1. Shou-Ching Tang MD, PhD, FACP, FRCP (C) GRU Cancer Center
2013 SABCS Review
Shou-Ching Tang
MD, PhD, FACP, FRCP (C)
GRU Cancer Center

2. Disclosure
Nothing to declare

3. outline Prognostic and predictive biomarkers Prevention
Early breast cancer
locally advanced breast cancer
Advanced breast cancer
Targeted therapy
Conclusion

4. Prognostic and predictive biomarkers

5. Genetic landscape of MBC Bachelot et al, #S6-07, SABCS 2013
Exome sequencing of 100 pairs of MBC and normal breast tissue DNA (Integragen Inc, Hiseq platform)
Targeted sequencing of 100 genes in 240 MBC biopsies
PIK3CA 26%, AKT1 4%, PTEN 4%, ERBB 2%, K-Ras 1%, ATM 1%, CDH1 2%, GATA3 2%. PTPN11 1%, PTPRD 1%, ROS1 1%
Many of them are drugable and involved in metastatic process and drug resistance

6. Exome sequencing to identify actionable mutations in mTNBC Blackwell et al, S4-04, SABCS 2013
38 pts with mTNBC and matched specimens of germ-line DNA, primary and metastatic tumors
Whole-exome sequencing by Agilent solution-based system of exon capture with 10 GB of sequencing data
Striking genetic heterogeneity between primary and metastatic tumors
continues

7. Exome sequencing to identify actionable mutations in mTNBC Blackwell et al, S4-04, SABCS 2013
No single driver mutation that was common to metastatic tumors, indicating diverse genetic pathways contributing to metastasis
Mutations in APC and mTOR more frequent in metastatic than primary tumors
Nonsense mutations of ER in primary and metastatic tumors but not in germ-line DNA
EGFR and HER2 mutations not detected

8. Gene mutations and protein expression in TNBC vs non-TNBC O’Shaughnessy et al, #PD4-1, SABCS 2013
5500 pts evaluated for mutation (Sanger or Illumina Truseq), protein expression (IHC) and/or amplification/rearrangement (FISH or CISH), 16% with TNBC
Mutation: TNBC has higher p53 mutation (60% vs 30%), lower PIK3CA (12% vs 31%)
Amplification: TNBC has higher amplification of EGFR (24% vs 13%), lower HER2, PIK3CA, cMYC and TOP2A
IHC: TNBC has higher AR (56% vs 15%)

9. Heterogeneity between primary and met BC prior to Tx Bidard et al, #S6-06, SABCS 2013
High-depth whole exome sequencing and SNP6 copy number profiling of primary and met biopsies from 7 pts with de novo MBC prior to systemic therapy
Significant genomic differences between primary and met tumors
Median 105 of single nucleotide variants (SNVs) and 54 insertions/deletions (indels) identified, of which 36 and 11 were shared between the primary and secondary tumors
50% driver SNV’s and 70% pathogenic indels were restricted to either primary or met tumors, including the epithelial-to-mesenchymal transition (EMT)-related genes TGFB1, SMAD4 and TCF7L2

10. Community-based NGS to guide clinical trial selection Yardley et al, abst PD4-3, SABCS 2013
594 advanced BC profiled
Most frequently altered gene: PIK3CA (24%), followed by RUNX1 (4%) and FGFR3 (2%)
Infrequent: PIK3R1, MET, KRAS, KIT, FGFR2, HER2, BRAF, SMO, MYC, DDR2 and AKT1, one pt each
6% pts enrolled in phas I trials based on NGS (PI3K and mTOR inhibitor), 29% pts potentially eligible for ongoing trials at SCRI
PIK3CA mutation accounted for 70% of 35% actionable mutations detected

11. PI3KCA mutation predicts resistance in HER2+/ER+ BC Loibl et al, #S4-06, SABCS 2013
Prospectively analyzed 512 pts from Geparsixto and validated in 225 pts from GeparQuinto trials
PI3KCA mutation found in 19.2% HER2+ tumors, more in HER2+/ER+, 21.5%
pCR in pts with and without PI3KCA mutation vs 43.6 %, p=0.001
with HER2+/ER+ tumors
6.5% vs 30.8%, p=0.005
No difference in HER2+/ER- tumors
42.9% vs 46.1%, p=0.852

12. PIK3CA mutation and/or low PTEN predict resistance to lapatinib and trastuzumab Contreras, et al, #PD1-2, SABCS 2013
Neoadjuvant L plus T (no chemo) x 12 wks
59 pts tested for PTEN (IHC) and 33 for PI3KCA mutation (36% by NGS)
pCR: overall 16%
high vs low PTEN 32% vs 9% p=0.04
PIK3CA mutation: 0% p=0.06
low PTEN and PIK3CA mutation vs normal:
0% vs 36% p=0.01

13. Prognostic value of tumor infiltrating lymphocytes (TIL’s)
% of lymphocyte infiltration in tumor stroma reflects host immune reaction
The presence of TIL’s was correlated with benefit from:
trastuzumab in HER2+ EBC in 156 pts from the neoadjuvant GeparQuattro trial (Loi et al, #S1-05, SABCS 2013)
the addition of carbo to neoadjuvant therapy in TN and HER2+ EBC in Geparsixto trial (Dunkert, et al, #S1-06)
adjuvant therapy in ECOG 2197 and 1199 in TNBC (Adams et al, #S1-07, SABCS 2013)

14. SWOG S0500 CTC’s in guiding CT in MBC Smerage et al, #S5-07, SABCS 2013
(CTC found in 75% MBC, half >5CTC/7.5 ml whole blood)
Primary end point: OS

19. SWOG S0500 CTC’s in guiding CT in MBC Smerage et al, #S5-07, SABCS 2013
Conclusion:
CTC prognostic in MBC at baseline and after first chemo
Changing chemo based on CTC after first chemo does not affect OS or PFS

20. PAM50 to predict late relapse in EBC Sestak et al, #S6-04, SABCS 2013
2485 pts from ABCSG-8 and transATAC trials who did not relapse in 0-5 yrs
Clinical treatment score (CTS, from transATAC) is the strongest prognostic score for late relapse
PAM50 risk of recurrence (ROR) score adds significant prognostic value for late relapse
Risk of distant relapse at 10 yrs for low risk group is 5.7%, intermediate risk 14.6% and high risk 29.3%
Pts with luminal A subtype had a 70% lower risk of distant relapse than luminal B (HR 0.03, p<0.0001)

21. prevention

22. IBIS-II Chemo-prevention in high risk postmenopausal women Cuzick et al, #S3-01, SABCS 2013
Randomized phase III UK trial
3864 women with high risks of BC, median f/u 5.03 yrs
Primary end point: incidence of BC, including DCIS
Anastrozole vs placebo for 5 years

23. IBIS-II: Chemo-prevention in high risk postmenopausal women Cuzick et al, #S3-01, SABCS 2013
5-yr BC incidence: 53% reduction, p<0.0001
Significant reduction in all invasive BC (50%), ER+ BC (58%) and DCIS (70%)
Significant reduction of cancer at other sites (RR=0.58)
Deaths from BC and other causes similar in both arms
Musculoskeletal and vosomotor events higher and bone # non-significantly higher in anastrozole arm
In support of other chemoprevention trials: TAM (NSABP P-1), raloxifen (STAR)and exemestane (MAP3)

24. Early breast cancer

25. Hormone and physical exercise (HOPE) in EBC Irwin et al, #S3-03, SABCS 2013
Randomized phase III multicenter US trial
121 pts on adjuvant AI for > 6 m and with >3/10 worst joint pain on Brief Pain Inventory-Short form (BPI)
150 min/wk mod-intense aerobic exercise and twice-wkly supervised resistance exercise or usual care
Primary end point: change in BPI worse joint pain score between 0-12 momths
reduction of BPI score (20% vs 3% , p=0.017), joint pain intensity (p=0.025), body wt (p=0.0057) and increase in cardiopulmonary fitness (p=0.024)
Impact on adherence to AI’s and survival?

26. Bisphosphonates and survival in EBC: meta-analysis Coleman et al, #S4-07, SABCS 2013
36 randomized trials, 22,982 pts
Primary end point: time to recurrence, to first distance recurrence and breast cancer mortality

27. Bisphosphonates and survival in EBC: meta-analysis Coleman et al, #S4-07, SABCS 2013
RR 10-yr gain % 2p value
All pts
BC mortality
distance recurrence
Post-menopausal pts
BC mortality
distance recurrence

28. Bisphosphonates and survival in EBC: meta-analysis Coleman et al, #S4-07, SABCS 2013
Reduction in bone relapse in postmenopausal pts similar regardless of type of BP tx, duration and schedule or concomitant chemotherapy
Adjuvant BP improves survival in postmenopausal pts with EBC
No benefit in premenpausal pts in bone or other recurrences
Currently indicated for prevention or treatment of bone loss

29. Phase II study of TH in HER2+ and node- EBC Tolaney, S et al, #S1-04, SABCS 2013
410 pts, HER2+ EBC
T1mi 3%; T1a 27%, T1b 20%, T1C 41%, T2<3 cm 9%
Wkly paclitaxel x12 with trastusumab for one year
Null hypothesis: 3-year failure rate of 9.2% (failure)
Alternative hypothesis: 3-year failure rate of 5% (success)
Due to limited number of events, DMSB approved data release with 1316 PYFU and median f/u of 3.2 years

31. TH in node-/HER2+ EBC TH is highly effective and well tolerated
Can be considered an option in majority of stage 1 HER2+ EBC
Single arm study, 67% HR+ tumor, limited follow up of 3.6 years
Superior survival data suggest not all pts with stage 1 HER2+ EBC require trastuzumab-based chemotherapy, esp those with T1aN0 tumor
Addition of another biological agent to TH backbone is unlikely to have substantial benefit in this pt population (TDM-1 vs TH ongoing)

32. Primary results of BETH trial in HER2+, node+ or node- high risk EBC Slamon D et al, #S1-03, SABCS 2013
3509 pts, phase III
Median f/u 3 years
Invasive disease-free survival (IDFS)
BETH Trial
Docetaxel x 6
Carboplatin x 6
Trastuzumab x 1 y
Bevacizumab 15mg
q3 wk x 1 y
92% or
5-FU x 3
Epirubicin x 3
Cylophos x 3
Docetaxel x 3
Trastuzumab x 1 y
Observation 8%

37. BETH primary result
Addition of one year bevacizumab to chemotherapy did not prolong invasive disease-free survival (IDFS)
TCH is an effective adjuvant regimen for pts with HER2+ EBC, including node+ tumors
No new or unexpected safely signals
No added benefit of bev in MBC, LABC and EBC in unselected pts, biomarker studies urgently needed (ongoing repeat of ECOG trial with biomarkers included)

38. GIM-2 EC or FEC with dd P or not in node+ EBC Cognetti et al, # S5-06, SABCS 2013
Italian multicenter randomized phase III 2x2 design
2019 pts, node+, < 70 yo, median f/u 7 yrs
EC x4 or FEC x4 then P q 2 (with G) or 3 wks x4
Primary end point: DFS
DD CT improved DFS and OS : HR 0.78 (p=0.007) and 0.68 (p=0.002) respectively
Benefit of DD CT independent of HR status
Addition of F to EC did not improve outcome

39. PRIME II: Adjuvant RT in pts > 65 yo Kunkler et al, #S2-01, 2013 SABCS
Multicenter UK trial, 1326 pts, median f/u 5 yrs
>65 yo, T 1-2 (up to 3 cm), N0/M0, HR+, margin > 1mm, could be grade 3 or LVI but not both, required adjuvant hormonal therapy
Primary end point: ipsilateral breast tumor recurrence
no RT (%) RT (%) p
IBTR OS
Regional relapse
Contralateral relapse
Distance relapse
Results similar to CALGB, ECOG and RTOG trial (pASCO 2010)
Omission of adjuvant RT safe in selected older pts

40. 10-yr survival update of NSABP B-32 Julian et al, #S2-05, SABCS 2013
Randomized phase III of SLND plus ALND or ALND
5611 pts
Still no difference in OS, DFS and loco-regional relapse (HR 1.09, p=0.35; HR 1.02, p=0.72; HR 0.96, p=0.77 respectively)
No difference in OS and DFS in pts with occult mets detected by IHC with or without ALND
IHC has no prognostic role in EBC

41. Locally advanced breast cancer

42. Neo ALTTO Survival update Piccar-Gebhart, M et al, #S1-01, SABCS 2013
Stratification:
T ≤ 5 cm vs. T > 5 cm
ER or PgR + vs.
ER & PgR –
N 0-1 vs. N ≥ 2
Conservative surgery
or not
Invasive operable
HER2+ BC
T > 2 cm
(inflammatory BC
excluded)
LVEF  50%
N=450 S U R
G E Y A N D O M I Z E
lapatinib
trastuzumab
paclitaxel
+ 12 wks
6 wks
34 weeks
52 weeks of anti-HER2 therapy
lapatinib
trastuzumab F E C X 3
Median f/u years 42

43. NeoALTTO Efficacy – pCR and tpCR
L: lapatinib; T: trastuzumab; L+T: lapatinib plus trastuzumab
pCR pathologic complete response HR: hormone receptors
Baselga J et al. SABCS 2010; abstract S3-3

48. NeoALTTO survival update
First study to show that pts with pCR had significantly better EFS and OS with HER2+ tumors
Study was powered to detect difference in pCR, but underpowered to detect moderate difference in survival
Dual HER2 blockade is superior
HER2+/HR- and HER2+/HR+ subgroups are different diseases

49. TRIO-US B07 final analysis Hurvitz S et al, #S1-02, SABCS 2013
Randomized phase II of neoadjuvant H or L or both in stage 1-3, HER2+ EBC
106 pts in 13 US centers, primary end point, pCR
Run-in cycle of H or L or both followed by 6 cycles of TCH (A) vs TCL (B) or TCHL (C)
Overal pCR: 42% (A 43%, B 25% and C 52%, p=0.069)
Pair-wise comparison: pCR in B significantly lower than C (p=0.021), not different between A and B (p=0.14) and A and C (p=0.45)

50. CALGB 40603 (Alliance) neoadjuvant carbo +/- Bev in TNBC Sikov et al, #S5-01, SABCS 2013
2x2 randomized phase II in locally advanced TNBC in 545 pts

51. CALGB 40603 (Alliance) neoadjuvant carbo +/- Bev in TNBC Sikov et al, #S5-01, SABCS 2013
pCR (%, breast and axilla):
no Cb Cb Bev effect
No Bev
Bev p=0.031
Cb benefit p=0.033
Addition of Cb or Bev to NAC significantly increases pCR in TNBC, and the increases are additive
Several studies now support the addition of Cb to standard CT in LABC (CALGB 40604, GeparSixto and I-Spy 2), adjuvant trials ongoing

52. Learn and adapt from each patient as we go along
I-SPY 2 TRIAL:
Learn, Drop, Graduate, and Replace Agents Over Time
Paclitaxel+ Trastuzumab
Randomize
Paclitaxel + Trastuzumab* + New Agent A
HER 2 (+) AC
Paclitaxel + Trastuzumab* + New Agent B
Surgery
Learn and adapt from each patient as we go along
Paclitaxel + Trastuzumab* + New Agent C
Paclitaxel + Trastuzumab* + New Agent F
Patient is on Study
Paclitaxel
MRI
Residual
Disease
(Pathology)
Key
Randomize
Paclitaxel +
New Agent C
Paclitaxel +
New Agent F
HER 2
(–) AC
Surgery
Paclitaxel +
New Agent GH
Paclitaxel +
New Agent D
Paclitaxel +
New Agent E
*Investigational agent may be used in place

53. I-SPY 2: the first graduate Rugo et al, #S5-02, SABCS, 2013
Primary end point: pCR
Graduate regimens have >85% Bayesian predictive probability of success in a 300-pts biomarker-linked neoadjuvant phase III trial
Veliparib+carbo met the 85% predictive probability criterion in HR-/HER2- and all HER2- pts
% pCR p V+Cb better p of successful phase III
All HER vs % 71%
HR+/HER vs % %
TNBC 52 vs % 92%
V/Cb graduated with a TNBC signature and recommended for future trial
Biomarker study? (lesson from iniparib)

54. NATAN, post-neoadjuvant zoledronate trial von Minckwitz et al, #S5-05, SABCS 2013
Randomized phase III trial in 693 pts with residual tumor after at least 4 cycles of NAC with taxanes and anthracyclines, median f/u 48 m
Z q4wks x6m, q3mx2yrs and q6mx2.5 yrs for 5 yrs vs no
Primary end point: EFS at 5 years
DFS: HR 0.96 p=0.7885
OS: HR p=0.4082
Decreased BC mortality in post-menopausal pts: RR 0.83 (SE 0.06)

59. Metastatic breast cancer

60. Resection of primary BC and ALN in MBC Badwe et al, #S2-02, SABCS 2013
Randomized phase III trial, local regional treatment (LRT) or not, 350 pts, median f/u 17 months,
Primary end point: OS
Median survival (M): 18.8 vs 20.5, HR=1.07, p=0.60
Overall survival at 2-yr (%): 40.8 vs 43.3
No difference in OS after adjusting age, ER, HER2, site and # of metastasis in Cox regression model (p=1.00)
LRT should be reserved for palliative reasons

61. Resection of primary BC in de novo stage IV MBC Soran et al, #S2-03, SABCS 2013
Randomized Turkish trial of LRT vs not, 278 pts, median f/u / m
Type of LRT and systemic therapy at the discretions of SO and MO
Primary end point: OS
OS at 5 m (%): 35 vs 31, p=0.24
OS longer in pts with bone only, HR+, age <50 yr but shorter in TNBC
Ongoing US cooperative trial (E2108)

62. ROSE/TRIO-12 trial of ramucirumab in MBC Mackey et al, #S5-04, SABCS 2013
Randomized multicenter phase III trial of ramucirumab (anti-VEGFR2) or placebo in first line HER2- MBC, with biomarker study
1144 pts, 1:2 randomization
Primary end point: PFS
Median f/u 16.3 m

67. Targeted therapy

68. Cross-talks among signal transduction pathways

69. Dual function of YAP-1 in caner
Wang and Tang, Can and Met Rev, 2013

70. Letrozole plus dasatinib improves PFS in MBC Paul et al, #S3-07, SABCS 2013
Randomized phase II multicenter USO trial
HR+, HER2- MBC first line, 116 evaluable pts
Adjuvant AI allowed if completed > 1yr before entry
Letrozole +/- dasatinib (Src TKI), cross over allowed
Primary end point: CBR (PR/CR/SD>6m)
DL L
CBR (%)
PFS (M) p=0.05
Toxicities: fatigue (38%), nausea (38%), anemia (25%), rash (23%), pleural effusion (16%) and edema (13%)
27% pts required dose reduction for dasatinib
Other promising drugs: everolimus, palbociclib, HDACI,PI3KI

71. New Drugs to Overcome Resistance in Hormonal Therapy
Afinitor
Product W
Product X
Product Y
Mechanism of Action
mTOR inhibitor
CDK4/6 kinase inhibitor
HDAC inhibitor
P13K inhibitor
Comparator
Exemestane
Letrozole
Fulvestrant
Median PFS
Afinitor + Exemestane -7.8 months vs. Exemestane alone -3.2 months (HR = 0.45)
Product W + Letrozole months vs. Letrozole alone months (HR = 0.37)
Product X + Exemestane -7.1 months vs. Exemestane alone -4.1 months (HR = 0.58)
N/A
Median OS
OS results are not mature
Product X + Exemestane months vs. Exemestane alone -22 months (HR = 0.75)
Ziaudinn and Tang
Review paper in preparation

72. Summary
Genetic alteration is common in primary and metastatic tumors and in tumors undergoing treatment
Identification of biomarkers and drugable mutations by genome sequencing will not only unravel mechanismS of drug resistance but help to offer pts tailored targeted therapy
TIL’s are associated with favorable response to breast cancer chemotherapy

73. Summary-2
Biosphophonates reduce tumor relapse in postmenopausal women with EBC, current approval is for their use in bone loss
Pts with stage I HER2+ tumors may be offered TH chemotherapy
Anti-angiogenesis (bev and ramucirumab) is unlikely effective in unselected pts with BC, biomarker studies are urgently needed

74. Summary-3
Veliparib and/or carboplatin added to taxane backbone increase pCR in TNBC
Surgical management of primary tumor in pts with MBC does not improve survival and should only be considered for symptom control and in clinical trials
Dasatinib increases the efficacy of letrozole in MBC. Blocking cross talks of ER pathways will help to overcome drug resistance

75. Acknowledgement Industry supporters: Amgen, Genomic Health and Merck
GRU support team: Susan Everitt, Lisa Middleton and Caroline English
GRU Cancer Center Leadership and educational grant

76. Thank you