Systemic therapy in MetastaticTriple Negative Breast Carcinoma
Giuseppe Curigliano, MD, PhDUniversity of Milano and Istituto Europeo di Oncologia
Milano, Italia
Disclosures
◆ Board Member : Ellipses
◆ Consultant: Lilly, Novartis, Seattle Genetics, Roche-Genentech
◆ Research grants to my Institute : MSD, Astra Zeneca
◆ Speakers bureau: Pfizer, Lilly, Novartis, Roche-Genentech, Samsung, Celltrion
◆ Stock ownership: None
• Triple negative breast cancer as an heterogeneous disease
• ABC Guidelines
• Tackling the diversity of triple negative breast cancer
• Conclusions
Outline
TNBC: An heterogeneous disease
• Invasive Ductal Carcinoma high grade
• Invasive Lobular Carcinoma high grade, pleomorphic
• High grade neuroendocrine
• Metaplastic, high grade
• Myoepithelial carcinoma
• Medullary
• Apocrine
• Adenoid-cystic
• Metaplastic, low grade
Poor prognosis
Goodprognosis
Triple negative disease
Subtype Gene expression profile ClinicalBasal-like 1 high Ki-67; DNA damage response BRCA-associatedBasal-like 2 GF pathways Higher pCRImmunomodulatory Immune genesMesenchymal Cell motility Lower DDFSMesenchymal stem-like Cell motility; claudin-lowLuminal androgen receptor Steroid pathways Apocrine features,
higher LRF; PI3Kmut
ESMO ABC 4 Guidelines, Cardoso F et al, Annals of Oncology 2018
ABC 4 Guidelines
?
(01)
(00)
(43)
(44)
2.2%
0.0%
97.7%
Total # of votes:
1. YES:
2. NO:
3. ABSTAIN:
For non-BRCA-associated triple negative ABC, there are no data supporting different or specific CT recommendations. Therefore, all CT recommendations for HER-2 negative disease also apply for triple negative ABC.(LoE: 1 A)
BRCA mutated TNBC
Subtype Gene expression profile ClinicalBasal-like 1 high Ki-67; DNA damage response BRCA-associatedBasal-like 2 GF pathways Higher pCRImmunomodulatory Immune genesMesenchymal Cell motility Lower DDFSMesenchymal stem-like Cell motility; claudin-lowLuminal androgen receptor Steroid pathways Apocrine features,
higher LRF; PI3Kmut
BRCA mutated TNBC
A PARP inhibitor (olaparib or talozaparib) is a reasonable treatment option for patients with BRCA-associated triple negative or luminal (after
progression on endocrine therapy) ABC, previously treated with an anthracycline with/without a taxane (in the adjuvant and/or metastatic
setting), since its use is associated with a PFS benefit, improvement in QoL and a favorable toxicity profile.
OS results are awaited. It is unknown how PARP inhibitors compare with platinum compounds in this setting and their efficacy in truly platinum-resistant tumors.
(LoE/GoR: I/B) (80%)
ESMO ABC 4 Guidelines, Cardoso F et al, Annals of Oncology 2018
OlympiAD
M=metastatic breast cancer, HER2=human epidermal growth factor 2, TNBC=triple negative breast cancer, TPC=treatment of physician’s choice, OS=overall survival, PFS=progression-free survival, PFS2=progression-free survival 2, ORR=objective response rate, HRQoL=health-related quality of life, FSI=first subject in, RECiST= Response Evaluation Criteria in Solid Tumors, ER=oestrogen receptor, PR=progresterone receptor, ECOG PS= Eastern Cooperative Oncology Group Performance Status, gBRCAm=germline BRCA mutation; po=oral1. https://clinicaltrials.gov/ct2/show/NCT02000622; 2. Robson et al. Poster OT1-1-04, San Antonio Breast Cancer Symposium 2014; 3. AZ data on file (2017), 4. Robson et al. N Engl J Med. 2017; 377:523-533
Olaparib300mg*po bid
Treatment of Physician’s
Choice (TPC)Capecitabine, eribuline and vinorellbine
• gBRCAm mBC
• TNBC or HER2-negative, ER/PR positive
• ≤2 prior chemotherapy lines for mBC
• Previous treatment must include anthracycline and taxane
• Hormone receptor positive (HR+) disease progressed on ≥1 endocrine therapy, or not suitable
• If patients have received platinum therapy there should be:
• No evidence of progression during treatment in the advanced setting
• At least 12 months since (neo)adjuvant treatment and randomisation
• ECOG PS 0-1
• At least one lesion that can be assessed by RECIST v1.1
Randomise 2:1N=3024
Stratification by2
• Prior chemotherapy regimens for metastatic breast cancer
• Hormonal receptor (HR) status
• Prior platinum therapy
Primary endpoint
• PFS (RECIST 1.1, Independent Review)
Secondary endpoints
• OS
• PFS2
• ORR
• PFS, PFS2 and OS based on Myriad gBRCAm status
• HRQoL (EORTC-QLQ-C30)
• Safety and tolerability
FSI May 20143
Global Study in 19 countries and approximately 141 sites1
Robson et al. N Engl J Med. 2017; 377:523-533
Patient characteristics
Olaparib n=205n (%)
TPCn=97n (%)
Totaln=302n (%)
Median age (min, max) 44 (22, 76) 45 (24, 68) 44 (22, 76)
Male 5 (2.4) 2 (2.1) 7 (2.3)
ECOG PS0 148 (72.2) 62 (63.9) 210 (69.5)
1 57 (27.8) 35 (36.1) 92 (30.4)
Race
White 134 (65.4) 63 (64.9) 202 (66.9)
Asian 66 (32.2) 28 (28.9) 94 (31.1)
Other 5 (2.4) 6 (6.2) 11 (3.6)
Olaparib n=205n (%)
TPCn=97n(%)
Totaln=302n (%)
Received previous chemotherapy for mBC
Yes 146 (71.2) 69 (71.1) 215 (71.2)
No 59 (28.8) 28 (28.8) 87 (28.8)
Hormonal receptorstatus
HR+ 103 (50.2) 49 (50.5) 152 (50.3)
TNBC 102 (49.8) 48 (49.5) 150 (49.7)
Received prior platinum therapy for breast cancer
Yes 60 (29.3) 26 (26.8) 86 (28.4)
No 145 (71) 71 (73) 216 (71.5)
Patient characteristics
Robson et al. N Engl J Med. 2017; 377:523-533
Patient characteristics
Robson et al. N Engl J Med. 2017; 377:523-533
Olaparibn=205n (%)
TPCn=97n(%)
Totaln=302n (%)
Number of metastatic sites
1 46 (22.4) 25 (25.8) 71 (23.5)
2 or more 159 (77.6) 72 (74.2) 231 (76.5)
Sites of metastatic lesions
Bone & locomotor only
16 (7.8) 6 (6.2) 22 (7.3)
CNS 17 (8.3) 8 (8.2) 25 (8.3)
BRCA mutation status
BRCA1 117 (57.1) 51 (52.6) 168 (55.6)
BRCA2 84 (41.0) 46 (47.4) 130 (43.0)
Both 4 (1.9) 0 4 (1.3)
De novo metastatic BC 26 (12.7) 12 (12.4) 38 (12.6)
Progressive disease at randomisation 159 (77.6) 73 (75.3) 232 (76.8)
Patient characteristics
Robson et al. N Engl J Med. 2017; 377:523-533
Olaparibn=205n (%)
TPCn=97n(%)
Totaln=302n (%)
Received prior endocrine therapy*†
Adjuvant/neoadjuvant 71 (68.9) 36 (73.5) 107 (70.4)
Metastatic 66 (64.1) 28 (57.1) 94 (61.8)
Total 97 (94.2) 45 (91.8) 142 (93.4)
Lines of previous cytotoxic chemotherapy for metastatic breast cancer
0 68 (33.2) 31 (32.0) 99 (32.8)
1 80 (39.0) 42 (43.3) 122 (40.4)
2 57 (27.8) 24 (24.7) 81 (26.8)
Received prior platinum therapy for BC†
Metastatic 43 (21.0) 14 (14.4) 57 (18.9)
Adjuvant/neoadjuvant 15 (7.3) 7 (7.2) 22 (7.3)
Patient characteristics
Robson et al. N Engl J Med. 2017; 377:523-533
Olaparib
n=205 n (%)
TPC
n=97 n (%)
Total
n=302 n (%)
Full analysis set (randomised, ITT) 205 (100) 97 (100) 302 (100)
Patients who received study treatment 205 (100) 91 (93.8) 296 (98.0)
Number who received olaparib 205 (100) - 205 (67.9)
Number who received capecitabine - 41 (42.3) 41 (13.6)
Number who received eribulin - 34 (35.1) 34 (11.3)
Number who received vinorelbine - 16 (16.5) 16 ( 5.3)
Safety
Robson et al. N Engl J Med. 2017; 377:523-533
21
17
18
18
12
21
7
15
22
50
23
15
26
35
1
9
11
14
16
16
17
20
21
27
29
30
40
58
0 25 755075 50 25Adverse events (%)
NauseaAnemiaVomitingFatigueNeutropeniaDiarrheaHeadacheCough
Decreased appetitePyrexiaIncreased ALTIncreased ASTHand-foot syndrome
Olaparib 300 mg bd (N=205)
Chemotherapy TPC (N=91)
Decreased white blood cells
Safety
Robson et al. N Engl J Med. 2017; 377:523-533
2
2
3
0
1
3
1
10
26
4
0
1
1
2
2
2
3
3
9
16Anemia
Fatigue
Neutropenia
Increased AST
Hand-foot syndrome
Dyspnea
Decreased platelet count
Leukopenia
0 25 755075 50 25
Headache
Adverse events (%)
Olaparib 300 mg bd (N=205)
Chemotherapy TPC (N=91)
Decreased white blood cells
Progression free survival
Robson et al. N Engl J Med. 2017; 377:523-533
17783
15946
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Pro
bab
ility
of
pro
gre
ssio
n-f
ree
su
rviv
al
Time from randomisation (months)
14121086420 16 18 20 22 24 26 28
234
408
6911
9421
10725
15444
20597
214
111
41
31
21
10
00
214
367
6111
7313
10024
12929
20188
111
111
31
21
10
10
OlaparibTPC
Number of patient’s at risk
Median PFS was improved by 69% with olaparib treatment compared to standard of care chemotherapy
Olaparib TPC
n 205 97
Events (%) 163 (79.5%) 71 (73.2%)
Median (m) 7.0 4.2
HR = 0.58
95 % CI (0.43, 0.80)
p=0.0009
PFS free at 6m (%) 54.1 32.9
PFS free at 12m (%) 25.9 15.0
Olaparib 300 mg bd (N=205)
TPC (N=97)
Response rate
Robson et al. N Engl J Med. 2017; 377:523-533
Olaparib TPC
Response Evaluable Population, n 167 66
ORR, n (%) 100 (59.9) 19 (28.8)
Complete Response, n (%) 15 (9.0) 1 (1.5)
Partial Response, n (%) 85 (51.0) 18 (27.3)
Median Duration of Response, months (95%CI)
6.4 (2.9-9.7) 7.1 (3.2-12.2)
Median Time to Onset of Response, days 47 45
Summary of efficacy data
Robson et al. N Engl J Med. 2017; 377:523-533
– OlympiAD showed a statistically significant improvement in PFS*
(HR=0.58 (95% CI 0.43-0.80), p=0.0009) with a median PFS of 7.0
months in the olaparib arm compared to 4.2 months in the TPC arm
– Treatment with olaparib increased PF2, demonstrating a continued and
consistent clinical benefit beyond progression with olaparib (HR: 0.57,
95% CI 0.40-0.83, p=0.0033)
– Median OS in the olaparib arm was 19.3 months compared to 17.1
months in the TPC arm, (HR= 0.9 (95% CI 0.66-1.23)); the difference did
not reach statistical significance p=0.51
– Patients treated with olaparib had a significantly better HRQoL
EMBRACA: Study DesignPatients with locally advanced or metastatic HER2-negative breast cancer and a germline BRCA1 or BRCA2mutation*†
Stratification factors:
• Number of prior chemo regimens (0 or ≥1)
• TNBC or hormone receptor positive (HR+)
• History of CNS mets or no CNS mets
Talazoparib1 mg PO daily
Physician's choice of therapy (PCT)‡:
capecitabine,eribulin,
gemcitabine,or vinorelbine
R2:1
*Additional inclusion criteria included: no more than 3 prior cytotoxic chemotherapy regimens for locally advanced or metastatic disease; prior treatment with a taxane and/or anthracycline unless medically contraindicated. †HER2-positive disease is excluded. ‡Physician's choice of therapy must be determined prior to randomization.CNS=central nervous system; EORTC=European Organisation for Research and Treatment of Cancer; HER2=human epidermal growth factor receptor 2; mets=metastases; PO= by mouth; QLQ-BR23=Quality of Life Questionnaire breast cancer module; QLQ-C30=Quality of Life Questionnaire Core 30; R=randomized; RECIST=Response Evaluation Criteria In Solid Tumors version 1.1; TNBC=triple-negative breast cancer.
Litton J, et al. N Engl J Med 2018; 379:753-763.
Primary endpoint• Progression-free survival by
RECIST by blinded central review
Key secondary efficacy endpoints• Overall survival (OS)
• Objective response rate (ORR) by investigator
• Safety
Exploratory endpoints• Duration of response (DOR)
for objective responders
• Quality of life (QoL; EORTC QLQ-C30, QLQ-BR23)
Treatment (21-day cycles) continues until progression or
unacceptable toxicity
TALA(n=287)
Overall PCT(n=144)
Age, median (range), y 45 (27.0-84.0) 50 (24.0-88.0)
<50 y, no. % 182 (63.4) 67 (46.5)
Gender, % female 98.6 97.9
ECOG = 0 / 1 / 2, % 53.0 / 44.0 / 2.0 58.0 / 40.0 / 1.0
Measurable disease by investigator, no. (%) 219 (76.3) 114 (79.2)
History of CNS metastasis, no. (%) 43 (15.0) 20 (13.9)
Visceral disease, no. (%) 200 (69.7) 103 (71.5)
Hormone receptor status, no. (%)
TNBC 130 (45.3) 60 (41.7)
HR+ 157 (54.7) 84 (58.3)
BRCA status, no. (%)
BRCA1+ 133 (46.3) 63 (43.8)
BRCA2+ 154 (53.7) 81 (56.3)
Disease free interval (initial diagnosis to aBC) <12 months
108 (37.6) 42 (29.2)
Patient characteristics
TALA(n=287)
Overall PCT(n=144)
Patients, no (%)
Prior adjuvant/neoadjuvant therapy
238 (82.9) 121 (84.0)
Prior hormonal therapy 161 (56.1) 77 (53.5)
Prior platinum therapy 46 (16.0) 30 (21.0)
No. of prior cytotoxic regimens for aBC
0 111 (38.7) 54 (37.5)
1 107 (37.3) 54 (37.5)
2 57 (19.9) 28 (19.4)
≥3 12 (4.2) 8 (5.6)
aBC=advanced breast cancer; PCT=physician’s choice of therapy; TALA=talazoparib.
Patient characteristics
Litton J, et al. N Engl J Med 2018; 379:753-763.
Safety
Litton J, et al. N Engl J Med 2018; 379:753-763.
TALA(n=286)
Overall PCT(n=126)
All Grade Grade 3 Grade 4 All Grade Grade 3 Grade 4
No. of patients with ≥1 AE, no. (%)
194 (67.8)
140
(49.0)17 (5.9) 63 (50.0) 29 (23.0) 19 (15.1)
Anemia151
(52.8)
110
(38.5)2 (0.7) 23 (18.3) 5 (4.0) 1 (0.8)
Neutropenia 99 (34.6) 51 (17.8) 9 (3.1) 54 (42.9) 25 (19.8) 19 (15.1)
Thrombocytopenia 77 (26.9) 32 (11.2) 10 (3.5) 9 (7.1) 2 (1.6) 0
Lymphopenia 21 (7.3) 9 (3.1) 0 4 (3.2) 0 1 (0.8)
Febrile neutropenia 1 (0.3) 0 1 (0.3) 1 (0.8) 0 1 (0.8)
Safety
Litton J, et al. N Engl J Med 2018; 379:753-763.
TALA(n=286)
Overall PCT(n=126)
All Grade Grade 3 Grade 4 All Grade Grade 3 Grade 4
No. of patients with ≥1 nonhematologic AE, no. (%)
282 (98.6) 91 (31.8) 123 (97.6) 48 (38.1)
Fatigue 144 (50.3) 5 (1.7) 0 54 (42.9) 4 (3.2) 0
Nausea 139 (48.6) 1 (0.3) 0 59 (46.8) 2 (1.6) 0
Headache 93 (32.5) 5 (1.7) 0 28 (22.2) 1 (0.8) 0
Alopecia 72 (25.2) ‒ ‒ 35 (27.8) ‒ ‒
Vomiting 71 (24.8) 7 (2.4) 0 29 (23.0) 2 (1.6) 0
Diarrhea 63 (22.0) 2 (0.7) 0 33 (26.2) 7 (5.6) 0
Constipation 63 (22.0) 1 (0.3) 0 27 (21.4) 0 0
Decreased appetite 61 (21.3) 1 (0.3) 0 28 (22.2) 1 (0.8) 0
Back pain 60 (21.0) 7 (2.4) 0 20 (15.9) 2 (1.6) 0
Dyspnea 50 (17.5) 7 (2.4) 0 19 (15.1) 3 (2.4) 0
Progression free survival
Litton J, et al. N Engl J Med 2018; 379:753-763.
Overall survival
Litton J, et al. N Engl J Med 2018; 379:753-763.
Response rate
Litton J, et al. N Engl J Med 2018; 379:753-763.
Summary of efficacy data
– Talazoparib resulted in prolonged progression-free survival vs physician’s
choice of therapy by blinded central review HR: 0.54 (95% CI: 0.41,
0.71); P<0.0001
– Overall survival is immature (51% of projected events); HR: 0.76 (95% CI:
0.54, 1.06); P=0.105
– Global Health Status/Quality of Life showed overall improvement from
baseline
– Talazoparib was generally well tolerated, with minimal nonhematologic
toxicity and few adverse events resulting in treatment discontinuation
Litton J, et al. N Engl J Med 2018; 379:753-763.
RANDOMISE
(1:1)
Docetaxel (D)
100mg/m2 q3w, 6 cycles
Carboplatin (C)
AUC 6 q3w, 6 cycles
ER-, PgR-/unknown & HER2- or known BRCA1/2
Metastatic or recurrent locally advanced
Exclusions include:
• Adjuvant taxane in ≤12 months
• Previous platinum treatment
• Non-anthracyclines for MBC
A Priori subgroup analyses:
• BRCA1/2 mutation
• Basal-like subgroups (PAM50 and IHC)
• Biomarkers of HRD
On progression,
crossover if appropriateOn progression,
crossover if appropriate
Carboplatin (C)
AUC 6 q3w, 6 cyclesDocetaxel (D)
100mg/m2 q3w, 6 cyclesn-376
BRCA1/2 =
9%/12%
Tutt A et al, 2108
Carboplatin in BRCA mutant
59/188 (31.4%)
67/188(35.6%)
0 20 40 60 80 100
Carboplatin
Docetaxel
% with OR at cycle 3 or 6 (95% CI)
Tutt, 2018
Absolute difference (C-D)
-4.2% (95% CI -13.7 to 5.3)
Exact p = 0.44
Randomised treatment - all
patients (N=376)
21/92*(22.8%)
23/90*(25.6%)
0 20 40 60 80 100
Carboplatin(Crossover=Docetaxel)
Docetaxel(Crossover=Carboplatin)
% with OR at cycle 3 or 6 (95% CI)
Absolute difference (D-C)
-2.8% (95% CI -15.2 to 9.6)
Exact p = 0.73
Crossover treatment - all
patients (N=182)
Carboplatin in BRCA mutant
17/25(68.0%)
6/18(33.3%)
0 10 20 30 40 50 60 70 80 90 100
Carboplatin
Docetaxel
Percentage with OR at cycle 3 or 6 (95% CI)
31
Absolute difference (C-D)34.7% (95% CI 6.3 to 63.1)
Exact p = 0.03
Germline BRCA 1/2 Mutation (n=43)
Interaction: randomised treatment & BRCA 1/2 status: p = 0.01
0 10 20 30 40 50 60 70 80 90 100
Carboplatin
Docetaxel
Percentage with OR at cycle 3 or 6 (95% CI)
No Germline BRCA 1/2 Mutation (n=273)
Absolute difference (C-D)-8.5% (95% CI -19.6 to 2.6)
Exact p = 0.16
36/128(28.1%)
53/145(36.6%)
Carboplatin in BRCA mutant
Carboplatin or PARP inhibitors?
Talazoparib / Olaparib Carboplatin
Number of patients 287 205 43 out of 376
BRCA 1 43.6% 57% 9%
BRCA 2 56.7% 41% 12%
Toxicities Hematological Emesis, neuropathy, nephrotoxicity
PR rates 60% 68%
Estimated costs of the treatment for 6 courses
$ 28.000 E 360
Carboplatin or PARP inhibitors?
Talazoparib / Olaparib Carboplatin
Number of patients 287 205 43 out of 376
BRCA 1 43.6% 57% 9%
BRCA 2 56.7% 41% 12%
Toxicities Hematological Emesis, neuropathy, nephrotoxicity
PR rates 60% 68%
Estimated costs of the treatment for 6 courses
$ 28.000 E 360
Subtype Gene expression profile ClinicalBasal-like 1 high Ki-67; DNA damage response BRCA-associatedBasal-like 2 GF pathways Higher pCRImmunomodulatory Immune genesMesenchymal Cell motility Lower DDFSMesenchymal stem-like Cell motility; claudin-lowLuminal androgen receptor Steroid pathways Apocrine features,
higher LRF; PI3Kmut
PDL-1 positive
PD-L1 Expression (ICH) As a Predictive Biomarker
Plots include patients with ≥1 evaluable postbaseline assessment (n = 143 for cohort A, n = 50 for cohort B).
1. Adams S, et al. ASCO Annual Meeting; Jun 2-6, 2017; Chicago, IL; Abstr 1088.
-100
-80
-60
-40
-20
0
20
40
60
80
100
Ch
ang e
F ro
mB
ase
l ine ,
%
-100
-80
-60
-40
-20
0
20
40
60
80
100
Ch
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ge
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i ne
,%
Cohort A (N = 170): Previously Treated,
Regardless of PD-L1 Expression
Cohort B (N = 52)1: Previously Untreated,
PD-L1 Positive
ORR:4.6% ORR:23.1%
All patients responding are still alive Median TTR:3.0moMedian duration of response: 6.3mo
Activity of immune-checkpoint inhibitors monotherapy in TNBC
• Modest activity• Impressive
outcomes in those with response
• PDL1+ and 1st line enriches for responsive tumors
From Emens LA, CCR 2018
Activity of immune-checkpoint inhibitors and CT
From Emens LA, CCR 2018
Atezolizumab and nab-Paclitaxel in mTNBC
Schmid P, et al. N Engl J Med. 2018 Nov 29;379(22):2108-2121
• Co-primary endpoints were PFS and OS in the ITT and PD-L1+ populationsd
– Key secondary efficacy endpoints (ORR and DOR) and safety were also evaluated
IC, tumour-infiltrating immune cell; TFI, treatment-free interval. a ClinicalTrials.gov: NCT02425891. b Locally evaluated per ASCO–College of American Pathologists (CAP) guidelines. c Centrally evaluated per VENTANA SP142 IHC assay (double blinded for PD-L1 status). d Radiological endpoints were investigator assessed (per RECIST v1.1).
Key IMpassion130 eligibility criteriaa:
• Metastatic or inoperable locally advanced TNBC
‒ Histologically documentedb
• No prior therapy for advanced TNBC
‒ Prior chemo in the curative setting, including taxanes, allowed if TFI ≥ 12 mo
• ECOG PS 0-1
Stratification factors:
• Prior taxane use (yes vs no)
• Liver metastases (yes vs no)
• PD-L1 status on IC (positive [≥ 1%] vs negative [< 1%])c
Atezo + nab-P arm:
Atezolizumab 840 mg IV
‒ On days 1 and 15 of 28-day cycle
+ Nab-paclitaxel 100 mg/m2 IV
‒ On days 1, 8 and 15 of 28-day cycle
Plac + nab-P arm:
Placebo IV
‒ On days 1 and 15 of 28-day cycle
+ Nab-paclitaxel 100 mg/m2 IV
‒ On days 1, 8 and 15 of 28-day cycle
Double blind; no crossover permittedRECIST v1.1 PD
or toxicityR
1:1
Statistical design
• Primary PFS analysis (PFS tested in ITT and PD-L1+ populations)
• First interim OS analysis (OS tested in ITT population, then, if significant, in PD-L1+ population)
a α recycled if PFS/ORR testing is significant. Hazard ratio (HR)/P value–stopping boundaries are dependent on the OS analysis timing.
Atezo + nab-P vs Plac + nab-P
α = 0.05
PFS (primary)α = 0.01
OSa
• Interim• Primary (α ≥ 0.04)
OS in ITT population
OS in PD-L1+ population
1. PFS in ITT population
α = 0.005
3. ORR in ITT population
α = 0.001
4. ORR in PD-L1+ population
α = 0.001
2. PFS in PD-L1+ population
α = 0.005
Schmid P, et al. N Engl J Med. 2018 Nov 29;379(22):2108-2121
Patients
Data cutoff: 17 April 2018. a Race was unknown in 12 patients in the Atezo + nab-P arm and 15 in the Plac + nab-P arm. b Of n = 450 in each arm. c ECOG PS before start of treatment was 2 in 1 patient per arm. d Of n = 450 in the Atezo + nab-P arm and n = 449 in the Plac + nab-P arm arm.
CharacteristicAtezo + nab-P
(N = 451)
Plac + nab-P (N = 451)
Median age (range), y 55 (20-82) 56 (26-86)
Female, n (%) 448 (99%) 450 (100%)
Race, n (%)a
White 308 (68%) 301 (67%)
Asian 85 (19%) 76 (17%)
Black/African American 26 (6%) 33 (7%)
Other/multiple 20 (4%) 26 (6%)
ECOG PS, n (%)b,c
0 256 (57%) 270 (60%)
1 193 (43%) 179 (40%)
Prior (neo)adjuvant treatment, n (%)
284 (63%) 286 (63%)
Prior taxane 231 (51%) 230 (51%)
Prior anthracycline 243 (54%) 242 (54%)
CharacteristicAtezo + nab-P
(N = 451)
Plac + nab-P (N = 451)
Metastatic disease, n (%) 404 (90%) 408 (91%)
No. of sites, n (%)d
0-3 332 (74%) 341 (76%)
≥ 4 118 (26%) 108 (24%)
Site of metastatic disease, n (%)
Lung 226 (50%) 242 (54%)
Bone 145 (32%) 141 (31%)
Liver 126 (28%) 118 (26%)
Brain 30 (7%) 31 (7%)
Lymph node onlyd 33 (7%) 23 (5%)
PD-L1+ (IC), n (%) 185 (41%) 184 (41%)
Schmid P, et al. N Engl J Med. 2018 Nov 29;379(22):2108-2121
Safety
• 1 grade 5 AESI per arm (both treatment related):
– Atezo + nab-P: autoimmune hepatitis
– Plac + nab-P: hepatic failure
• All hypothyroidism AESIs were grade 1-2; none led to discontinuation
– Atezo + nab-P: 17%
– Plac + nab-P: 4%
• Pneumonitis was infrequent with only 1 grade 3-4 event in the Atezo + nab-P arm
– Atezo + nab-P: 3%
– Plac + nab-P: < 1%
• Hepatitis rates were balanced
AESI, adverse event of special interest. Data cutoff: 17 April 2018. a Baskets of preferred terms according to medical concepts. b All events of photophobia. c Includes all AESIs occurring in ≥ 1% of patients in either arm.
AESI, n (%)a
Atezo + nab-P (n = 452)
Plac + nab-P (n = 438)
Any Grade Grade 3-4 Any Grade Grade 3-4All 259 (57%) 34 (8%) 183 (42%) 19 (4%)
Important AESIsHepatitis (all) 69 (15%) 23 (5%) 62 (14%) 13 (3%)Hepatitis (diagnosis) 10 (2%) 6 (1%) 7 (2%) 1 (< 1%)Hepatitis (lab abnormalities) 62 (14%) 17 (4%) 58 (13%) 12 (3%)
Hypothyroidism 78 (17%) 0 19 (4%) 0Hyperthyroidism 20 (4%) 1 (< 1%) 6 (1%) 0Pneumonitis 14 (3%) 1 (< 1%) 1 (< 1%) 0Meningoencephalitisb 5 (1%) 0 2 (< 1%) 0Colitis 5 (1%) 1 (< 1%) 3 (1%) 1 (< 1%)Adrenal insufficiency 4 (1%) 1 (< 1%) 0 0Pancreatitis 2 (< 1%) 1 (< 1%) 0 0Diabetes mellitus 1 (< 1%) 1 (< 1%) 2 (< 1%) 1 (< 1%)Nephritis 1 (< 1%) 0 0 0
Other AESIsc
Rash 154 (34%) 4 (1%) 114 (26%) 2 (< 1%)Infusion-related reactions 5 (1%) 0 5 (1%) 0
Schmid P, et al. N Engl J Med. 2018 Nov 29;379(22):2108-2121
Primary PFS analysis: ITT population
NE, not estimable. Data cutoff: 17 April 2018. Median PFS durations (and 95% CI) are indicated on the plot. Median follow-up (ITT): 12.9 months.
0 3 6 9 12 15 18 21 24 27 30 33Months
No. at risk:Atezo + nab-P 451 360 226 164 77 34 20 11 6 1 NE NE
Plac + nab-P 451 327 183 130 57 29 13 5 1 NE NE NE
Atezo + nab-P (N = 451)
Plac + nab-P (N = 451)
PFS events, n 358 378
1-year PFS(95% CI), %
24%(20, 28)
18%(14, 21)
7.2 mo(5.6, 7.5)
5.5 mo(5.3, 5.6)
100
80
60
40
20
0
Pro
gre
ssio
n-f
ree
su
rviv
al
Stratified HR = 0.80(95% CI: 0.69, 0.92)
P = 0.0025
Schmid P, et al. N Engl J Med. 2018 Nov 29;379(22):2108-2121
Primary PFS analysis: PD-L1+ population
Data cutoff: 17 April 2018.
0 3 6 9 12 15 18 21 24 27 30 33Months
No. at risk:Atezo + nab-P 185 146 104 75 38 19 10 6 2 1 NE NE
Plac + nab-P 184 127 62 44 22 11 5 5 1 NE NE NE
7.5 mo(6.7, 9.2)
5.0 mo(3.8, 5.6)
100
80
60
40
20
0
Pro
gre
ssio
n-f
ree
su
rviv
al
Stratified HR = 0.62(95% CI: 0.49, 0.78)
P < 0.0001
Atezo + nab-P (n = 185)
Plac + nab-P (n = 184)
PFS events, n 138 157
1-year PFS(95% CI), %
29%(22, 36)
16%(11, 22)
As opposed to what is observed in melanoma and lung cancer, there is NO tail of the PFS curve in TNBC
Schmid P, et al. N Engl J Med. 2018 Nov 29;379(22):2108-2121
aThe 31% figure is for all tumors; the ORR was 37% in nonsquamous tumors and 12% in squamous cases. In PDL-1 negative cases, ORR was 14% in nonsquamous tumors and 0% in squamous tumors. bThis study concerned squamous cell carcinomas only. cThese authors also used the anti-PD-1 monoclonal M3 in their immunohistochemical analysis. dIHC score 3, ≥10% TIICs positive; IHC score 2–3, ≥5% TIICs positive; IHC score 1–2–3, ≥1% TIICs positive.
PD-L1 Expression (ICH) As a Predictive Biomarker
Kerr KM, et al. J Thorac Oncol. 2015;10(7):985-989. IHC, immunohistochemistry; Rx, treatment; TIICs, tumor infiltrating immune cells
Drug
Biomarker
Antibody Rx Line
Definition of
“Positive” (%) N Positive (%)
Positive
Predictive
Outcome
ORR % IHC
Positive Cases
ORR % IHC
Negative Cases
Nivolumab Dako 28-8 1st ≥5 in >100 cells 59 Yes 31a 10
Nivolumab Dako 28-8 ≥2nd ≥5, ≥1 49, 56 No 15, 13 14, 17
Nivolumab +
IpilimumabDako 28-8 1st ≥5 in >100 cells 42 No 19 14
Nivolumab Dako 28-8 ≥2nd ≥5 33b Yes 24 14
Nivolumab 5H1c ≥2nd ≥5, also
studied TIICs67 Yes No data for lung No data for lung
Pembrolizumab Dako 22C3 Any“Strong” ≥50,
“Weak” 1-4925, 70 Yes, Yes 37, 17 9
Pembrolizumab Dako 22C3 1st ≥5, ≥1 ? Yes 47, 26 ?
MPDL3280A Roche Ventana, SP142 ≥2nd ≥10d, ≥5, ≥1 TIICs 13, 28, 56 Yes 83, 46, 31 18, 18, 20
MEDI-4736 Roche Ventana, SP263 ≥2nd Data not available 41 Yes 25 3
Dedicated Different
Primary PFS analysis
CharacteristicPatient
s
All 902
Baseline liver metastases Yes 244No 658
Prior taxane use Yes 461No 441
PD-L1 status PD-L1+ (IC1/2/3) 369PD-L1– (IC0) 533
Age group 18-40 y 11441-64 y 569≥ 65 y 219
ECOG PSb 0 5261 372
Baseline disease status Locally advanced 88Metastaticc 812
No. of metastatic sites 0-3c 673> 3c 226
Brain metastases Yes 61No 841
Lung metastases Yes 468No 434
Prior (neo)adjuvant chemo Yes 570No 332
0.81 (0.70, 0.93)
0.80 (0.62, 1.04)0.79 (0.66, 0.94)
0.80 (0.65, 0.97)0.81 (0.66, 1.00)
0.64 (0.51, 0.80)0.95 (0.79, 1.15)
0.79 (0.53, 1.16)0.84 (0.70, 1.01)0.69 (0.51, 0.94)
0.78 (0.64, 0.94)0.82 (0.66, 1.03)
0.66 (0.40, 1.09)0.82 (0.71, 0.96)
0.76 (0.64, 0.91)0.89 (0.67, 1.17)
0.86 (0.50, 1.49)0.80 (0.69, 0.93)
0.87 (0.72, 1.07)0.74 (0.60, 0.91)
0.85 (0.71, 1.03)0.72 (0.57, 0.92)
0.2 2
Hazard Ratio (95% CI)a
P + nab-P betterA + nab-P better 1
Stratification factors
Schmid P, et al. N Engl J Med. 2018 Nov 29;379(22):2108-2121
Interim OS analysis: ITT populationa
Data cutoff: 17 April 2018. Median OS durations (and 95% CI) are indicated on the plot. Median follow-up (ITT): 12.9 months.a For the interim OS analysis, 59% of death events had occurred. b Significance boundary was not crossed.
0 3 6 9 12 15 18 21 24 27 30 33 36Months
No. at risk:Atezo + nab-P 451 426 389 337 271 146 82 48 26 15 6 NE NE
Plac + nab-P 451 419 375 328 246 145 89 52 27 12 3 1 NE
21.3 mo(17.3, 23.4)
17.6 mo(15.9, 20.0)
100
80
60
40
20
0
Ove
rall
surv
ival
Stratified HR = 0.84(95% CI: 0.69, 1.02)
P = 0.0840b
Atezo + nab-P (N = 451)
Plac + nab-P (N = 451)
OS events, n 181 208
2-year OS(95% CI), %
42%(34, 50)
40%(33, 46)
Schmid P, et al. N Engl J Med. 2018 Nov 29;379(22):2108-2121
Interim OS analysis: PD-L1+ population
Data cutoff: 17 April 2018. Median OS durations (and 95% CI) are indicated on the plot. a Not formally tested.
25.0 mo(22.6, NE)
15.5 mo(13.1, 19.4)
100
80
60
40
20
0
Ove
rall
surv
ival
0 3 6 9 12 15 18 21 24 27 30 33 36Months
No. at risk:Atezo + nab-P 185 177 160 142 113 61 36 22 15 9 5 NE NE
Plac + nab-P 184 170 147 129 89 44 27 19 13 6 NE NE NE
Stratified HR = 0.62 (95% CI: 0.45, 0.86)a
Atezo + nab-P (n = 185)
Plac + nab-P (n = 184)
OS events, n 64 88
2-year OS(95% CI), %
54%(42, 65)
37%(26, 47)
Schmid P, et al. N Engl J Med. 2018 Nov 29;379(22):2108-2121
• Numerically higher and more durable responses were seen in the Atezo + nab-P arm
– Differences were not significant based on α level = 0.1% (ITT: P = 0.0021; PD-L1+: P = 0.0016)
• The CR rate was higher in the Atezo+ nab-P arm vs the Plac + nab-P arm
– ITT population: 7% vs 2%
– PD-L1+ patients: 10% vs 1%
Secondary efficacy endpoints
0
10
20
30
40
50
60
70
ITT A-nabPx
ITT P-nabPx
PD-L1+ A-nabPx
PD-L1+ P-nabPx
OR
R (
%)
ITTa PD-L1+b
56%
46%
59%
43%
49%
44%
49%
42%
7% 10%CR:
PR:
Atezo + nab-P
Plac + nab-P
Atezo + nab-P
Plac + nab-P
DOR, median(95% CI), mo
7.4(6.9, 9.0)
5.6(5.5, 6.9)
8.5(7.3, 9.7)
5.5(3.7, 7.1)
No. of ongoing responses, n (%)c 78 (31%) 52 (25%) 39 (36%) 19 (24%)
Schmid P, et al. N Engl J Med. 2018 Nov 29;379(22):2108-2121
OS analysis: ITT population
OS analysis: PD-L1+ population
Clinical Heterogeneity of TNBC
Subtype Gene expression profile ClinicalBasal-like 1 high Ki-67; DNA damage response BRCA-associatedBasal-like 2 GF pathways Higher pCRImmunomodulatory Immune genesMesenchymal Cell motility Lower DDFSMesenchymal stem-like Cell motility; claudin-lowLuminal androgen receptor Steroid pathways Apocrine features,
higher LRF; PI3Kmut
Bicalutamide 150 mg dailyER/PR(-)
(IHC ≤10%)LABC/MBC
AR+ DAKO Ab >
10%
• Primary endpoint = CBR24 (CR + PR + SD > 24 weeks)
Gucalp et al CCR 2013
Screened patients 12% AR+ (mostly TNBC)
Clinical Benefit Rate = 19% (95% CI 7-39%)
All SD
Bicalutamide
• MBC ER/PR ≤10% • 138 screened → 38% AR+ (≥10%)
• Primary Endpoint = CBR24
• N = 30 evaluable patients• ~ 2.5 prior lines Rx• ~ 50% visceral mets
• Most common, related AEs: • fatigue (18%)• HTN (12%)• hypokalemia (9%)• nausea (6%)
Bonnefoi et al, Ann Onc 2016
Median PFS 2.8m
CBR24 = 20% (95%CI: 8-39%)
1 confirmed CR
Abiraterone
Enzalutamide 160 mg dailyER/PR/HER2 (-) LABC/MBC
AR+ Ventana
> 0%
• Primary endpoint = CBR16 (CR + PR + SD > 16) weeks)Screened patients 79% AR+ (55% by 10% cutoff)
• Median 1 prior Rx
Evaluable (n=75 AR > 10%)
CBR16 35% (24-46%)
CBR24 29% (20-41%)
RR 8%
SAE 29%
0 8 16 24 33 41 49 6164
100
80
60
40
20
0
PFS
(%
)
PFS 14.7 weeks95% CI: 8.1, 19.3
Enzalutamide
64
PREDICT AR−
0 8 16 24 32 40 52Time (weeks)
PREDICT AR− PREDICT AR+
Total, n (%) 62 (53%) 56 (47%)
CBR16, %(95% CI)
n
11%(5, 21)
n = 7
39%(27, 53)
n = 22
CBR24, %(95% CI)
n
6%(2, 16)
n = 4
36%(24, 49)
n = 20
CR or PR, %n
3%n = 2
9%n = 5
Active
Confirmed CR or PR
0–1 Prior Lines2+ Prior Lines
PREDICT AR+
0 8 16 24 32 40 52 64Time (weeks)
Traina et al, ASCO 2015
Gene expression classifier created = “PredictAR”(Basal-, apocrine+, etc to identify LAR)
Enzalutamide
56
56
62
53
55
49
46
45
37
42
27
40
24
32
13
15
6
11
6
3
2
Data cutoff 1Jul2015
ITT = intent to treat; mOS = median survival; CI = confidence interval; .
Patients at risk
PREDICT AR+
PREDICT AR−
0
80
40
20
n = 118
PREDICT AR−
mOS 32.3 weeks
(95% CI: 20.7, 48.3)
PREDICT AR+
mOS 75.6 weeks
(95% CI: 51.6, 91.4)
0 8 16 24 33 41 49 61 64
Weeks
100
60
Overa
ll S
urv
ival
(%)
85
ITT Population
NCT01889238
PREDICT AR+ mOS 18.0 months
PREDICT AR – mOS 7.5 months
Courtesy of J. Cortes, ECCO 2015
Enzalutamide
Antibody drug conjugated
1. Yardley DA, et al. J Clin Oncol. 2015;33(14):1609-1619. 2. Forero-Torres A, et al. Cancer Res. 2017;77(4_Suppl): Abstract P6-12-04. 3. Bardia A, et al. J Clin Oncol. 2017;35(19):2141-2148.
ADCs GlembatumumabVedotin1
LadiratuzumabVedotin2
SacituzumabGovitecan3
Other name CDX-011 SGN-LIV1A IMMU-132
Target gpNMB LIV-1 Trop-2
Tumor expression ~40% 71% 88%
Cytotoxin MMAE MMAE SN-38
Single-agent activity (ORR)
28% 37% 30%
Registrational trials
METRIC1st-3rd line
Active arm in ISPY-2Phase II trial 2018
ASCENT≥3rd line
ABT 414: depatuxizimab mafodotin, targets EGFR linked to MMAF
Glembatumumab Vedotin in GPNMB+ TNBC
GPNMB, glycoprotein NMB
Yardley DA, et al. J Clin Oncol. 2015;33(14):1609-1619.
Phase I I T rial Sacitu zumab Go vitecan
Median DoR 7.6 mon thsMed PF S 5.5 mon ths
Met T NB C 3/4/5 th -Line Pha se II
CT , com p u ted t o mo g raph y; M RI, mag netic r es o n ance imag ing
Bardi a A , e t a l. P re s e nt e d a t: S a n A nt onio Brea s t Canc e r S y mpos ium;
Dec e mbe r 5 -9 , 2 0 1 7 : S a n A nt onio, Te x a s .>90% TNBC s ex pres s Trop -2
• Chemotherapy is still a standard for many patients
• Molecular subtypes cannot be used in clinical practice
• PARP inhibitors standard in BRCA carriers (will work in somaticallyinactivated?)
• Atezolizumab and nabpaclitaxel a new standard in PD-L1 positiveTNBC
• AR inhibitors: may be in very well selected population
Conclusions
Thank You
Giuseppe Curigliano MD, PhD