decrease in LVEF 59% 65% 65%
>20% decrease in LVEF 3% 2% 0%
Less than lower limit of
normal
5% 1% 4%
47. Treatment discontinuation
Overall, the incidence of AEs leading to discontinuation of study
treatment was low (3% for LAP plus TRAS plus AI [n=4];
6%forTRAS plus AI [n=7]; and 9% for LAP plus AI [n=11]).
The most frequent AE leading to discontinuation was transaminases
increase (n=8), which occurred in the LAP plus AI arm in which the
dose of LAP was the highest.
LAP dose reduction was observed in 20% of patients in the LAP
plus TRAS plus AI arm and in 17% of patients in the LAP plus AI
arm; the primary reasons for reduction were AEs (71% and 37%,
respectively) and patient noncompliance (25% and 63%,
respectively).
48. Dose interruptions of LAP in the LAP plus TRAS plus AI and the
LAP plus AI arms were required in 38% and 35% of patients,
respectively, mainly because of AEs (51% and 50%, respectively).
In the LAP plus TRAS plus AI and TRAS plus AI arms, dose delays
of TRAS were recorded in 19% and 9%, respectively; the main
reasons for the delays were AEs (38% and 15%, respectively) and
noncompliance (28% and 15%, respectively).
49. Treatment discontinuation was reported in 75%, 82%, and 84% of
patients in the LAP plus TRAS plus AI, TRAS plus AI, and LAP
plus AI arms, respectively.
The most common reasons for discontinuation in the LAP plus
TRAS plus AI, TRAS plus AI, and LAP plus AI arms were disease
progression (64%, 72%, and 70%, respectively) and AEs (4%, 6%,
and 9%, respectively).
51. This is the first large, randomized clinical trial
exclusively evaluating this chemotherapy-sparing
regimen in a HER2-positive/HR-positive MBC
population of patients who had already received prior
ET and prior TRAS plus chemotherapy in the
neo(adjuvant) and/or first- line metastatic setting
52. It demonstrated that the combination of LAP plus TRAS plus AI
provided a clinically meaningful prolongation of PFS compared with
TRAS plus AI (mPFS, 11.0 v 5.6 months, respectively), representing a
statistically significant 38% reduction in the risk of disease
progression (hazard ratio, 0.62).
The PFS benefit was observed consistently in various subgroups of
patients. Furthermore, the ORR (31.7% v 13.7%) and CBR (40% v
30%) favored the LAP plus TRAS plus AI combination.
Although survival data were immature, there was also a trend in favor
of the dual-blockade treatment (median, 46.0 versus 40.0 months).
53. The PFS outcome observed with LAP plus TRAS plus AI in
ALTERNATIVE is in line with the results of various chemotherapy
plus single HER2 blockade regimens in patients with HER2-
positive MBC (including both HR-positive and HR-negative
patients) treated previously with TRAS and ET.
Trials specifically designed for patients with HER2-positive/HR-
positive MBC evaluating chemotherapy plus single blockade are
limited.
55. PERTAIN
However, this trial was conducted only in the first-line metastatic setting,
and approximately 77% of patients were TRAS naıve and 55% of patients
had received induction chemotherapy.
58. Invasive disease–free survival rates were 90.6% for pertuzumab vs
87.8% for placebo in the intent-to-treat population.
Node-positive patients had clear benefit from the addition of
pertuzumab, with an absolute 4.5% improvement in 6-year invasive
disease–free survival: 87.9% with pertuzumab vs 83.4% with
placebo.
No treatment effect was observed in the node-negative population in
the two arms: 95% and 94.9%, respectively.
59. This discrepancy may be the result, at least in part, of
the excellent outcome with adjuvant single HER2
blockade with TRAS, making the demonstration of
additional benefit with dual blockade challenging.
Dual HER2 blockade may benefit only a small subset of
high-risk patients.
60. ALTERNATIVE included a third arm investigating LAP plus AI,
which was a mandated study design after the EGF30008 study and
the approval of LAP plus LET.
The median PFS in the LAP plus AI arm was 8.3 months, which
was not statistically different compared with 5.6 months with TRAS
plus AI in patients with HER2-positive/HR- positive MBC
previously treated with TRAS plus ET.
This finding is consistent with the findings of other randomized
trials in BC that compared LAP- and TRAS-containing regimens.
61. The safety profile of the 3 treatment arms was consistent with the
known safety profile of LAP and TRAS.
The frequency of AEs, mostly grade 1 or 2, was higher in the 2 LAP
arms (92% each) than in the TRAS arm (74%).
Diarrhea, rash, paronychia, and nausea were among the most
frequent AEs.
However, the frequency of grade 3 or 4 AEs and SAEs was similar
in the 3 arms, with the exception of grade 3 diarrhea, which was
higher in the LAP plus TRAS plus AI arm (13%).
62. CONCLUSION
The PFS benefit obtained with LAP plus TRAS plus AI in patients with
HER2-positive, HR-positive MBC who had been treated previously with
TRAS and ET is clinically meaningful and robust.
The ALTERNATIVE trial showed relevant clinical benefit with a relatively
good tolerability, supporting the finding that patients with HER2-
positive/HR-positive MBC who are not candidates for chemotherapy can be
adequately treated with dual HER2 blockade (LAP plus TRAS) plus an AI.
This combination can potentially offer an effective and well-tolerated,
chemotherapy-sparing alternative treatment regimen for patients for whom
chemotherapy is not intended.
Editor's Notes
Human epidermal growth factor receptor 2 (HER2)– positive breast cancer (BC) constitutes approximately 20% to 25% of BC and is associated with poor prognosis and survival outcomes.
Approximately 50% of HER2-positive BCs are hormone receptor (HR)-positive. Thus HER2-positive/HR-positive BC represents roughly 10% of all BCs.
HER2-targeted therapies such as trastuzumab (TRAS), lapatinib (LAP), pertu- zumab (PTZ), and trastuzumab-emtansine (T-DM1) have significantly improved treatment outcomes in HER2-positive
irrespective of HR status.
HER2 signaling reduces ER expression, whereas HER2 inhibition by trastuzumab or lapatinib induces ER transcription
..
Crosstalk between the estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) pathways is shown. In the absence of HER2 inhibition, signaling through the phosphatidylinositide 3‐kinase (PI3‐K) pathway allows for the displacement of forkhead box O3 (FOXO3a) from the nucleus, resulting in (Left) inhibition of ER‐regulated gene transcription. When HER2 is inhibited by antibodies or tyrosine kinase inhibitors, decreased activity of the PI3‐K pathway allows FOXO3a to remain associated with ER, which induces ER‐regulated gene transcription. This causes ER signaling to act as an escape mechanism, resulting in (Right) the development of resistance to HER2‐directed agents.
Two previous studies21,22 have demonstrated the benefit of combining a single HER2 blockade and ET, without che- motherapy, in the first-line setting compared with ET alone in HER2-positive/HR-positive MBC. A significant reduction in the risk of progression was observed with the combination of TRAS plus anastrozole (ANA) or LAP plus letrozole (LET) compared with each ET alone (ie, median progression-free survival [mPFS], 4.8 v 2.4 months [Trastuzumab and Anastrozole Directed Against ER-Positive HER2-Positive Mammary Carcinoma; TAnDEM
Patients in the trastuzumab plus anastrozole arm experienced significant improvements in PFS compared with patients receiving anastrozole alone; however, 70% of patients in the anastrozole alone arm crossed over to receive trastuzumab after progression on anastrozole alone. Incidence of grade 3 and 4 adverse events was 23% and 5%, respectively, in the trastuzumab plus anastrozole arm, and 15% and 1%, respectively, in the anastrozole alone arm; one patient in the combination arm experienced New York Heart Association class II congestive heart failure.
. This error had minor numerical impact on some time-to-event efficacy endpoints such as median PFS and duration of response without change in the interpretation of the results. For instance, the corrected median PFS in TRAS plus AI arm changed from 5.7 months to 5.6 months, and the corrected median durations of response changed from 13.9 to 14 months, and from 8.3 to 8.4 months, in the LAP plus TRAS plus AI and the TRAS plus AI arm, respectively. The identification of this additional error triggered a thorough check and validation by Novartis of all RECIST-related efficacy SDTM and ADAM data sets/outputs and safety data sets/outputs. No other errors were found. QoL outputs were not included in this round of rechecking.
This was caused by an incorrect programming step performed by the outsourcing statistical vendor during the calculation of the hazard ratio with pike estimator using SAS PROC LIFETEST command. The treatment code for the LAP plus AI versus TRAS plus AI was mistakenly assigned as 2 versus 0 instead of 1 versus 0, leading to the calculation error of the SAS PROC LIFETEST command, in which the treatment arms were treated as numerical variables instead of categorical variable
The corrected hazard ratio for the secondary end point comparing PFS between LAP plus AI and TRAS plus AI changed from 0.71 (95% CI, 0.51 to 0.98) to 0.85 (95% CI, 0.62 to 1.17) and P value changed from .03 to .3159. Although the P value changed, the study was not powered for this comparison, and the P values were provided only as nominal value. Accordingly, no firm conclusion on this comparison was made. The corrected hazard ratio for the secondary end point comparing OS in LAP plus AI and TRAS plus AI changed from 0.82 (95% CI, 0.49 to 1.36) to 0.91 (95% CI, 0.55 to 1.50), and the P value changed from .699 to .718. At that time, Novartis identified
Patients with either measurable or non- measurable disease per RECIST version 1.1.
Patients for whom chemotherapy was intended per investigator’s judgment were excluded.
PFS with TRAS plus AI versus LAP plus AI and LAP plus TRAS plus AI versus LAP plus AI;
FISH; Abbott Molecular)
ollected (Covance Laboratory) and submitted to a central laboratory (University of Southern California)
March 11, 2016), 355 patients were enrolled across 112 sites in 29 countries
Patients were HER2 positive and HR positive by local as- sessment and received prior HER2-targeted therapy and prior ET. Two hundred ninety-one tumor samples were available for central testing. HER2 assessment by FISH was evaluable in 220 samples (173 [78.6%] were HER2 positive). In addition to these 173 HER2-positive tumors (by FISH), 17 additional samples, in which FISH was not evaluable, were assessed as HER2 positive by IHC (total, 190 HER2 positive). HR assessment confirmed HR-positive status in 241 of 285 evaluable samples (84.5%) by IHC. Of 190 HER2-positive tumors, 154 were confirmed as HR positive by central testing.
The mPFS with LAP plus AI versus TRAS plus AI was 8.3 versus 5.6 months, respectively (hazard ratio, 0.85 [95% CI, 0.62 to 1.17]; P 5 .3159;
The median OS was 45.1 months with LAP plus AI and 40.0 months with TRAS plus AI (hazard ratio, 0.91 [95% CI, 0.55 to 1.51]).
The most common AEs (any grade) with LAP plus TRAS plus AI, TRAS plus AI, and LAP plus AI (> 10% in any arm) were diarrhea (69%, 9%, and 51%, respectively), rash (36%, 2%, and 28%, respectively), nausea (22%, 9%, and 22%, respectively), and paronychia (30%, 0%, and 15% respectively;
Most events were of grade 1 or 2. The frequency of grade 3 or 4 AEs was low in the 3 treatment arms (, 5%), with the exception of 13% and 6% of grade 3 diarrhea in the LAP plus TRAS plus AI and LAP plus AI arms, respectively. There were no grade 4 diarrhea events .
Hertax
Sak22 ---- trastuzumab sequential or combined with chemo
Combined –PFS –14m,,,,sequenti—12m
Trast monotherapy – 4months
The PERTAIN31 trial showed the benefit of dual HER2 blockade (hazard ratio, 0.65) with an mPFS of 18.9 months with PTZ plus TRAS plus ET versus 15.80 months with TRAS plus ET.
Although these results are arguably strong for a regimen excluding chemotherapy, it must be noted that one-half of women received induction therapy with a taxane for 18 to 24 weeks prior to the initiation of endocrine therapy.
At a median follow-up of 74 months, invasive disease–free survival was significantly improved with pertuzumab, and node-positive patients continued to derive the greatest benefit with the addition of pertuzumab. At the time of the 2019 San Antonio meeting, 272 deaths had occurred, which comprised 42.5% of deaths required for a definitive overall survival analysis.
“Overall survival was excellent in both arms,” Dr. Piccart said. A total of 94.8% of patients were alive in the pertuzumab arm compared with 93.9% in the placebo arm, a difference that was not statistically significant. Dr. Piccart emphasized that “a very stringent P value of .0012” was required for statistical significance in this second interim overall survival analysis.
A total of 508 patients had an invasive disease–free survival event. In a descriptive analysis, invasive disease–free survival rates were 90.6% for pertuzumab vs 87.8% for placebo in the intent-to-treat population. Dr. Piccart noted that this absolute difference of about 2.8% was driven by a reduction in distant and locoregional recurrence. There was no difference between the two study arms in the rate of central nervous system metastases, contralateral invasive breast cancers, and death.
“Node-positive patients continued to derive clear benefit from the addition of pertuzumab, with an absolute 4.5% improvement in 6-year invasive disease–free survival: 87.9% with pertuzumab vs 83.4% with placebo, representing a 28% relative reduction.” No treatment effect was observed in the node-negative population in the two arms: 95% and 94.9%, respectively.
representing a 28% relative reduction.
6years
However, these trials were conducted in different patient populations (with both HR-positive and HR-negative tumors) and in a different clinical setting (eg , neoadjuvant), included chemotherapy-containing regimens, and/or had different requirements for prior TRAS treatment.