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Therapeutic options for relapsed / refractory HER2 positive metastatic breast cancer. William J. Gradishar MD, FACP Betsy Bramsen Professor of Breast Oncology Director, Maggie Daley Center For Women's Cancer Care Robert H. Lurie Comprehensive Cancer Center - PowerPoint PPT Presentation
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•William J. Gradishar MD, FACP•Betsy Bramsen Professor of Breast Oncology
•Director, Maggie Daley Center For Women's Cancer Care•Robert H. Lurie Comprehensive Cancer Center
•Northwestern University Feinberg School of Medicine•Chicago, IL
Therapeutic options forrelapsed / refractory HER2 positive
metastatic breast cancer
Lapatinib added to capecitabine for patients with HER2 MBC progressing on trastuzumab: PFS
Geyer et al, N Engl J Med. 2006;355:2733-43.
No. of patients at risk: L + C C
163161
9678
5233
2114
104
41
Weeks
Patients Free of Disease Progression (%)100
80
60
40
20
00 10 20 30 40 50 60
P<0.001
Lapatinib + capecitabine (49 events; median time to progression, 8.4 mo)
Capecitabine alone ( 72 events; median time to progression, 4.4 mo)
30
Lapatinib added to capecitabine for patients with HER2 MBC progressing on trastuzumab: Efficacy
Geyer et al, N Engl J Med. 2006;355:2733-43.
Lapatinib + capecitabine
(n=163)Capecitabine
(n=161)HR
(95% CI) PMedian TTP (months) 8.4 4.4 0.49
(0.34–0.71) <0.001
Median PFS (months) 8.4 4.1 0.49
(0.33–0.67) <0.001
Overall response (%) 22 14 0.09
Death (%) 22 22
Lapatinib added to capecitabine for patients with HER2 MBC progressing on trastuzumab: Adverse events
Geyer et al, N Engl J Med. 2006;355:2733-43.
Lapatinib + capecitabine(n=164)
Capecitabine(n=152)
P(incidence
- any grade)
Grade 1 2 3 4 Any 1 2 3 4 Any
Diarrhea (%) 27 20 12 1 60 14 14 11 0 39 <0.001
Dyspepsia (%)8 3 0 0 18 3 <1 0 0 5 0.014
Rash (%) 20 7 1 0 27 9 5 7 0 15 0.011
Lapatinib ± trastuzumab in patients with trastuzumab refractory MBC: PFS
Blackwell et al, J Clin Oncol. 2010;28:1124-30.
No. of patients at risk: L L + T
148148
5373
2142
1327
58
02
Time from random assignment (weeks)
Alive without progression (cumulative %)100
80
60
40
20
00 10 20 30 40 50 60
13
28 6-month PFS
p=0.008
Lapatinib + trastuzumab
(n=146)Lapatinib(n=145)
Progressed or died (n) 127 128
Median (weeks) 12.0 8.1
Hazard ratio (95% CI) 0.73 (0.57–0.93)
Lapatinib ± trastuzumab for trastuzumab refractory MBC: OS (updated analysis)
Blackwell et al, J Clin Oncol 2012;30:2585-92.
No. of at risk: L+T L
146145
120100
8764
6346
4228
1
Time since random assignment (months)
Overall Survival (%)100
80
60
40
20
00 5 10 15 20 25 35
6 month OS
41%
Lapatinib + trastuzumab
(n=146)Lapatinib(n=145)
Died, n (%) 105 (72) 113 (78)
Median (weeks) 14 9.5
Hazard ratio (95% CI)
0.74 (0.57–0.97)
Log-rank P .026
12-month OS
56%
80%
70%
30
2513
Current standards of care for HER2 positive MBC: patients progressing on trastuzumab (NCCN)
Agents for trastuzumab-exposed HER2-positive diseaseCapecitabine + lapatinibCapecitabine + trastuzumabLapatinib + trastuzumab
NCCN Category 2A
NCCN 2012; Breast cancer V3.2012
Single arm phase II trials of trastuzumab emtansine
Burris et al, J Clin Oncol. 2011;29:398-405.Krop et al, J Clin Oncol. 2012;30(26):3234-41.
Burris et al Krop et alPatients Patients with MBC progressing
after HER2 therapy with chemotherapy (n=112)
Patients with MBC previously treated with trastuzumab and lapatinib, anthracylines, capecitabine and taxane(n=110)
Treatment Trastuzumab emtansine 3.6 mg/kg q3w
Trastuzumab emtansine 3.6 mg/kg q3w
Objective response rate (%)
25.9 (all PR)(33.8% in HER2 positive tumors tested centrally)
35 (all PR)
PFS N/R 6.9 months
Results from a randomized phase II trial of trastuzumab emtansine
Hurvitz et al, Eur J Cancer. 2011;47(Suppl 1):#5001.
Series10
24
14.2
9.2
Trastuzumab emtansine(n=67)
Trastuzumab + taxane(n=70)
HR: 0.59 (0.36–0.97) p=0.0035
PFS (months)
EMILIA – Trastuzumab emtansine vs lapatinib + capecitabine in patients progressing after trastuzumab: Study design Entry criteria
Centrally confirmed HER2+ locally advanced or metastatic, progressive breast cancerPrior taxane and trastuzumab ECOG PS 0–1
Secondary endpointsORR and clinical benefit, duration of responseTime to symptom progression
Verma et al, N Engl J Med. 2012; 367: 1783-91.
Trastuzumab emtansine(3.6 mg/kg q21d)
Primary endpoints: OS, PFS and safetyR
HER2 + MBCPrior T failure(Target n=978)
Lapatinib (1250mg/d)+ capecitabine
(1000 mg/m2 q12 hr x 14/21d)
EMILIA – Trastuzumab emtansine vs lapatinib + capecitabine in patients progressing after trastuzumab: PFS
Verma et al, N Engl J Med. 2012; 367: 1783-91.
Months
Progression-free survival (%)
p<0.001
0 6 12 18 24 30
100
80
60
40
20
0
No. at risk:Lapatinib +capecitabineTrastuzumabemtansine
496
495
176
236
28262220161410842
404
419
310
341
5
9
0
0
1
3
0
1
129
183
35
72
73
130
53
101
25
54
8
18
14
44
9
30
Trastuzumab emtansine (265 events; median time, 9.6 mo)
Lapatinib + capecitabine (304 events; median time, 6.4 mo)
Stratified hazard ratio0.65 (95% CI, 0.55-0.77)
EMILIA – Trastuzumab emtansine vs lapatinib + capecitabine in patients progressing after trastuzumab: OS
Verma et al, N Engl J Med. 2012; 367: 1783-91.
Months
Overall survival (%)
0
100
80
60
40
20
0
496
495
435
457
471
485
453
474
27
38
4
5
17
28
7
13
403
439
240
293
368
418
297
349
110
136
45
62
86
111
63
86
204
242
159
197
133
164
6 12 18 24 3028262220161410842 363432
78.2%
51.8%
85.2%
64.7%
Trastuzumab emtansine (149 events; median time, 30.9 mo)
Lapatinib + capecitabine (182 events; median time, 25.1 mo)
Stratified hazard ratio,0.68 (95% CI, 0.55–0.85) p<0.001
No. at risk:Lapatinib +capecitabineTrastuzumabemtansine
EMILIA – Trastuzumab emtansine vs lapatinib + capecitabine in patients progressing after trastuzumab: ORR
Trastuzumab emtansine(n=397)
Lapatinib + capecitabine(n=389)
0
25
50
CRPR
30.8
Verma et al, N Engl J Med. 2012; 367: 1783-91.
Patients (%)43.6
p<0.001
Duration ofresponse (mo): 12.6 6.5
EMILIA – Trastuzumab emtansine vs lapatinib + capecitabine in patients progressing after trastuzumab: Dose reduction
Trastutumab emtansine (n=495)
Lapatinib + capecitabine (n=496)
Dose reduction (patients, %)
16.3 L: 27.3C: 53.4
Median daily dose 3.5 mg/kg/21d L:1250 mg/dC: 1730 mg/m2/d
Discontinued due to adverse events (patients, %)
5.9 L: 7.6C: 9.4
Verma et al, N Engl J Med. 2012; 367: 1783-91.
EMILIA – Trastuzumab emtansine vs lapatinib + capecitabine in patients progressing after trastuzumab:
Grade 3 or 4 events in ≥2% in either arm
Verma et al, N Engl J Med. 2012; 367: 1783-91.
Adverse Event Trastuzumab emtansine(n=490)
Lapatinib + capecitabine(n=488)
Events of any grade
(%)
Grade 3 or 4 events
(%)
Events of any grade
(%)
Grade 3 or 4 events
(%)
Any event 470 (95.9) 200 (40.8) 477 (97.7) 278 (57.0)
Specific events†
Diarrhea 114 (23.3) 8 (1.6) 389 (79.7) 101 (20.7)
Palmar-plantar erythrodysesthesia 6 (1.2) 0 283 (58.0) 80 (16.4)
Vomiting 93 (19.0) 4 (0.8) 143 (29.3) 22 (4.5)
Neutropenia 29 (5.9) 10 (2.0) 42 (8.6) 21 (4.3)
Hypokalemia 42 (8.6) 11 (2.2) 42 (8.6) 20 (4.1)
Fatigue 172 (35.1) 12 (2.4) 136 (27.9) 17 (3.5)
Nausea 192 (39.2) 4 (0.8) 218 (44.7) 12 (2.5)
Mucosal inflammation 33 (6.7) 1 (0.2) 93 (19.1) 11 (2.3)
Anemia 51 (10.4) 13 (2.7) 39 (8.0) 8 (1.6)
Elevated ALT 83 (16.9) 14 (2.9) 43 (8.8) 7 (1.4)
Elevated AST 110 (22.4) 21 (4.3) 46 (9.4) 4 (0.8)
Thrombocytopenia 137 (28.0) 63 (12.9) 12 (2.5) 1 (0.2)
Summary For patients with relapsed / refractory metastatic
breast cancer lapatinib + capecitabine is the current standard of careBased on a comparison with capecitabine alone
improvements in PFS and OS Studies have shown that dual HER2 inhibition with
lapatinib and trastuzumab also has clinical activity in this setting and may be considered
The novel drug-antibody conjugate trastuzumab emtansine is now approved by the FDA in this settingThe EMILIA trial demonstrated improved PFS and OS with
less dose reduction due to AEs