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![Page 1: ASCO 2005 Adjuvant Breast Cancer Update Lori J. Goldstein, MD Director, Breast Evaluation Center Leader, Breast Cancer Research Program Fox Chase Cancer.](https://reader036.fdocuments.us/reader036/viewer/2022062518/56649ddf5503460f94ad80ea/html5/thumbnails/1.jpg)
ASCO 2005 Adjuvant Breast Cancer
UpdateLori J. Goldstein, MD
Director, Breast Evaluation Center
Leader, Breast Cancer Research Program
Fox Chase Cancer Center
Philadelphia, PA
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ASCO 2005 Breast Cancer Update
Abstract #/ Session Title/ Subject
512 E2197: Adjuvant AT vs. AC
513 ECTO: A->CMF vs AT->CMF
MoAB Ed N9831/ NSABP B31 Joint Analysis – Adjuvant Trastuzumab
MoAB Ed N9831 – Adjuvant Trastuzumab
MoAB Ed HERA: Adjuvant Trastuzumab
MoAB Ed E2100: T +/- bevacizumab MBC
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E2197: Phase III AT vs. AC in the Adjuvant Treatment of Node Positive and High Risk Node
Negative Breast Cancer
Goldstein LJ, O’Neill A, Sparano JA, Perez EA, Shulman LN, Martino S, Davidson NE.
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E2197 RationalePhase II Studies Anthracyline + Taxane
Study A/Por D mg/m2 RR % CHF %
Gianni/ 60/P200 80-90 20Dombernowsky
Sledge E1193 50/P150 47 9.8
Sparano E4195 60/P200 57 6
Sparano E1196 60/D60 57 6
Cresta 60/D60 63 10
Misset 50/D75 81 0
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E2197 RationalePhase III Studies:Anthracyline + Docetaxel
Phase III Studies:
MBC AT (50/75) AC (60/600)
RR% 60 47 p=.012
TTPwk 37.1 31.9 p=.015
CHF % 2 4
FN% 33 10
No difference OS Nabholtz JCO 2003
TAC vs. FAC MBC Mackey ASCO 2002
Increase RR with TAC; no difference in TTP or OS
TAC vs. FAC Adjuvant: Nabholtz ASCO 2002
TAC increase DFS/ OS
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E2197: Schema
T1-3 N0-1 M0
No then T> 1.0cm
Tamoxifen 20mg daily x 5 yearspost chemotherapy for ER and/or PR positive tumor
Adriamycin 60mg/m2
Docetaxel (T) 60mg/m2
Adriamycin 60mg/m2
Cyclophosphamide 600mg/m2
Stratified:•Nodal Status•HR Status (ER+PR+,ER+PR-,ER-PR+,ER- PR-,ER/PR unknown)•Menopausal Status
RANDOMIZE
IV q 3wk x 4
IV q 3wk x 4Cipro 500mg po. bid D8 x 10d
*G-CSF -per ASCO guidelines
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E2197: Objectives
• To determine whether AT will improve DFS and OS
• To compare toxicity of AT vs. AC
No difference in LVEF between AT and AC reported ASCO 2003.
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E2197: Study Design
• Primary endpoint: DFS-recurrences, new breast primaries, or death without recurrence whichever comes first.
• Design: 83% power to detect a 25% reduction of the DFS failure hazard rate(5% absolute improvement in 5 yr DFS from 78% to 83% by using AT)
• Sample size: 2778 including an estimated 10% ineligible
• Primary Analysis: Intent-to-treat analysis on eligible patients.
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E2197:Results
• Opened 7/30/98; closed 1/21/00
• 2952 entered through the collaborative effort of ECOG, CALGB, NCCTG, SWOG and EPP.
• 3% Ineligibility rate
• 2885 eligible and analyzable
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E2197: Patient Characteristics
• Balanced for age, HR, menopause, nodes, surgery, grade and size
• Age range 24-85 yo, Median age 51
• 64% ER +
• 65% LN-
• Grade: 10% low, 38% int., 46% high
• Size: 0.1 – 12.5 cm; Median – 2.0 cm
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E2197: Toxicity Summary
AT AC
Feb/Infxn/N 28% 10%
AML/MDS 7 7
Lethal Events
Related 4
Unrelated 2 2
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E2197 Cardiac Safety
AT AC
Grade 3 4 5 3 4
CHF 15 2 1 10
Total 18 10
% .01 .006
No statistically significant difference
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E2197: DFS• Fall 2004 DMC (409/ 420 DFS failures)• O’Brien-Fleming boundary had not been
crossed, there was not enough evidence to suggest a significant difference
• April 2005 - Median follow-up = 59 months • 432/ 2885 (15%) recurred, developed
second breast cancer or died.
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E2197: DFS/OSHazard Ratio
HR > 1 favors AT
HR (adjusted)
DFS 1.03 (0.86-1.25), p=0.70
OS 1.09 (0.85-1.40), p=0.49
As of 4/4/05, 242 deaths
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Per
cen
t
0
10
20
30
40
50
60
70
80
90
100
Months
0 12 24 36 48 60 72
ATAC
1444 2131441 219
N Events87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)87 (1)
4-Yr % (S.E.)
E2197 Disease-Free Survival
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Per
cen
t
0
10
20
30
40
50
60
70
80
90
100
Months
0 12 24 36 48 60 72
ATAC
1444 1171441 125
N Events94 (1)94 (1)94 (1)94 (1)94 (1)94 (1)94 (1)94 (1)94 (1)94 (1)94 (1)94 (1)94 (1)94 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)93 (1)
4-Yr % (S.E.)
E2197 Overall Survival
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E2197: DFSSubgroup Analysis
No significant effect within any of the following subgroups :
•Nodes
•Size
•Age
•Menopausal Status
•Grade
•Type of Surgery
•Race
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Per
ce
nt
0
10
20
30
40
50
60
70
80
90
100
Months
0 12 24 36 48 60 72
ATAC
454 85463 109
N Events83 (2)83 (2)83 (2)79 (2)79 (2)79 (2)79 (2)79 (2)79 (2)79 (2)79 (2)
4-Yr % (S.E.)
E2197 Disease-Free Survival:ER-/PR-
Per
ce
nt
0
10
20
30
40
50
60
70
80
90
100
Months
0 12 24 36 48 60 72
ATAC
52 1438 3
N Events77 (6)95 (4)
4-Yr % (S.E.)
E2197 Disease-Free Survival:ER-/PR+P
erc
en
t
0
10
20
30
40
50
60
70
80
90
100
Months
0 12 24 36 48 60 72
ATAC
162 22164 34
N Events90 (2)83 (3)81 (3)81 (3)
4-Yr % (S.E.)
E2197 Disease-Free Survival:ER+/PR-
Per
ce
nt
0
10
20
30
40
50
60
70
80
90
100
Months
0 12 24 36 48 60 72
ATAC
767 91770 73
N Events90 (1)90 (1)90 (1)90 (1)90 (1)90 (1)90 (1)92 (1)92 (1)92 (1)92 (1)92 (1)92 (1)92 (1)
4-Yr % (S.E.)
E2197 Disease-Free Survival:ER+/PR+
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Disease Free Survival
0.1 0.2 0.5 1 2 5
ER+/PR+ 0.79 (0.58, 1.10)
ER+/PR- 1.64 (0.96, 2.80)
ER-/PR+ 0.30 (0.10, 0.95)
ER-/PR- 1.30 (0.96, 1.70)
Favors AC Favors AT
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E2197 Conclusions• These results show a better than expected
outcome for both regimens.87%(obs) vs 78% (expected for AC) DFS at 4 yrs.
• At 59 mo median follow-up, there is no difference in DFS or OS between AT and AC.
• Prespecified stratifications at randomization: LN, menopause, ER/PR – no significant difference between the 2 treatment arms.
• In PR negative tumors, a potential benefit to AT may be suggested.
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E2197: Issues for DiscussionWould longer f/u change these results? Unlikely
Observed DFS = 87% at 4 yrs. Expected DFS = 78% at 4yrs.
Aromatase Inhibitor Affect:60% on Tam; Median 41 mo; AI info collected; future analysis
Subset analysis of prespecified ER/PR stratifications:Hypothesize that the biology of the primary tumor predicts outcome and benefit to specific therapies.Central review of ER/PR/Her 2 pending
Genomic Health/ Sanofi-Aventis Analysis:OncotypeGenomic profiling Use as training set for validation with E1199Pharmacogenomics
PACCT- 1 Trial
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Thank You
Patients
Data managers/ CRA’s
CALGB, NCCTG, SWOG, EPP
Anne O’Neill, Deborah Namande, Eric Ross
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European Cooperative Trial in Operable Breast Cancer(ECTO):
Improved freedom from progression from adding
paclitaxel(T) to doxorubicin(A) followed by CMF
Luca Gianni
Abstract 513
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ECTO: Schema
Tumors > 2 cm randomized to :
A. SURG ->A 75 mg/m2 x 4 -> CMF x 4
B. SURG ->AT 60/ 200 x 4 -> CMF x 4
C. AT 60/ 200 x 4 -> CMF x 4 -> SURG
Tam for HR +
Analysis: FFP A vs B
B vs C
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ECTO at 5 years Analysis A vs. B
Pts. Events HR p
A-CMF 453 91 .66 0.01*
AT-CMF 451 63
Analysis B vs. C
S-AT-CMF 451 63 1.22 0.24
AT-CMF-S 451 78
Data super imposable so far, no significant difference, however pCR had improved FFP.
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ECTO: Main Treatment Outcomes
A(%) B(%) C(%)
Total FFP
pCR 89
no pCR 75
N - 81 89 86
N + 1-3 79 86 71
N +>3 58 65 59
OS 82 91 90
No significant difference in OS.
No significant difference in cardiac toxicity
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Combined Analysis ofNSABP-B31/NCCTG-N9831
Doxorubicin and Cyclophosphamide Followed by Paclitaxel with or without Trastuzumab as Adjuvant Therapy for Patients with
HER-2 Positive Operable Breast Cancer
Romond EH, Perez EA, Bryant J, Suman V, Geyer CE,Davidson N, Tan-Chiu E, Martino S, Swain SM, Kaufman
P, Fehrenbacher L, Pisansky T, Vogel V, Kutteh LA, Yothers G, Visscher D, Brown AM, Jenkins R, Seay TE,
Mamounas E, Abrams J, Wolmark N
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NSABP B-31
NCCTG N9831
Arm 1Arm 2
Arm A
Arm B
Arm C
= doxorubicin/cyclophosphamide (AC) 60/600 mg/m2 q 3 wk x 4= paclitaxel (T) 175 mg/m2 q 3 wk x 4= paclitaxel (T) 80 mg/m2/wk x 12
= trastuzumab (H) 4mg/kg LD + 2 mg/kg/wk x 51
Control: ACT
Investigational: ACT+H
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Patient Eligibility• HER-2 positive by FISH or +++ by IHC verified
centrally (N9831) or by approved reference lab (B-31)
• Normal left ventricular ejection fraction
• No past or active cardiac disease including:• History of myocardial infarction• History of congestive heart failure• Angina pectoris requiring medication• Arrhythmia requiring medication• Clinically significant valvular disease• Uncontrolled hypertension• LVH• Cardiomegaly on CXR
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B-31 Arm 2 / N9831 Arm C AC Paclitaxel + Trastuzumab
B-31 Arm 1 / N9831 Arm A AC Paclitaxel
0mo.
18mos.
6mos.
9mos.
3mos.
0mo.
18mos.
6mos.
9mos.
3mos.
LVEF Evaluation ScheduleLVEF Evaluation Schedule
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Within Normal Limits
1- 5 % below LLN
6 % below LLN
Cont.
Hold *
Hold *
Relationship of LVEF to LLN
Absolute Decreaseof < 10%
Absolute Decrease of 10 - 15%
Absolute Decrease of 16%
Hold *
Hold *
Hold *
Cont.
Cont.
Cont.*
* Repeat LVEF assessment after 4 weeks - If criteria for continuation met – resume trastuzumab - If 2 consecutive holds, or total of 3 holds occur – discontinue trastuzumab
Asymptomatic PatientsRules for Trastuzumab Continuation
Based on Serial LVEFs
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2.1
7.2
2.9
7.7
0
5
10
15
20
25
1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
B-31: Trastuzumab Discontinuation Due to Asymptomatic or Symptomatic Cardiac Dysfunction by Quarter
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Patient and Tumor Characteristics (%)AC Paclitaxel AC Paclitaxel
+ Trastuzumab
872B-31
807N9831
864B-31
808N9831
Age<5050-59≥60
523415
513415
513216
503218
No. Pos Nodes01-34-910+
0572914
13482515
0572914
11502514
Hormone ReceptorsER+ER-PR+PR-
53474158
52464157
51483960
51483960
Tumor Size≤2.0 cm.2.1-4.0 cm.>4.0 cm.
414314
404613
374417
384714
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Statistical Analysis
• Median follow-up: 2.0 years (2.4 years on B-31/1.5 years on N9831)
• Primary endpoint: DFS– analyzed by intent-to-treat
• Secondary endpoints: OS and Time to 1st Distant Recurrence
• Definitive analysis after 710 DFS events
• First interim analysis after 355 DFS events
• Stop trials only if equivalence is rejected at p=0.0005 (2p=0.001)
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Disease-Free Survival
87%87% 85%85%
67%
75%
N EventsACT 1679 261ACTH 1672 134
%
HR=0.48, 2P=3x10-12
ACACTHTH
ACT
Years From Randomization B31/N9831
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Hazard Ratio0.2 0.4 0.6 0.8 1.0 1.2 1.4
Forest Plot For Disease-Free Survival
Protocol
No.PositiveNodes
TumorSize
HormoneReceptor
Age
N9831NSABP B-31
≥ 4.1cm2.1- 4.0 cm<2.0 cm
PositiveNegative
≥6050-5940-49≤39
ALL DATA
10+4-91-30
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0 1 2 3 4 550
60
70
80
90
100
0 1 2 3 4 5
50
60
70
80
90
100
Disease-Free Survival
B-31 N9831
ACTH 864 83ACT 872 171 ACT 807 90
ACTH 808 51
N Events N Events
HR=0.45, 2P=1x10-9 HR=0.55, 2P=0.0005
ACACTHTH ACACTHTH
ACTACT
74%
87%85%
66%
78%
87% 86%
68%
Years From Randomization
%
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Time to First Distant Recurrence
90%90%
81%
74%
AC->T+H 1672 96AC->T 1679 194
HR=0.47, 2P=8x10-10
N Events
AC->T+H
AC->T
0 1 2 3 4 5
50
60
70
80
90
100
90%90%
81%
74%
ACTH 1672 96ACT 1679 194
HR=0.47, 2P=8x10-10
N Events
ACACTHTH
ACT
B31/N9831Years From Randomization
90%90% 90%90%
81%
74%%
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Hazard of Distant Recurrence
0 1 2 3 4
0
20
40
60
80
100
120R
ate
per
100
0 W
om
en /
Yr
Years From Randomization
ACACTHTH
ACT
B31/N9831
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B-31/N9831 Survival
ACACTHTH94%94%
91%91%
87%
92%ACT
N DeathsACT 1679 92ACTH 1672 62
HR=0.67, 2P=0.015
Years From Randomization B31/N9831
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3574.00.63.0
5324.00.62.5
7194.00.42.0
9243.90.41.5
11683.50.41.0
14122.50.30.5
No. A
t Risk
Cum
Inc A
rm2 (%
)
Cum
Inc A
rm 1 (%
)
Yrs P
ost Day 1 C
yc5
Cohort Arm 1 Evaluable CohortArm 2 Evaluable Cohort
%
0
2
4
6
Years Post Day 1 Cyc 50.0 0.5 1.0 1.5 2.0 2.5 3.0
B-31: Cumulative Incidence ofCardiac Events in the Evaluable Cohort
HR=7.2
4.0%
0.6%
Arm 2: AC→T HN=846, 30 CHFs,No Cardiac Deaths
Arm 1: AC→T N=811, 3 CHFs, 1 Cardiac Death
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LV
EF
(%
)
Age
B-31: Post-AC LVEF and Age Are Independent Predictors of Trastuzumab-Associated CHF
P(Age)=0.04P(LVEF)<0.0001
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Conclusions1. For high risk HER-2 positive breast cancer,
trastuzumab given concurrently with paclitaxel following AC chemotherapy, reduces the risk of a first breast cancer event at 3 years by 52%.
2. The relative risk reduction benefit was present and of similar magnitude in all subsets of patients analyzed. There is not, however, statistical power to establish efficacy in the node negative subset.
3. The addition of trastuzumab reduced the probability of distant recurrence by 53% at 3 years, and the hazard of developing distant metastases appears, thus far, to decrease over time.
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Conclusions
4. Results at a median follow-up of 2 years show a statistically significant survival advantage with a relative risk reduction of 33%.
5. The combination of trastuzumab and chemotherapy has a notable risk of cardiac toxicity. Careful monitoring of cardiac function is of vital importance if trastuzumab is to be used in the adjuvant setting.
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NCCTG N9831May 2005 Update
NCCTG N9831May 2005 Update
Perez EA, Suman VJ, Davidson N, Martino S, Kaufman P, on Behalf of
NCCTG, ECOG, SWOG, CALGB
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Perez E. Protocol NCCTG-N9831. H=trastuzumab (4mg/kg loading dose, followed by 2mg/kg); doxorubicin dose 60mg/m2; cyclophosphamide, 600mg/m2; paclitaxel, 80mg/m2
q3w=every 3 weeks; qw=weekly
NCCTG N9831 Schema
RRAANNDDOOMMIIZZEE
Radiation and/or hormonal therapy as indicatedRadiation and/or hormonal therapy as indicated
Paclitaxel qw x 12Paclitaxel qw x 12Arm A:Arm A: AC q3w x 4AC q3w x 4
Paclitaxel qw x 12Paclitaxel qw x 12Arm B: Arm B: AC q3w x 4AC q3w x 4 H qw x 52H qw x 52
AC q3w x 4Paclitaxel qw x 12 Paclitaxel qw x 12
++H qw x 12H qw x 12
Arm C:Arm C: H qw x 40H qw x 40
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Statistical PlanAddition of H to AC T
• Two pairwise comparisons
• Goal
– To detect a 33% increase in median DFSfrom 6.3 to 8.4 years
• Final analysis
– At 663 events for A vs C comparison
– At 789 events for A vs B comparison
Control: AC TSequentialAC T H
Concurrent AC T + H H
Control: AC T
T=paclitaxel; DFS=disease free survival
vs
vs
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Statistical Plan Timing of H Initiation
• Pairwise comparison
• Goal
– To detect a 29% increase in median DFSfrom 7.3 to 9.4 years
• Final analysis
– At 590 events for B vs C comparison
SequentialAC T H
Concurrent AC T + H H
vs
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Cardiac Testing
Time (months)
LVEF measurement
6 9 18–210 3
Arm B: AC x 4 Paclitaxel H
Arm A: AC x 4 Paclitaxel
Arm C: AC x 4 Paclitaxel + H H
LVEF=left ventricular ejection fraction; LLN=lower limit of normal
Pre-AC Post-AC
No H if symptoms or LVEF ↓ >15% or ↓ to <LLN
RRAANNDDOOMIMIZZEE
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Impact of Joint Analysis on N9831 April 2005
• Joint analysis with B-31: Concurrent approach
• DMC asked for an unplanned interim analysis comparing Arm B (sequential) vs Arm C (concurrent) to assist in patient management
DMC=data monitoring committee
AC AC T + H T + H HH significantly improves significantly improves disease-free and overall survival vs disease-free and overall survival vs controlcontrol: : AC AC T T
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Patient/Event Status at Time of Joint Analysis April 2005
• Patients
– Enrollment goals met (n: >3300)
700 patients on chemotherapy
• 2701 patients entered prior to 1/1/2005
– Median follow up: 1.5 years
• Total disease-free survival events
– A and B: 220 (of 789 needed)
– B and C: 147 (of 590 needed)
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Pairwise Comparison
Number of events
Log rank p-value*
HR* (95% CI)
AC → T vs AC → T + H → H
395 3x10–12 0.48 (0.39-0.60)
Pairwise Comparison
Number of events
Log rank p-value*
HR* (95% CI)
AC → T vs AC → T → H
(n=1964)**
220 0.2936 0.87 (0.67-1.13)
AC → T → H vs AC → T + H → H (n=1682)**
137
0.0114 0.64 (0.46-0.91)
Results Disease-Free Survival
*Stratified – nodal status and receptor status**for patients randomized before 1/1/2005
*Stratified – nodal status and receptor status
Joint Analysis
N9831 Analysis
A B
BC
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Disease-Free Survival: A vs BN9831
100
90
80
70
60
50
40
30
20
10
00 1 2 3 4
YearsNumber of patients followedA 979 629 353 168 15B 985 637 403 169 20
AC AC →→ T TEvents=117Events=117
Hazard ratio=0.87Hazard ratio=0.87Stratified logrank Stratified logrank 2P2P=0.2936=0.2936
AC AC →→ T T →→ H HEvents=103Events=103
%
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Disease-Free Survival: B vs CN9831
100
90
80
70
60
50
40
30
20
10
00 1 2 3 4
YearsNumber of patients followedB 842 501 285 162 20C 840 520 285 178 17
AC AC →→ T T →→ H H Events=84Events=84
AC AC →→ T + H T + H →→ H HEvents=53Events=53
%
Hazard ratio=0.64Hazard ratio=0.64Stratified logrank Stratified logrank 2P2P=0.0114=0.0114
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Pairwise Comparison
Number of events
Log rank p-value*
HR* (95% CI)
AC → T vs AC → T + H → H
154 0.015 0.67 (0.48-0.93)
Pairwise Comparison
Number of events
Log rank p-value*
HR* (95% CI)
AC → T vs AC → T → H
79 0.4752 0.85 (0.55-1.33)
AC → T → H vs AC → T + H → H
56
0.2696 0.74 (0.43-1.26)
Overall Survival
*Stratified – nodal status and receptor status
*Stratified – nodal status and receptor status
Joint Analysis Results
N9831 Analysis Results
AB
BC
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Other Relevant Factorsfor Patient Management
• HER2 testing
• Cardiac tolerability comparisons based on planned analyses
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HER2 Testing in N9831• Modest level of concordance between local and
central laboratories for both IHC and FISH
– With HercepTest™: 81% (78-83%)
– With FISH: 87% (84-90%)
• High level of agreement between central and reference laboratory results for HER2
– 94.5% for IHC (0, 1+, 2+)
– 95.1% for FISH (not amplified)
• Accurate HER2 testing is critical given the degree of trastuzumab benefit as a component of adjuvant therapy
Updated from Perez EA, et al. ASCO 2004 (abstract 567)
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Cardiac Monitoring Plan
• Monthly formal review of LVEF, clinical data
• Interim analyses after 100, 300, and 500 patients per arm
– completed AC and followed at least 6 months
• ~ 9 months from registration
Perez EA, et al. ASCO 2005 (abstract 556)
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• Difference in the incidence of cardiac events (CHF and cardiac deaths) between non-H and H arms is <4%
• 9 month analysis; 500 per arm with nl LVEF or LVEF decrease 15% from baseline (after AC)
– 0.0% (95% CI,0.0-0.7%) for control
– 2.2% (95% CI,1.1-3.8%) for control vs sequential
– 3.3% (95% CI,2.0-5.1%) for control vs concurrent* therapy with paclitaxel
Effect of the Introduction of H on Cardiac Tolerability
Perez EA, et al. ASCO 2005 (abstract 556)
* at month 9, concurrent pts have received 3 additional months of H compared to sequential
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Effect of Introduction of H on Disease Recurrence
Conclusions• 52% decreased recurrence with concurrent
vs control treatment (P=3X10-12) (joint analysis finding)
• 13% decreased recurrence with sequential vs control treatment (P=0.2936)
• 36% decreased recurrence with concurrent vs sequential treatment (P=0.0114)
• More follow up is needed to determine whether this trend continues
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NCCTG N9831Next Steps
• Pre-specified interim analyses at 50%, 67%, and 75% of events still planned
• Continued exploration of predictive factors for cardiac toxicity
• Continued patient follow up
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A randomized three-arm multi-centre comparison of:A randomized three-arm multi-centre comparison of:• 1 year Herceptin®1 year Herceptin®• 2 years Herceptin®2 years Herceptin®• or no Herceptin®or no Herceptin®
in women with HER-2 positive primary breast cancer in women with HER-2 positive primary breast cancer who have completed adjuvant chemotherapywho have completed adjuvant chemotherapy
Martine J. Piccart-Gebhart, MD, PhD on behalf of: Martine J. Piccart-Gebhart, MD, PhD on behalf of: The Breast International Group (BIG), NON-BIG participating The Breast International Group (BIG), NON-BIG participating
groups, Independent sites, F. Hoffmann – La Roche Ltd.groups, Independent sites, F. Hoffmann – La Roche Ltd.
FIRST RESULTS OF THE FIRST RESULTS OF THE HERA TRIALHERA TRIAL
ASCO, Scientific Session, May 16, 2005ASCO, Scientific Session, May 16, 2005
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EU
71.5%
EASTERN EASTERN EUROPE: EUROPE:
11%11%
JAPAN JAPAN
12%12%
ASIA ASIA PACIFICPACIFIC
CENTRAL &
SOUTH AMERICA
5.5%5.5%
ACCRUAL: 5090 WOMEN ACCRUAL: 5090 WOMEN 478 centers from 39 countries (2002-2005)478 centers from 39 countries (2002-2005)
CANADACANADA
NORDIC NORDIC COUNTRIESCOUNTRIES
SOUTH SOUTH AFRICAAFRICA
AUSTRALIA – AUSTRALIA – NEW ZEALANDNEW ZEALAND
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HERA TRIAL DESIGN HERA TRIAL DESIGN
Women with HER2 POSITIVE invasive Women with HER2 POSITIVE invasive breast cancer IHC3+ or FISH+ centrally confirmedbreast cancer IHC3+ or FISH+ centrally confirmed
Surgery + (neo)adjuvant chemotherapy (CT) Surgery + (neo)adjuvant chemotherapy (CT) radiotherapy radiotherapy
StratificationStratificationStratificationStratificationNodal status, adjuvant CT regimen, hormone receptor status and endocrine therapy, Nodal status, adjuvant CT regimen, hormone receptor status and endocrine therapy,
age, regionage, region
RandomizationRandomizationRandomizationRandomization
TrastuzumabTrastuzumab8 mg/kg 8 mg/kg 6 mg/kg 6 mg/kg3 weekly x 2 years3 weekly x 2 years
TrastuzumabTrastuzumab8 mg/kg 8 mg/kg 6 mg/kg 6 mg/kg3 weekly x 1 year3 weekly x 1 year
ObservationObservation
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KEY INCLUSION CRITERIAKEY INCLUSION CRITERIA
• Centrally confirmed HER-2 overexpression Centrally confirmed HER-2 overexpression or amplificationor amplification
• Node-positive or (sentinel) node-negative Node-positive or (sentinel) node-negative with with T1c T1c
• Completed Completed 4 cycles of approved 4 cycles of approved (neo)adjuvant chemotherapy regimen(neo)adjuvant chemotherapy regimen
• Baseline LVEF Baseline LVEF 55% (Echo or MUGA) 55% (Echo or MUGA)• Known hormone receptor statusKnown hormone receptor status
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Primary endpoint: Primary endpoint: DFSDFS
Secondary endpoints: RFS, DDFS, OS, Secondary endpoints: RFS, DDFS, OS, 2 years vs 1 year trastuzumab2 years vs 1 year trastuzumab
EFFICACYEFFICACY
ENDPOINTS AND ANALYSIS PLANENDPOINTS AND ANALYSIS PLAN
Target accrual: 4482Target accrual: 4482HR = 0.77 (power 80% 2 sided HR = 0.77 (power 80% 2 sided = 0.025) = 0.025)
for each pairwise test (1y vs nil or 2y vs nil)for each pairwise test (1y vs nil or 2y vs nil)
Target accrual: 4482Target accrual: 4482HR = 0.77 (power 80% 2 sided HR = 0.77 (power 80% 2 sided = 0.025) = 0.025)
for each pairwise test (1y vs nil or 2y vs nil)for each pairwise test (1y vs nil or 2y vs nil)
One interim efficacy analysis (n = 475 events)One interim efficacy analysis (n = 475 events)One primary core analysis (n = 951 events)One primary core analysis (n = 951 events)
SAFETYSAFETY
• TolerabilityTolerability• Incidence of cardiac Incidence of cardiac
dysfunction.dysfunction.
Three interim analysis of Three interim analysis of cardiac endpoints aftercardiac endpoints aftern = 300n = 300 n = 600n = 600 n = 900 n = 900 ptspts
Stopping rule: Stopping rule: 4% 4% absolute increase in primary absolute increase in primary
cardiac eventscardiac events
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HERA FLOW CHARTHERA FLOW CHART
5090 Women enrolled5090 Women enrolled
5081 with available data5081 with available data1 year median follow-up1 year median follow-up
2y trastuzumab2y trastuzumabN=1694N=1694
Efficacy Efficacy AnalysisAnalysisN=3387N=3387
N= 1677N= 16771y trastuzumab1y trastuzumab
N=1736N=1736ObservationObservation
Safety Safety AnalysisAnalysisN=3413N=3413
N=3N=3N=20N=20N=26N=26
ObservationObservationN=1693N=1693
1y trastuzumab1y trastuzumabN=1694N=1694
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PATIENT/TUMOR CHARACTERISTICSPATIENT/TUMOR CHARACTERISTICS
Age (%)Age (%)
< 35 y< 35 y
35- 49 y35- 49 y50 - 59 y50 - 59 y 60 y60 ymissingmissing
Observation (n = 1693) 1 year trastuzumab (n = 1694)
Adjuvant chemotherapy (%)Adjuvant chemotherapy (%)
Anthracyclines + taxanesAnthracyclines + taxanes
No anthracyclines,No anthracyclines,no taxaneno taxane
AnthracyclinesAnthracyclines
missingmissing
7.3 7.6
31.844.343.7
16.20.2
32.7
0.216.2
6.26.1
26.025.50.1 0.2
68.3 67.9
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Menopausal status at randomization (%)Menopausal status at randomization (%)
Observation (N=1693)Observation (N=1693) 1 year trastuzumab (N=1694)1 year trastuzumab (N=1694)
50.0
37.9
16.115.4
37.2
47.1 Postmenopausal
Uncertain
PremPrem
PATIENT/TUMOR CHARACTERISTICSPATIENT/TUMOR CHARACTERISTICS
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Observation (N=1693)Observation (N=1693) 1 year trastuzumab (N=1694)1 year trastuzumab (N=1694)
28.532.1
11.1
28.328.9
32.910.2
27.9
Node neg.Node neg.1-3 + nodes1-3 + nodes 4 + nodes4 + nodes
0.20.20.10.1missingmissing
Nodal Status (%)Nodal Status (%)
Hormone Receptor (%)Hormone Receptor (%)
49.9
50.0
49.0HR negativeHR negative
HR positiveHR positive
Any (neoadjuvant)Any (neoadjuvant)
50.9
49.0
PATIENT/TUMOR CHARACTERISTICSPATIENT/TUMOR CHARACTERISTICS
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ADJUVANT ENDOCRINE THERAPYADJUVANT ENDOCRINE THERAPY
ObservationObservation 1 year trastuzumab1 year trastuzumab
TAMTAM
64%64%AIAI
TAMTAMAIAI
9%9%
11%11%
LHRH ± TAMLHRH ± TAM
16%16%
TAMTAM
66%66%8%8%
8%8%
17%17%
AIAI
TAMTAMAIAI
LHRH ± TAMLHRH ± TAM
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OVERVIEW OF ADVERSE EVENTSOVERVIEW OF ADVERSE EVENTS
7.97.91321324.34.37575Patients with at least Patients with at least one grade 3 or 4 AEone grade 3 or 4 AE
8.58.5143 143 (c)(c)Treatment withdrawals Treatment withdrawals
6 6 (b)(b)3 3 (a)(a)Fatal AEFatal AE
7.07.01171174.74.78181Patients with at least Patients with at least one SAEone SAE
%%NN%%NN
1 year trastuzumab1 year trastuzumab
(N=1677)(N=1677)
ObservationObservation
(N=1736)(N=1736)
a)a) Cardiac failure, suicide, unknownCardiac failure, suicide, unknownb)b) Cerebral hemorrhage, cerebrovascular accident, sudden death, appendicitis, two unknownCerebral hemorrhage, cerebrovascular accident, sudden death, appendicitis, two unknownc)c) Reason: safety in 6%, refusal in 2.5%Reason: safety in 6%, refusal in 2.5%
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SAFETY ANALYSIS POPULATIONSAFETY ANALYSIS POPULATIONCardiotoxicityCardiotoxicity
0.5%0.5%
(95% CI: 0.25-1.02)(95% CI: 0.25-1.02)
0 %0 %
(95% CI: 0.00-0.21)(95% CI: 0.00-0.21)
Same LVEF criteriaSame LVEF criteriaandand symptomatic CHF symptomatic CHF NYHA class III/IV, NYHA class III/IV, confirmed by confirmed by cardiologist cardiologist
Cardiac deathCardiac death
7.1 %7.1 %2.2 %2.2 %Decrease by Decrease by 10 EF points 10 EF points and LVEF < 50% and LVEF < 50%
1 year trastuzumab1 year trastuzumab
N=1677N=1677
ObservationObservation
N=1736N=1736
0.1% 0%
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DISEASE-FREE SURVIVALDISEASE-FREE SURVIVAL
% alive % alive and and
disease disease freefree
Months fromMonths from randomizationrandomization00 55 1010 1515 2020 2525
16931693 14281428 994994 580580 280280 8787
16941694 14721472 10671067 629629 303303 102102
EventsEvents22--yryr
DFSDFS %% HRHR [95% CI][95% CI] p valuep value
127127 85.885.8 0.540.54 [0.43, 0.67][0.43, 0.67] <0.0001<0.0001
220220 77.477.4
1 year trastuzumab1 year trastuzumab
ObservationObservation
10010090908080707060605050404030302020101000
No. No. at riskat risk
Months fromMonths from randomizationrandomization00 55 1010 1515 2020 2525
16931693 14281428 994994 580580 280280 8787
16941694 14721472 10671067 629629 303303 102102
EventsEvents22--yryr
DFSDFS %% HRHR [95% CI][95% CI] p valuep value
127127 85.885.8 0.540.54 [0.43, 0.67][0.43, 0.67] <0.0001<0.0001
220220 77.477.4
1 year trastuzumab1 year trastuzumab
ObservationObservation
10010090908080707060605050404030302020101000
No. No. at riskat risk
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3%3% n=6n=6 n=3n=3 2%2%
n=6n=6 5%5%
DISEASE-FREE SURVIVALDISEASE-FREE SURVIVALType of First EventType of First Event
Observation Observation n= 220 eventsn= 220 events
1 year trastuzumab1 year trastuzumabn= 127 eventsn= 127 events
n=154n=154 n= 85n= 85 67%67%
23%23% n=50n=50
3%3% n=7n=7
1%1% n=3n=3
n=6n=6 5%5%
Distant eventDistant event
Loco regional eventLoco regional event
Contralateral breast CaContralateral breast Ca
Death as first eventDeath as first event
Second non breast malignancySecond non breast malignancy
70%70%
n=27n=27 21% 21%
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DFS BENEFIT IN SUBGROUPSDFS BENEFIT IN SUBGROUPSHR: 1 year trastuzumab vs observationHR: 1 year trastuzumab vs observation
0 1 2
All
Any, neo-adjuvant chemotherapyNodalstatus
0 pos, no neo-adjuvant chemotherapy
3387
3581100
872
2032307
n
0.54
0.530.52
0.77
0.640.43
Hazardratio
1-3 pos, no neo-adjuvant chemotherapy4 pos, no neo-adjuvant chemotherapy
No anthracycline or taxaneAdjuvant chemotherapy regimen
Anthracycline, no taxaneAnthracycline + taxane
NegativeReceptor status/endocrine therapy
Pos + no endocrine therapyPos + endocrine therapy
<35 yrsAge group
35-49 yrs50-59 yrs
60 yrs
Europe, Nordic, Canada, SA, Aus, NZRegion
Asia Pacific, JapanEastern Europe
Central + South America
972953
0.510.53
1674 0.514671234
0.490.68
251 0.4714901091
0.520.53
549 0.70
2430 0.58405364
0.420.31
188 0.90
Favorstrastuzumab
Favorsobservation
0 1 2
All
Any, neo-adjuvant chemotherapyNodalstatus
0 pos, no neo-adjuvant chemotherapy
3387
3581100
872
2032307
n
0.54
0.530.52
0.77
0.640.43
Hazardratio
1-3 pos, no neo-adjuvant chemotherapy4 pos, no neo-adjuvant chemotherapy
No anthracycline or taxaneAdjuvant chemotherapy regimen
Anthracycline, no taxaneAnthracycline + taxane
NegativeReceptor status/endocrine therapy
Pos + no endocrine therapyPos + endocrine therapy
<35 yrsAge group
35-49 yrs50-59 yrs
60 yrs
Europe, Nordic, Canada, SA, Aus, NZRegion
Asia Pacific, JapanEastern Europe
Central + South America
972953
0.510.53
1674 0.514671234
0.490.68
251 0.4714901091
0.520.53
549 0.70
2430 0.58405364
0.420.31
188 0.90
Favorstrastuzumab
Favorsobservation
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SECONDARY EFFICACY ENDPOINTSSECONDARY EFFICACY ENDPOINTSIntent-to-treat AnalysisIntent-to-treat Analysis
RFSRFS DDFSDDFS OSOS
0.500.50 0.510.51
0.760.76
95% CI95% CIpp value (logrank) value (logrank)2y outcome (%)2y outcome (%)
0.40-0.630.40-0.63< 0.0001< 0.0001
78.6 vs 87.278.6 vs 87.2
0.40-0.660.40-0.66< 0.0001< 0.0001
81.8 vs 89.781.8 vs 89.7
0.47-1.230.47-1.23<0.26<0.26
95.0 vs 96.095.0 vs 96.0ObservationObservation1 year trastuzumab1 year trastuzumab
No of No of eventsevents
209209 113113 179179 9898 3737 2929
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CONCLUSIONSCONCLUSIONS
At one year median follow-up:At one year median follow-up:
• Trastuzumab given every 3 weeks for one year following Trastuzumab given every 3 weeks for one year following adjuvant chemotherapy significantly prolongs DFS and RFS adjuvant chemotherapy significantly prolongs DFS and RFS for women with HER-2 positive early breast cancerfor women with HER-2 positive early breast cancer
• Trastuzumab significantly reduces the risk of distant Trastuzumab significantly reduces the risk of distant metastasesmetastases
• Trastuzumab’s clinical benefits are independent of Trastuzumab’s clinical benefits are independent of patients’ baseline characteristics (nodal status, hormone patients’ baseline characteristics (nodal status, hormone receptor status, ...) and of receptor status, ...) and of type of adjuvant chemotherapy type of adjuvant chemotherapy receivedreceived
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• Trastuzumab therapy is associated with a low incidence of Trastuzumab therapy is associated with a low incidence of severe symptomatic congestive heart failure; longer severe symptomatic congestive heart failure; longer
follow-up is needed to better quantify this riskfollow-up is needed to better quantify this risk
• All patients continue to be followed for long-term safety: All patients continue to be followed for long-term safety: patients in the observation arm will be offered trastuzumab patients in the observation arm will be offered trastuzumab (guidelines in preparation)(guidelines in preparation)
• Results regarding optimal trastuzumab duration (1 versus 2 Results regarding optimal trastuzumab duration (1 versus 2 years) should be available by 2008years) should be available by 2008
CONCLUSIONSCONCLUSIONS
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HERA Study Design Elements
•Randomized following ctx
•DFS was primary endpoint
•Most patients did not receive taxane
•In contrast to the Joint analysis, HERA included a large percentage of node negative pts(About 1/3).
•Very short median follow-up
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Adjuvant Trastuzumab Summary and Conclusions
•Does adjuvant trastuzumab improve DFS? YES!
•Should we give trastuzumab with or following CTX?
•What is the appropraite duration of trastuzumab?
•What is the price of trastuzumab?
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Should we give Trastuzumab before or after CTX?
•Preclinical data suggest that trastuzumab may amplify ctx’s pro-apoptotic effects.
•Synergistic activity in preclinical models for some ctx
•Cardiotoxicity concerns when trastuzumab is given in proximity to anthracyclines.
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What is the appropriate duration of Trastuzumab?
•Unknown (HERA 1 vs. 2 yr pending)
•Current data supports one year of therapy
•Current data supports initiation of therapy for up to 6 months following completion of chemotherapy or radiation therapy
•Could we get by with less trastuzumab?
( ie. only with chemo?)
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What is the price of Trastuzumab?
Cardiac Toxicity(CHF) can be consequence of using trastuzumab
Rate = 3.3-4.3% AC-TH vs. 0-0.5% AC-T (B31/ N9831)
Rate = 0.5-2.2% post ctx (HERA/N9831)
Degree of reversibility uncertain and requires further follow-up
Long term effects unknown
While benefit far outweighs the risks, the price is real and should be discussed with patients
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BCIRG 006Adjuvant Breast Cancer
Node Positive and High Risk Node Negative
HER2 +FISH
4 x AC60/600 mg/m2
4 x Docetaxel100 mg/m2
6 x Docetaxel and Platinum salts75 mg/m2 75 mg/m2 or AUC 6
1 Year Trastuzumab
N=3150480
centres
1 Year Trastuzumab
ACT
ACTH
TCH
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BCIRG 006 LVEF Decline by NYHA Class
AC-T AC-TH TCH
>10 < LLN 9 34 7
>15%< LLN 6 25 4
Grade 3-4 CHF 1 18 1
Implication: Trastuzumab by itself is not cardiotoxic; it becomes so when it keeps company with doxorubicin.
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Intergroup Guidelines for N9831
•For women receiving trastuzumab, continue until 1 year is completed.
•For women randomized to 1 yr TH, continue as planned
•For women on Arm A: AC-T and are at most 6 months from completion of paclitaxel, begin weekly trastuzumab and continue until you have completed 1 yr of trastuzumab with cardiac testing.
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Intergroup Guidelines for N9831
•For women on Arm A: AC-T and have not started paclitaxel, begin weekly trastuzumab with paclitaxel and continue until 1 yr of trastuzumab is completed, with cardiac testing.
•For women on Arm B: AC-T-H, and you have not begun trastuzumab, begin trastuzumab with paclitaxel and continue for 1 yr. with cardiac testing.
•If ctx completed > 6 mo. and have not received trastuzumab, discuss risks and benefits.
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E2100A Randomized Phase III Trial of Paclitaxel
versus Paclitaxel plus Bevacizumab as First-Line Therapy for Locally Recurrent or
Metastatic Breast Cancer
KD Miller, M Wang, J Gralow, M Dickler, MA Cobleigh, EA Perez, TN Shenkier,
NE Davidson
Indiana University Cancer Center, Dana Farber Cancer Institute, Pudget Sound Oncology Consortium, Memorial Sloan Kettering Cancer Center, Rush-Presbyterian-St. Luke’s Medical
Center, Mayo Clinic, British Columbia Cancer Agency, Vancouver Cancer Center, Johns Hopkins Oncology Center
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Rationale• Tumor growth is dependent on
angiogenesis• Bevacizumab is a humanized
monoclonal antibody directed against VEGF
• Recognizes all VEGF-A isoforms
• Active in patients with refractory MBC
• 9% response rate as monotherapy
• Increases ORR but not PFS in combination with capecitabine
• Greater activity expected in less heavily pre-treated patients
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Stratify:• DFI < 24 mos. vs. > 24 mos.• < 3 vs. > 3 metastatic sites• Adjuvant chemotherapy yes vs. no• ER+ vs. ER- vs. ER unknown
RANDOMIZE
Paclitaxel + Bevacizumab
Paclitaxel
Study Design
28-day cycle:Paclitaxel 90 mg/m2 D1, 8 and
15Bevacizumab 10 mg/kg D1
and 15
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Key Eligibility Criteria
• Locally recurrent or metastatic breast cancer– HER2+ only if prior treatment with
trastuzumab or contraindication• No prior chemo regimens for MBC
– Adjuvant taxane allowed if DFI > 12 months• ECOG PS 0 or 1• No anti-tumor therapy within 21 days• No CNS mets (head CT or MR required)• No significant proteinuria (> 500 mg/24 hr)• No therapeutic anticoagulation
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Statistical Design - Efficacy
• Primary endpoint: Progression-Free Survival– 85% power for a 33% improvement
• 6 vs. 8 months
– One-sided type I error 2.5%– Requires 650 eligible patients
• Final analysis after 546 PFS events– Interim analyses after 270 and 425 events– Asymmetric boundaries to stop early either for
demonstrated benefit or for lack of benefit– O-Brien-Fleming boundaries and repeated
confidence interval analyses at each interim
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Statistical Design - Safety
• Type I event: Grade 4 hemorrhage or HTN– Acceptable rate: 1%
• Type II event: Grade 3/4 thrombosis or embolism– Acceptable rate: 5%
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Current Analysis
• Study activated Dec 21, 2001• Closed March 24, 2004
– 715 eligible patients
• First planned interim analysis• Data cut-off February 9, 2005• 355 events
– Progression – 291– Death without documented progression - 64
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Patient Characteristics
Paclitaxel
(n=350)
Pac. + Bev.
(n=365)
Treated 346 365
Median age 55 (27-85) 56 (29-84)
DFI < 24 months 41% 41%
> 3 sites 29% 28%
Adjuvant chemo. 64% 65%
ER+ 63% 64%
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All patients Measurable Disease
0
10
20
30
40
Paclitaxel
Ov
era
ll R
es
po
ns
e R
ate
Pac + Bev
Response
316 236330 250
34.3%
16.4%
28.2%
14.2%
P<0.0001P<0.0001
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Progression Free Survival
HR = 0.498 (0.401-0.618)
Log Rank Test p<0.001
Months
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0PFS
Pro
port
ion
0 10 20 30
Pac. + Bev. 10.97 monthsPaclitaxel 6.11 months
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Overall Survival
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0 10 20 30 40
Months
OS P
rop
ort
ion
Pac. + Bev.
Paclitaxel
HR = 0.674 (0.495-0.917)
Log Rank Test p=0.01
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Bevacizumab ToxicityNCI-CTC Grade 3 and 4
Paclitaxel
(n=330)
Pac. + Bev.
(n=342)
%
Grade 3
Grade 4
Grade 3
Grade 4
HTN* 0 0 13 0.3
Thromboembolic 0.3 0.9 1.2 0
Bleeding 0 0 0.6 0.3
Proteinuria** 0 0 0.9 1.5NCI-CTC v3.0, worst per patient
*p<0.0001; **p=0.0004
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Other ToxicitiesNCI-CTC Grade 3 and 4
Paclitaxel
(n=330)
Pac. + Bev.
(n=342)
%
Grade 3 Grade 4
Grade 3
Grade 4
Neuropathy* 13.6 0.6 19.9 0.6
Fatigue 2.7 0 4.7 0.3
Neutropenia 0 3 0.9 4.4
LVEF 0 0 0.3 0
NCI-CTC v3.0, worst per patient *p=0.01
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Ongoing Correlative Studies
• Quality of Life (FACT-B)
• Circulating markers– Serum VCAM-1– Urine VEGF
• Analysis of primary tumor samples– VEGF expression
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Conclusions and Future Directions
• Addition of bevacizumab to paclitaxel– Significantly prolongs progression free
survival– Increases objective response rate– Longer follow-up required to assess impact on
OS
• Further studies should – Explore the role of Bevacizumab in the
adjuvant setting– Develop methods to identify patients who are
most likely to benefit from VEGF-targeted therapies
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Adjuvant Pilot TrialRationale
• Most successful use of anti-angiogenic therapy predicted to be in adjuvant setting– Require large trial for proof of concept
• Limitations of metastatic trials– Chronic therapy in only a few patients– Different tolerance for toxicity– Different metabolism (?)– Less concern for rare but potentially fatal
toxicities
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E2104 Schema
REGISTER
Doxorubicin 60 mg/m2 plus Cyclophosphamide 600 mg/m2 Bevacizumab 10 mg/kgevery 14 days x 4
Arm A: ddBAC >BT >B
Arm B: ddAC >BT >B
Doxorubicin 60 mg/m2 plus Cyclophosphamide 600 mg/m2 every 14 days x 4
Paclitaxel 175 mg/m2 Bevacizumab 10 mg/kg every 14 days x 4
Paclitaxel 175 mg/m2 Bevacizumab 10 mg/kg every 14 days x 4
Bevacizumab 10 mg/kg every 14 days x 18
Bevacizumab 10 mg/kg every 14 days x 22
*Hormone therapy and radiation per standard care