La malattia triplo negativa metastatica: quali trattamenti nella pratica clinica? - Roma, 27 Ottobre 2018 Relatore: Francesca Poggio - Aiom

Page created by Florence Singh
 
CONTINUE READING
La malattia triplo negativa metastatica: quali trattamenti nella pratica clinica? - Roma, 27 Ottobre 2018 Relatore: Francesca Poggio - Aiom
2018 CARCINOMA MAMMARIO: I TRAGUARDI RAGGIUNTI E LE NUOVE SFIDE

La malattia triplo negativa metastatica:
 quali trattamenti nella pratica clinica?

                   Roma, 27 Ottobre 2018
                  Relatore: Francesca Poggio
La malattia triplo negativa metastatica: quali trattamenti nella pratica clinica? - Roma, 27 Ottobre 2018 Relatore: Francesca Poggio - Aiom
Disclosure Information
         Relationship Relevant to this Session

Poggio, Francesca:

No relevant relationship to disclose.
La malattia triplo negativa metastatica: quali trattamenti nella pratica clinica? - Roma, 27 Ottobre 2018 Relatore: Francesca Poggio - Aiom
Agenda
• Introduction

• Chemotherapy

• PARPi

• Immunotherapy

• Endocrine therapy

• Conclusions
La malattia triplo negativa metastatica: quali trattamenti nella pratica clinica? - Roma, 27 Ottobre 2018 Relatore: Francesca Poggio - Aiom
Triple-Negative Breast Cancer (TNBC)
• TNBC lacks expression of ER (
La malattia triplo negativa metastatica: quali trattamenti nella pratica clinica? - Roma, 27 Ottobre 2018 Relatore: Francesca Poggio - Aiom
Triple-Negative Breast Cancer (TNBC)

• Triple negative paradox aggressive clinical course,
  but high sensitivity to cytotoxic treatment

• Patients with metastatic TNBC experience poor
  outcomes relative to patients with other breast cancer
  subtypes, with a median OS of ≈ 18 months or less

Gobbini EJC 2018. Carey LA et al, Clin Cancer Res 2007.
La malattia triplo negativa metastatica: quali trattamenti nella pratica clinica? - Roma, 27 Ottobre 2018 Relatore: Francesca Poggio - Aiom
The Heterogeneity of TNBC

Subtype                     Gene expression profile           Possible sensitivity

Basal-like 1                high Ki-67; DNA damage response   Platinum, PARPi
Basal-like 2                GF pathways                       AntiEGFR
Immuno-modulatory           Immune genes                      Immunotherapy
Mesenchymal                 Cell motility                     PIK3i
Mesenchymal stem-like       Cell motility; claudin-low        Anti-angio
Luminal androgen receptor   Steroid pathways                  AR antagonist
La malattia triplo negativa metastatica: quali trattamenti nella pratica clinica? - Roma, 27 Ottobre 2018 Relatore: Francesca Poggio - Aiom
Agenda
• Introduction

• Chemotherapy

• PARPi

• Immunotherapy

• Endocrine therapy

• Conclusions
La malattia triplo negativa metastatica: quali trattamenti nella pratica clinica? - Roma, 27 Ottobre 2018 Relatore: Francesca Poggio - Aiom
Cardoso F et al, Ann Oncol 2018
La malattia triplo negativa metastatica: quali trattamenti nella pratica clinica? - Roma, 27 Ottobre 2018 Relatore: Francesca Poggio - Aiom
Performance of CT in HER2-
Regimen                     Inv Ass PFS (m)     ORR (%)                   Ref

                                              (Measurable)
                                                             Robert,
Capecitabine                     6.2               -         JCO 2011
                                                             Miles,
Paclitaxel                       9.1               -         EJC 2017
                                                             Robert,
Tax/Anthra                       8.2               -         JCO 2011
                                                             Robert,
Cape + Beva                      9.2               -         JCO 2011
                                                             Welt,
Cape + Beva                      8.8               -         BCRT 2016
                                                             Brodowicz,
Cape + Beva (high risk)          8.3              30         BJC 2014
                                                             Brodowicz,
Cape + Beva (low risk)           11.5             28         BJC 2014
                                                             Miles,
Paclitaxel + Beva                11.2              -         EJC 2017
                                                             Robert,
Tax/Anthra + Beva                10.3              -         JCO 2011
                                                             Brodowicz,
Paclit + Beva (high risk)        11.1             46         BJC 2014
                                                             Brodowicz,
Paclit + Beva (low risk)         14.4             35         BJC 2014
                                                             Welt,
Cape+ Vinor + Beva               9.6               -         BCRT 2016
La malattia triplo negativa metastatica: quali trattamenti nella pratica clinica? - Roma, 27 Ottobre 2018 Relatore: Francesca Poggio - Aiom
Beva-based CT
When the response is an end point
MonoCT with Carboplatin
                          TNT trial: study design

                                     1:1

Tutt A, SABCS 2016.
MonoCT with Carboplatin
                                     TNT in unselected TNBC

                                                                 mPFS
                                                        Carboplatin vs. Docetaxel
                                                            3.1 vs 4.4 months
                                                                 (p=0.40)

                                                                  ORR
                                                        Carboplatin vs. Docetaxel
                                                              31.4% vs 34.0%
                                                                 (p=0.66)

Tutt A et al, Nature Medicine 2018
MonoCT with Carboplatin
                                      TNT in mBRCA

                                                            mPFS
                                                 Germline BRCA vs no germline
                                                     Carboplatin: 6.8 vs 2.9 months
                                                      Docetaxel: 4.4 vs 4.6 months
                                                               (p=0.002)

                                                            ORR
                                                 Germline BRCA vs no germline
                                                      Carboplatin: 68.0% vs 28.1%
                                                       Docetaxel: 33.3% vs 34.5%
                                                               (p=0.01)

Tutt A et al, Nature Medicine 2018
PolyCT with Carboplatin
                                         tnAcity trial

Yardley D et al, Ann Oncol 2018
Eribulin beyond first-line in TNBC

  • Pooled analysis:
     • Study 301
         • Eribulin
         • TPC
     • Study 305
         • Eribulin
         • Capecitabine
  • 1644 patients
     • eribulin: 946
     • control: 698
  • 352 TNBC

Pivot et al. Ann Oncol 2016
Antibody drug coniugate
                              Sacituzumab Govitecan (IMMU-132)

              The phase III trial ASCENT is ongoing…

Bardia et al, J Clin Oncol 2017
Agenda
• Introduction

• Chemotherapy

• PARPi

• Immunotherapy

• Endocrine therapy

• Conclusions
BRCA and PARPi
                                       OlimpyAD trial
302 MBC BRCA+:
     • 205 olaparib
     • 97 standard CT (capecitabine, vinorelbine, eribuline)
≤ 2 previous CT lines
About 75% with ≥ 2 mts sites

                                             Median PFS: 7 vs 4 months
                                                ORR 59.9 vs 28.8%

Robson M et al, N Engl J Med 2017.
BRCA and PARPi
                                                 EMBRACA trial
   431 MBC BRCA+:
       • 287 talazoparib
       • 144 standard CT
           (cape, vino, eri)
   ≤ 3 previous CT lines
   About 70% with visceral mts

                                     Median PFS: 8.6 vs 5.6 months
                                         ORR: 62.6 vs 27.2 %

Litton J et al, N Engl J Med 2018.
BRCA and PARPi
                                    PFS results

Poggio F et al, ESMO Open 2018.
BRCA and PARPi
                                  TNBC and platinum-naïve

Poggio F et al, ESMO Open 2018.
Agenda
• Introduction

• Chemotherapy

• PARPi

• Immunotherapy

• Endocrine therapy

• Conclusions
Immunotherapy
                             PD-1 blockade: activity as single agent
      Drug                                 Phase          Subtype                        PD-L1                     N pts                      ORR

      Pembrolizumab                        Ib             TNBC                           ≥ 1% TC                   32                         18.5%
      (anti-PD-1)                                         PD-L1+                         Stroma+

                                           Ib             ER+/HER2-                      ≥ 1% TC                   25                         12%
                                                          PD-L1+                         Stroma+

                                           II             TNBC                           ≥1 CPS
                                                          1°line, PD-L1+                                           52                         23.1%
                                                          >1 line                                                  170                        4.7%

      Atezolizumab                         Ia             TNBC                           ≥5% IC                    115                        10%
      (anti-PD-L1)

      Avelumab                             Ib             All                            ≥1% TC                    168                        3.0%
      (anti-PD-L1)                                                                       ≥5% TC
                                                                                         ≥10%IC
                                                          TNBC                                                     58                         5.2%
                                                          ER+/HER2-                                                72                         2.8%

Nanda R et al, J Clin Oncol 2016; Rugo H et al, SABCS 2015; Adams S et al, ASCO 2017; Schmid P et al, AACR 2017; Dirix YL et al, Breast Cancer Res and Treat 2017.
Immunotherapy
                         Combination with chemotherapy: results

       Drugs                                  Phase   Subtype   Line of     N pts   ORR
                                                                treatment

       Atezolizumab +                         Ib      mTNBC                 24      42%
       nab-Paclitaxel                                           1           9       67%
                                                                2           8       25%
                                                                ≥3          7       29%

       Pembrolizumab +                        Ib/II   mTNBC                 39      33.3%
       Eribuline                                                1L          17      41.2%
                                                                2-3L        22      27.3%

Adams et al, ASCO 2016; Tolaney S et al, SABCS 2016
Immunotherapy
                      IMpassion130: trial design

Schmid P, NEJM 2018
IMpassion130: PFS results

                                                  ITT population

                                                  PD-L1 positive

Schmid P, NEJM 2018
IMpassion130: OS results

                                                 ITT population

                                                 PD-L1 positive

Schmid P, NEJM 2018
Immunotherapy
Ongoing phase III trials
Agenda
• Introduction

• Chemotherapy

• PARPi

• Immunotherapy

• Endocrine therapy

• Conclusions
Endocrine therapy
                                                            Clinical evidence

             Author                              N                                    Drug           CBR (%)

             Gucalp                              452                                  Bicalutamide   19

             Traina                              118                                  Enzalutamide   35

             Bonnefoi                            30                                   Abiraterone    20

Gucalp A, Clin Cancer Res 2013; Traina TA J Clin Oncol 2018; Bonnefoi H, Ann Oncol 2016.
Endocrine therapy
  Ongoing studies
Agenda
• Introduction

• Chemotherapy

• PARPi

• Immunotherapy

• Endocrine therapy

• Conclusions
Conclusions
•   Current standard treatment options for unselected TNBC
    remains chemotherapeutic approaches

•   In mTNBC, a platinum regimen may be considered,
    especially in BRCA-associated

•   Results of OLIMPYAD and EMBRACA lead to add single agent
    PARPi in the therapeutic repertoire of BRCA-associated
    breast cancers

•   Combination of PD-L1 blockade and chemotherapy new
    standard for metastatic TNBC patients? Further research is
    needed to better select patients who are likely to benefit
You can also read