Jonathan Krell

Clinical validity of circulating tumour cells in patients with metastatic breast cancer: a pooled analysis of individual patient data

BACKGROUNDnWe aimed to assess the clinical validity of circulating tumour cell (CTC) quantification for prognostication of patients with metastatic breast cancer by undertaking a pooled analysis of individual patient data.nnnMETHODSnWe contacted 51 European centres and asked them to provide reported and unreported anonymised data for individual patients with metastatic breast cancer who participated in studies between January, 2003, and July, 2012. Eligible studies had participants starting a new line of therapy, data for progression-free survival or overall survival, or both, and CTC quantification by the CellSearch method at baseline (before start of new treatment). We used Cox regression models, stratified by study, to establish the association between CTC count and progression-free survival and overall survival. We used the landmark method to assess the prognostic value of CTC and serum marker changes during treatment. We assessed the added value of CTCs or serum markers to prognostic clinicopathological models in a resampling procedure using likelihood ratio (LR) χ(2) statistics.nnnFINDINGSn17 centres provided data for 1944 eligible patients from 20 studies. 911 patients (46·9%) had a CTC count of 5 per 7·5 mL or higher at baseline, which was associated with decreased progression-free survival (hazard ratio [HR] 1·92, 95% CI 1·73-2·14, p<0·0001) and overall survival (HR 2·78, 95% CI 2·42-3·19, p<0·0001) compared with patients with a CTC count of less than 5 per 7·5 mL at baseline. Increased CTC counts 3-5 weeks after start of treatment, adjusted for CTC count at baseline, were associated with shortened progression-free survival (HR 1·85, 95% CI 1·48-2·32, p<0·0001) and overall survival (HR 2·26, 95% CI 1·68-3·03) as were increased CTC counts after 6-8 weeks (progression-free survival HR 2·20, 95% CI 1·66-2·90, p<0·0001; overall survival HR 2·91, 95% CI 2·01-4·23, p<0·0001). Survival prediction was significantly improved by addition of baseline CTC count to the clinicopathological models (progression-free survival LR 38·4, 95% CI 21·9-60·3, p<0·0001; overall survival LR 64·9, 95% CI 41·3-93·4, p<0·0001). This model was further improved by addition of CTC change at 3-5 weeks (progression-free survival LR 8·2, 95% CI 0·78-20·4, p=0·004; overall survival LR 11·5, 95% CI 2·6-25·1, p=0·0007) and at 6-8 weeks (progression-free survival LR 15·3, 95% CI 5·2-28·3; overall survival LR 14·6, 95% CI 4·0-30·6; both p<0·0001). Carcinoembryonic antigen and cancer antigen 15-3 concentrations at baseline and during therapy did not add significant information to the best baseline model.nnnINTERPRETATIONnThese data confirm the independent prognostic effect of CTC count on progression-free survival and overall survival. CTC count also improves the prognostication of metastatic breast cancer when added to full clinicopathological predictive models, whereas serum tumour markers do not.nnnFUNDINGnJanssen Diagnostics, the Nuovo-Soldati foundation for cancer research.

The efficacy of lapatinib in metastatic breast cancer with HER2 non-amplified primary tumors and EGFR positive circulating tumor cells: a proof-of-concept study.

Background Analysis of circulating tumor cells (CTCs) provides real-time measures of cancer sub-populations with potential for CTC-directed therapeutics. We examined whether lapatinib which binds both HER2 and EGFR could induce depletion of the EGFR-positive pool of CTCs, which may in turn lead to clinical benefits. Patients and Methods Patients with metastatic breast cancer and HER2 non-amplified primary tumors with EGFR-positive CTCs were recruited and lapatinib 1500 mg daily was administered, in a standard two step phase 2 trial. Results There were no responses leading to termination at the first analysis with 16 patients recruited out of 43 screened. In 6 out of 14 (43%) individuals eligible for the efficacy analysis, a decrease in CTCs was observed with most of these having a greater decrease in their EGFR-positive CTC pool. Conclusions This is one of the first studies of CTC-directed therapeutics and suggests that lapatinib monotherapy is not having any demonstrable clinical effects by reducing the EGFR-positive pool of CTCs in HER2 non-amplified primary tumors. Our attempt to expand the pool of patients eligible for a targeted therapy was unsuccessful; the role of clonal populations in cancer biology and therapeutic strategies to control them will require extensive evaluation in years to come. Trial Registration Clinical trials.gov NCT00820924

Human Epidermal Growth Factor Receptor 2–Positive Breast Cancer Relapsing Post-Adjuvant Trastuzumab: Pattern of Recurrence, Treatment and Outcome

BACKGROUNDnThe purpose of this study is to evaluate the response to and benefit of first-line metastatic treatment (including re-exposure to trastuzumab) for patients relapsing after exposure to adjuvant trastuzumab (AT).nnnPATIENTS AND METHODSnAll HER2-positive breast cancer cases relapsing after exposure to AT at our institutions were identified. Clinico-pathologic details, pattern of relapse, and treatment in the metastatic setting were documented. Response to treatment and outcome were assessed.nnnRESULTSnTwenty-nine relapses were recorded. The median time to relapse was 18.4 months from diagnosis, and 8.7 months from AT initiation. At a median time of observation of 9.9 months, 18 patients had progressed on first-line therapy. The median time-to-progression (TTP) was 8.6 months. Fifteen patients received trastuzumab as first-line treatment, with no statistical difference in TTP between this group and those not re-exposed to trastuzumab. TTP was not statistically different between those relapsing on or after AT. Overall survival was longer for those who relapsed after completion of 1 year of AT as well as those who received further trastuzumab at relapse; however, this did not reach statistical significance.nnnCONCLUSIONnOverall survival was longer in patients who relapse after completion of AT and who received further trastuzumab at progression.

MicroRNAs in the cancer clinic.

Over recent years there have been major advances in our understanding of tumour biology which have led to improved diagnostic and prognostic techniques and the development of novel targeted therapies. However the reliability of such biomarkers is questionable and the efficacy of new treatments remains predominantly limited by a combination of drug resistance, toxicity and persisting insufficiencies in our comprehension of tumour-signalling pathways. Following their recent discovery, microRNAs (miRNAs) have been established as key regulators of gene-expression, and their putative roles as oncogenes and tumour suppressor genes has provided a potentially new dimension to our clinical approach to cancer diagnosis and treatment. Their role as biomarkers and therapeutic targets is appealing but several obstacles have as yet limited our ability to translate this potential into a clinical reality. This review focuses on currently accepted roles of miRNAs in cancer pathogenesis, and highlights the challenges and breakthroughs in this field to date with relevance to the cancer clinic.

MicroRNA-23b regulates cellular architecture and impairs motogenic and invasive phenotypes during cancer progression

The cytoskeleton is a dynamic three dimensional structure contained within the cytoplasm of a cell, and is important in cell shape and movement, and in metastatic progression during carcinogenesis. Members of the Rho family of small GTPases, RHO, RAC and cell cycle division 42 (Cdc42) proteins regulate cytoskeletal dynamics, through the control of a panel of genes. We have recently shown that the microRNA (miRNA) miR-23b represents a central effector of cytoskeletal remodelling. It increases cell-cell interactions, modulates focal adhesion and reduces cell motility and invasion by directly regulating several genes involved in these processes.

Abstract P2-08-08: Circulating tumor cells count-based nomograms to predict survival of metastatic breast cancer patients: Results from the European pooled analysis

Background: The European Pooled Analysis of CTC (EPAC) in metastatic breast cancer, based on 1,944 individual data from patients with various tumor types and clinical settings (Bidard et al, Lancet Oncol 2014), has established CTC count (CellSearch) at baseline and during therapy as a level of evidence 1 independent prognostic biomarker and demonstrated its superiority over serum blood markers. As part of the study pre-planned objectives, we sought to establish nomograms allowing accurate individual survival predictions. Methods: Using individual data from 17 centers, we built simplified multivariate prognostic models taking into account the independent prognostic clinico-pathological (CP) characteristics including CTC count, dichotomized using the 5CTC/7.5ml threshold, at baseline and at 3-5 weeks after the start of a new treatment regimen, and derived nomograms for progression-free survival (PFS) and overall survival (OS) prediction at baseline and after 3-5 weeks of treatment. We report here the internal validation of these nomograms. Discrimination of the models was assessed using the c-index estimated by a jackknife procedure and the calibration was visually assessed through 10-fold crossvalidated calibration plots at 1,2,3 years for OS and 1,2 years for PFS. Results: Multivariate models at baseline for PFS and OS were fitted on 1501 and 568 individual patient data with CTC count at baseline and CTC count at baseline and after 3-5 weeks, respectively. Models include tumor subtype, the number of previous chemotherapy lines (0/1/≥2), PS, age ( 50-65/>65 years), metastasis-free intervals (0/>0-3/>3 years), metastatic sites (liver and CNS) and CTC count at baseline and eventually at 3-5 weeks of treatment. The C-index increased from 0.722 to 0.755 (increase in C-index:0.033, 95% CI [0.019;0.045]) when adding baseline CTC to the CP only model for OS (n=1501). For those patients with CTC values at 3-5 weeks (n=568), there was an additional increase in the C-index when adding CTC at 3-5 weeks to a model with already CP and baseline CTC from 0.731 to 0.743 (increase in C-index 0.013, 95% CI [-0.004;0.025]). The model with CP and baseline CTC counts showed a good calibration for OS at 1,2,3 years and the model with CP, baseline CTC and CTC count at 3-5 weeks a moderately good calibration. Similar results were obtained for PFS. Conclusion: From the largest database with individual CTC data, we were able to build PFS and OS survival nomograms, with satisfactory discrimination and calibration. Our planned next step is to validate the nomogram in an additional cohort. Citation Format: Bidard F-C, Peeters D, Fehm T, Nole F, Gisbert-Criado R, Mavroudis D, Grisanti S, Generali D, Garcia-Saenz JA, Stebbing J, Caldas C, Gazzaniga P, Manso L, Zamarchi R, Fernandez de Lascoiti A, de Mattos-Arruda L, Ignatiadis M, van Laere SJ, Meier-Stiegen F, Sandri M-T, Vidal-Martinez J, Politaki E, Consoli F, Bottini A, Diaz-Rubio E, Krell J, Dawson S-J, Raimondi C, Rutten A, Janni W, Munzone E, Caranana V, Agelaki S, Almici C, Dirix L, Solomayer E, Zorzino L, Reis-Filho JS, Squifflet P, Pantel K, Beije N, Sleijfers S, Pierga J-Y, Michiels S. Circulating tumor cells count-based nomograms to predict survival of metastatic breast cancer patients: Results from the European pooled analysis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-08-08.

Abstract PD6-5: Pooled analysis of circulating tumor cells in metastatic breast cancer: Findings from 1944 individual patients data

Background: Clinical validity of CTCs (CellSearch®) in metastatic breast cancer (MBC) patients has previously been assessed in studies with limited statistical power. We aimed to pool all European studies to obtain high-level evidence on the prognostic value of CTCs, to investigate their effects across different clinico-pathological characteristics and therapies and to further validate the MD Anderson/Institut Curie/Fox Chase CTC-based prognostic nomogram established in first-line treated MBC patients (Giordano et al, Clin Cancer Res 2013). Material and methods: Methods were predefined in a written protocol. In December 2012, we searched for eligible studies that accrued patients in 2003-2012. We contacted all European laboratories using CellSearch®. We used likelihood ratio tests (LR) in Cox regression models stratified by study to assess the independent prognostic value of CTC when added to a clinicopathological (CP) model for progression-free (PFS) and overall survival (OS). Landmark analyses were used to assess the prognostic effect of early changes in CTC. The CTC-based nomogram (http://cancernomograms.com/CTCOnline.html) score was retrieved for every patient; we calculated C-indices, drew calibration plots and Kaplan-Meier curves according to quintiles of the nomogram score. Results: We collected individual data of 1944 MBC patients, from 20 different studies (some unpublished), from 17 centers in 7 European countries. We observed 1507 PFS events and 929 deaths. Baseline CTC count was significantly associated with several patient characteristics, such as performance status (PS, p Conclusions: This pooled analysis is the largest study ever reported on CTC in MBC, with a previously unreached statistical power. It provides a clear level-of-evidence 1 on the independent prognostic value of CTCs before and during treatment in MBC. Also, the CTC-based prognostic nomogram is independently validated. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr PD6-5.

Management and outcome of HER2-positive breast cancer treated with and without adjuvant trastuzumab: The Imperial College London experience.

650 Background: Adjuvant trastuzumab (AT) is the standard of care in the management of HER2-positive breast cancer (BC) treated with chemotherapy (CT). Controversy remains regarding AT in low-risk disease and older patients. Little data is available outside large well controlled clinical trials with regard to the usage, efficacy and toxicity of AT, and no prospective data is available on the outcome of untreated HER2-positive patients diagnosed in the AT era. Methods: All cases of early invasive HER2-postive BC diagnosed at Imperial College London (ICL) between 2006-2008 were identified. In addition, patients referred for AT but who did not undergo breast surgery at ICL were included in analysis of efficacy. Results: Local HER-positivity rate for early invasive BC was 13.2% (128/1194), with 53.8% (85/158) receiving AT. Main reason for omission of AT was low-risk disease (32.7%). 128 cases (85 local and 43 referred) received AT. Median tim to AT after completion of radiotherapy (RT) was 28 days (range 2-18...

Treatment and outcome of metastatic HER2-positive breast cancer relapsing post adjuvant trastuzumab exposure.

1080 Background: Since 2006 adjuvant trastuzumab (AT) has been standard care for HER2 +ve early breast cancer (BC) treated with chemotherapy (CT). No data exists on the response and benefit of subsequent treatment, including trastuzumab (T) re-exposure, in cases developing recurrent disease following AT. Methods: All cases of early HER2 +ve BC exposed to AT at our institutions were reviewed and cases of recurrent/metastatic disease identified. Clinicopathological and adjuvant treatment details in recurrent cases were recorded. Sites of relapse, treatment, and details of further T based therapy were recorded. Response to treatment and outcome were analyzed. Results: 284 cases were identified who had received ≥1 dose of AT and 29relapses recorded (Local recurrence: 13.8%; distant recurrence: 86.2%). 34.5% received adjuvant CT and 65.5% neoadjuvant (NA) CT, 2 received NA T. Median time to relapse from diagnosis was 18.3 months (m) (range 9.2-48.2) and 8.5m (range 1.4-40.0) from AT initiation. 55% of relapses...

Combining luteinising hormone releasing hormone agonists and aromatase inhibitors in breast cancer

2010 Elsevier Ltd. All rights reserved. Except for those individuals with significant visceral disease, current guidelines tend to recommend endocrine therapy rather than chemotherapy as first-line treatment of metastatic breast cancer. For the most part, aromatase inhibitors (AIs) have superseded tamoxifen as the treatment of choice in postmenopausal women with advanced breast cancer, and also as an adjuvant systemic therapy for early disease in postmenopausal women with ER positive tumours. Combined analysis of two international randomised, double-blind trials (n = 1021) demonstrated that in patients with ER/PgR+ tumours, first-line treatment with anastrozole significantly prolonged the time to progression (median TTP: 10.7 versus 6.4 months, respectively; p = 0.022) and response rate (29.0% versus 27.1%) compared with tamoxifen. An EORTC trial also showed superiority of exemestane over tamoxifen as first-line hormonal therapy in terms of overall response rate and early progression-free survival and a multinational randomised trial of letrozole versus tamoxifen, showed letrozole was associated with superior time to progression, overall objective response rate and overall survival in the first 2 years of treatment. Data regarding fulvestrant are now also maturing: in a randomised comparison in postmenopausal women who had progressed on adjuvant tamoxifen, there were no statistically significant differences in TTP or response rates er Ltd. All rights reserved llege Healthcare NHS Tru fax: +44 208 846 1433. (J. Stebbing). between fulvestrant and exemestane. Results from another trial, the FIRST study, demonstrated that first-line fulvestrant was at least as effective as anastrozole in terms of clinical benefit rate and overall response rate and was associated with a significantly longer time to progression in postmenopausal women with advanced hormone receptor)positive breast cancer. However, for premenopausal women with metastatic ER disease, AIs or fulvestrant can only be used in patients who have undergone ovarian suppression or ablation. Luteinising hormone releasing hormone (LHRH) agonists (e.g. goserelin) have been shown to produce effective ovarian function suppression in a similar manner to surgical oophorectomy or ovarian irradiation. Trials have now confirmed the effectiveness of an LHRH agonist in combination with tamoxifen, in both advanced and adjuvant settings for premenopausal women with ER positive breast cancer However, in the metastatic setting, there are no randomised data to demonstrate whether goserelin plus an AI confers superiority or non-inferiority to the combination of goserelin and tamoxifen in premenopausal women. Instead, there are now data from three studies showing efficacy of combining an LHRH agonist with an AI in this patient group; the mechanistic synergy of rendering individuals functionally postmenopausal using an LHRH agonist coupled with an AI is easy to appreciate. . st, Charing Cross Hospital, 1st Floor, E Wing, Fulham Palace Road, 2868 E U R O P E A N J O U R N A L O F C A N C E R 4 6 ( 2 0 1 0 ) 2 8 6 7 –2 8 6 9 The first study was a prospective, single-arm, multicenter phase II trial involving 35 (32 evaluable) premenopausal individuals with ER/PgR, metastatic or recurrent breast cancer. This demonstrated a 72% clinical benefit rate (3.1% complete response, 34.4% partial response and 34.4% stable disease) with a median time to progression of 8.3 months. The most common adverse events were fatigue (50%), arthralgias (53%), and hot flashes (59%). The second report is from a multi-centre study in France involving 33 patients with a clinical benefit rate of 63.6% and TTP of 13 months. The third study to report on the use of goserelin plus an AI in premenopausal women with advanced breast cancer is presented in this issue of the European Journal of Cancer by Cheung et al. Here, 36 premenopausal patients with metastatic hormone receptor positive breast cancer from a single institution were treated with goserelin plus anastrazole as first-line therapy. Within this, they report on a further 13 individuals who subsequently received goserelin plus exemestane as a later line of treatment, having previously had goserelin plus anastrozole. This ‘AI switch’ strategy makes this the first report on the continued use of goserelin to enable further use of another AI, in this case a non-steroidal (anastrazole) to a steroidal (exemestane) AI. Serial measurements of estradiol, androgens, and FSH and LH were also undertaken. Out of the 36 patients treated with goserelin plus anastrozole as first-line therapy, 24 (67%) achieved a clinical benefit at 6 months. The overall median duration of treatment measured >18 months (range 2)78 months) and the median TTP was 12 months (range 2)47 months). The treatment was well tolerated with no patients withdrawing due to adverse events. Out of the 13 patients who received goserelin plus exemestane as further therapy, five patients derived some benefit. The combination of goserelin plus anastrazole resulted in 98% reduction (from pre-treatment to 6-month) in median levels of oestradiol while the levels of other hormones had minimal fluctuations during therapy. No further significant fluctuation in hormone levels were seen in those patients who progressed on goserelin plus anastrozole and switched to goserelin plus exemestane. Interestingly those who received megestrol acetate at some stage during their treatment sequence had a further reduction in testosterone and DHEAS levels and also a slight surge of FSH and LH levels during that treatment phase. The authors have conducted an important study that demonstrates the combination of goserelin plus an AI produces sustained clinical benefit and minimal side-effects in many premenopausal women with ER advanced breast cancer, in line with the two previous studies in this setting. This study is unique in reporting the use of an LHRH with sequential AI therapy, a practice that is surprisingly under-reported although used clinically in many institutions. Interestingly the combination of goserelin with an AI is sometimes used in the adjuvant setting, in those ‘intolerant’ to tamoxifen, without much supportive evidence. Cheung et al.’s study is also the first to report serial measurements of estradiol, androgens, and FSH and LH in this patient cohort although the patient numbers are limited. Within the sample size limitations of such a study these data appear to support the use of goserelin plus AIs in hormone sensitive advanced breast cancer. The main toxicity of note observed across these studies is arthralgias, and as individuals with hormone sensitive metastatic breast cancer may now have prolonged survivals it is probably worthwhile to also monitor bone density. Randomised studies as opposed to single-arm trials, comparing the use of first-line goserelin plus tamoxifen with goserelin plus AIs or fulvestrant may also help us understand the most effective sequencing of these agents in premenopausal women with hormone sensitive advanced breast cancer. In view of the recent decision of the US Food and Drug Administration to withdraw the label for bevacizumab in breast cancer, a trial comparing goserlin plus an AI versus paclitaxel and bevacizumab, or versus a taxane alone, in first-line therapy would be of enormous interest in hormone sensitive metastatic disease. Conflict of interest statement