Dual HER2 Blockade Improves Overall Survival With Metastatic Breast Cancer

NEW YORK (Reuters Health) Jul 09 - Dual HER2 blockade with trastuzumab and lapatinib extends overall
survival in women with heavily pretreated HER2-positive metastatic breast cancer, researchers say,
The findings from the phase III EGF104900 study were published online June 11 in the Journal of Clinical
Oncology.
A 2010 paper with preliminary data from the same trial reported that the combination improved progression-
free survival (PFS) significantly compared to lapatinib alone. At that point the immature overall survival data
showed a trend to improvement with combination therapy.
Dr. Kimberly L. Blackwell from Duke University Medical Center, Durham, North Carolina, and colleagues now
present the trial's final PFS and overall survival data.
In the final efficacy analysis in 291 patients, median PFS was significantly longer with combination therapy
than with lapatinib (11.1 vs 8.1 weeks; p=0.011)
Median overall survival was also significantly longer with combination therapy (14 vs 9.5 months; p=0.026).
The absolute overall survival rate with the combination was 10% better at six months and 15% better at 12
months than with monotherapy.
Significant factors influencing overall survival included Eastern Cooperative Oncology Group performance
status, site of disease, number of metastatic sites, and time from initial diagnosis until random assignment.
Just over half of the patients enrolled in the lapatinib monotherapy arm (77/148) crossed over to combination
therapy. Excluding them from a preplanned exploratory analysis resulted in a slight relative improvement in
median overall survival.
In subgroup analyses, combination therapy conferred a significant survival benefit for patients with HER2-
positive/estrogen receptor (ER)-negative breast cancer but not for those with HER2-positive/ER-positive breast
cancer.
Women who had received up to three prior trastuzumab regimens derived a greater overall survival benefit than
women who had received four or more.
Median survival after progression did not differ significantly in the combination vs lapatinib groups (10.7 vs 6.4
months; p=0.106).
Similar proportions of patients had adverse events (94% with combination therapy, 90% with monotherapy).
Most adverse events with at least 10% incidence were only grade 1 or 2. The proportion with serious adverse
events was larger in the combination group, however (26% vs 16%).
In summary, the authors say, "These data support the hypothesis that combining anti-HER2 agents may
optimize their use."
They note that the ongoing ALTTO study (NCT00490139) is testing sequential administration of trastuzumab
followed by lapatinib, lapatinib or trastuzumab monotherapy, or lapatinib plus trastuzumab.
Eight of the 12 authors reported financial or other interests in GlaxoSmithKline, including three who are
employed by the company.
SOURCE: http://bit.ly/MgUCB0
J Clin Oncol 2012.
Latest Advances in Treating Human Epidermal Growth Factor Receptor
2 Overexpressing Breast Cancer
Vandana G. Abramson, MD; Ingrid A. Mayer, MD, MSCI
Posted: 06/28/2012; Ther Adv Med Oncol. 2012;4(3):139-147. © 2012 Sage Publications, Inc.
Abstract and Introduction
Abstract
In recent years, new strategies for the treatment of breast cancer have focused on extensive target identification
and understanding the expression, regulation and function of critical signaling pathways involved in breast
cancer initiation and progression. This has led to significant progress in developing and understanding human
epidermal growth factor receptor 2 (HER2)-targeted therapies, which in turn, has translated into significant
increases in median survival for patients with HER2-overexpressing breast cancer. It is becoming increasingly
difficult to make specific recommendations for the optimal treatment of HER2-overexpressing breast cancer
since the field is evolving so rapidly. However, despite the many randomized trials that have been undertaken
showing improvement in survival, the current standard treatment for HER2-overexpressing breast cancer
continues to revolve around the addition of chemotherapy to a HER2-targeted agent, which in turn, carries
substantial toxicities. This article reviews agents that have recently been investigated to treat HER2-
overexpressing breast cancers. The goal is ultimately to increase the magnitude and duration of response to
trastuzumab-based treatment while minimizing toxicity. Studies addressing length of therapy duration, the
superiority and side-effect profile of the different biological drug combinations, and determination of
biomarkers of resistance to HER2 therapy will be instrumental in decreasing morbidity and mortality for
patients with HER2-overexpressing breast cancer.
Introduction
Trastuzumab (Herceptin, Genentech, San Francisco, CA), a humanized monoclonal antibody that binds the
ectodomain of the human epidermal growth factor receptor 2 (HER2), has been approved by the United States
Food and Drug Administration (FDA) for the treatment of HER2-overexpressing breast cancer in the adjuvant
and metastatic settings [Piccart-Gebhart et al.2005; Romond et al. 2005; Smith et al. 2007]. Despite initial
encouraging results, the response rate to trastuzumab is ≤40% as single agent in the first-line treatment of
metastatic breast cancer, and the median duration of response is between9 and 12 months [Baselga, 2001;
Burstein et al. 2001; Vogel et al. 2002]. This suggests that de novo and acquired resistance to trastuzumab occur.
A major focus in the treatment of HER2-overexpressing breast cancer in recent years has been on developing
therapeutic agents to either potentiate the effect of trastuzumab or to target cells which have become resistant to
trastuzumab. Although many randomized trials in recent years have shown improvement in overall survival
(OS) of patients with HER2-overexpressing metastatic breast cancer, almost all have included a chemotherapy
backbone and the current standard of care treatment for HER2-overexpressing breast cancer still revolves
around the addition of chemotherapy to a HER2-targeted agent, which in turn carries substantial toxicities. This
article will review agents that have been recently added to the repertoire of drugs available to treat HER2-
overexpressing breast cancers. Through unique mechanisms of action and synergistic combinations of targeted
agents, the magnitude and duration of response to trastuzumab-based treatment may be increased while
achieving a less toxic side-effect profile.
HER2-Targeted Agents
Lapatinib
Besides trastuzumab, the only other HER2-targeting therapy which has received FDA approval is lapatinib
(Tykerb, GlaxoSmithKline, Philadelphia, PA). Lapatinib is a dual adenosine triphosphate competitive, small
molecule tyrosine kinase inhibitor which targets epidermal growth factor receptor and HER2 [Rusnak et al.
2001]. Lapatinib inhibits the catalytic activity of p95HER2 [Scaltriti et al. 2007], a mechanism of action which
is especially relevant in some HER2-overexpressing tumors in which oncogene product is expressed as a kinase
active 95 kDa cytosolic fragment which lacks the trastuzumab binding epitope and can thus potentially serve as
a resistance mechanism to trastuzumab.
Lapatinib has been found to be active against HER2-overexpressing breast cancers, as first-line therapy and in
tumors which have developed resistance to trastuzumab [Geyer et al. 2006; Gomez et al. 2008]. In the study
that led to its approval by the FDA, women with HER2-overexpressing, locally advanced or metastatic breast
cancer that had progressed after treatment with anthracyclines, taxanes and trastuzumab were randomized to
capecitabine with or without lapatinib. In tumors with confirmation of HER2 overexpression by central review,
progression-free survival (PFS) and time to progression (TTP) were almost doubled from 4.4 months to 8.4
months in the lapatinib arm [hazard ratio (HR) 0.49, 95% confidence interval (CI) 0.34–0.7, p < 0.001) [Geyer
et al. 2006]. This improvement occurred without any increase in serious adverse events in the combination arm.
Another randomized trial of paclitaxel with or without lapatinib in patients receiving first-line therapy for
metastatic breast cancer demonstrated an improvement in median TTP from 5.8 months to 8.1 months in the
lapatinib-containing arm [Di Leo et al. 2007].
In an effort to investigate preclinical studies which showed synergism between lapatinib and trastuzumab, a
study of lapatinib alone or in combination with trastuzumab in patients with HER2-overexpressing and
trastuzumab-refractory metastatic breast cancer was initiated [Blackwell et al. 2010]. Patients had received a
median of three prior trastuzumab-containing regimens and the primary endpoint was PFS. In the 296 patients
included in the intent-to-treat analysis, the combination of lapatinib and trastuzumab resulted in a PFS
improvement of 12 weeks compared with 8 weeks for the lapatinib alone arm (HR 0.73, 95% CI 0.57–0.93, p =
0.008). A trend toward an improvement in OS was seen (HR 0.5, 95% CI 0.53–1.07, p = 0.106) despite the fact
that 49% of women who were randomized to the lapatinib alone arm crossed over to the combination arm after
4 weeks of therapy. The safety profile was acceptable with diarrhea, rash, nausea, and fatigue being the most
common toxicities. Only diarrhea was more significant in the combination arm, and as expected, neutropenia
and febrile neutropenia were not factors in this chemotherapy-free treatment regimen. This study confirmed the
hypothesis that dual blockade of HER2 is more effective than single therapy and set the stage for future studies
to omit chemotherapy and/or to include dual target inhibition.
The combination of lapatinib and trastuzumab has also been evaluated in the neoadjuvant setting for patients
with locally advanced HER2-overexpressing breast cancer [Chang et al. 2011]. In a recent phase II study
(TBCRC006), patients received weekly trastuzumab and daily lapatinib for 12 weeks, and patients who were
estrogen receptor (ER) and/or progesterone receptor (PR) positive also received letrozole (with goserelin if
premenopausal) [Chang et al. 2011]. The median tumor size was 6 cm, with almost two-thirds of patients
having tumors greater than 5 cm in size. The primary endpoint was pathologic complete response (pCR) in the
breast plus near pCR, defined as residual tumor in the breast less than 1 cm. In the 64 evaluable patients, the
pCR rate was 28% and the pCR plus the near pCR rate was 53%. The therapy was well tolerated with the main
toxicities being grade 1 diarrhea, nausea, and acneiform rash. The only grade 3 or 4 toxicity was abnormal liver
function tests which reverted to normal after discontinuation of therapy; this occurred in less than 5% of the
patients. In a population of locally advanced HER2-overexpressing breast cancers, achieving pathologic tumor
size of less than 1 cm in over 50% of patients without chemotherapy and without significant toxicity is a
remarkable achievement. Whether extending treatment will further increase the pCR will be evaluated in future
studies.
Two other large studies, NeoALTTO (neo-Adjuvant Lapatinib and/or Trastuzumab Treatment Optimization) and
the GeparQuinto trials, examined the role of trastuzumab, lapatinib, or the combination in early-stage breast
cancer as adjuvant therapy. GeparQuinto (GBG 44) [Untch et al. 2010] was a randomized phase III study aimed
to determine the pCR rate (defined as no invasive or non-invasive tumor residuals in breast and nodes) of the
addition of trastuzumab or lapatinib to an anthracycline- and taxane-based chemotherapy regimen
(epirubicin/cyclophosphamide followed by docetaxel) for patients with high-risk (> T2 or clinically or
pathologically confirmed lymph node involvement) HER2-overexpressing breast cancer. Median tumor size
was 4 cm. Trastuzumab or lapatinib was administered throughout all cycles of chemotherapy. The trastuzumab
combination arm yielded a significantly higher pCR rate (31%) compared with the lapatinib arm (22%).
Balselga and colleagues evaluated the efficacy of neoadjuvant paclitaxel with trastuzumab versus paclitaxel
with lapatinib or paclitaxel with lapatinib and trastuzumab [Baselga et al. 2010a]. Eligible patients had operable
HER2-overexpressing breast cancer. Patients received the targeted agent(s) alone for 6 weeks after which
paclitaxel was added for 12 weeks. After surgery, patients received adjuvant FEC (5-fluorouracil, epirubicin,
and cyclophosphamide) followed by the same targeted therapy they had received prior to surgery to complete 1
year of anti-HER2 therapy. The primary endpoint was pCR in the breast. The targeted therapy combination arm
yielded a significantly higher pCR rate (51%) compared with 25% in the lapatinib arm and 29.5% in the
trastuzumab arm. The total locoregional pCR rate, which included lymph nodes, was also significantly higher in
the trastuzumab/lapatinib arm. In both GeparQuinto and NeoALTTO studies, the lapatinib-containing arms were
associated with significantly more grade 3 and higher toxicity than the trastuzumab alone arms, including
diarrhea, hepatic toxicity, neutropenia, and skin disorders. In the NeoALTTO study, the toxicity led to reduced
treatment exposure, with only 61% of patients in the lapatinib/trastuzumab arm completing therapy compared
with 92% in the trastuzumab arm. Despite this decrease in exposure, the combination still had a much higher
pCR rate, indicating that dual inhibition is important, but the dosing of lapatinib needs to be modified for future
studies. Adverse events including diarrhea can also be controlled more effectively with prophylactic measures
and strict dosing reduction guidelines in future studies.
ALTTO (Adjuvant Lapatinib and/or Trastuzumab Treatment Optimization [ClinicalTrials.gov Identifier:
NCT00490139]), a randomized, open-label multi-centre phase III study comparing the activity of lapatinib
alone versus trastuzumab alone versus trastuzumab followed by lapatinib versus lapatinib concomitantly with
trastuzumab in the adjuvant treatment of patients with ErbB2-overexpressing breast cancer has recently
completed accrual and final results are pending. However, the study's independent data monitoring committee
recently reported that the comparison of lapatinib alone versus trastuzumab alone crossed the futility boundary,
indicating that the lapatinib alone arm was unlikely to meet the prespecified criteria to demonstrate non-
inferiority to trastuzumab alone with respect to disease-free survival (DFS). The study will continue the other
three arms (trastuzumab alone, sequential trastuzumab/lapatinib, and the combination arm) as planned.
Initial trials of adjuvant chemotherapy with trastuzumab or placebo in early-stage HER2-positive patients
showed that the brain as the first site of relapse was significantly higher in the trastuzumab arm, confirming the
hypothesis that the brain could serve as a sanctuary site for patients receiving trastuzumab [Romond et al.
2005]. Unlike trastuzumab, lapatinib and other small molecule HER2-kinase inhibitors have the potential to
cross the blood–brain barrier. In lapatinib's phase III registration study, central nervous system metastases
occurred in fewer women in the lapatinib/capecitabine arm compared with the capecitabine alone arm [Geyer et
al. 2006]. This trend was evaluated in a phase II study of 39 patients with HER2-positive breast cancer and
brain metastases [Lin et al. 2008]. The results further demonstrated evidence of some activity of lapatinib in the
brain with one partial response in the brain and 18% PFS at 16 weeks. The ALTTO study, in addition to
determining lapatinib's place in the adjuvant treatment of HER2-overexpressing breast cancer in regards to
systemic control, will also provide insights into whether a small molecule can improve DFS and OS by
preventing CNS relapses.
Trastuzumab Emtansine
Trastuzumab emtansine (T-DM1) is a novel HER2 antibody–drug conjugate in which trastuzumab is bound to
the highly potent antimicrotubule agent (DM1) which is derived from the toxic chemotherapy, maytansine. T-
DM1 binds to HER2 with affinity similar to that of trastuzumab and delivers its antitumor activity to HER2-
overexpressing cells by combining the action of trastuzumab with receptor-mediated internalization and
intercellular release of maytansine [Widdison et al. 2006]. A phase II study of 112 patients receiving single-
agent T-DMI showed an overall response rate (ORR) of 26% [Vogel et al. 2009]. To confirm the finding of the
first phase II study in a more homogenous population, another open-label phase II study of 110 patients who
had received a prior anthracycline, taxane, capecitabine, trastuzumab and lapatinib was performed. This study
demonstrated an ORR of 32.7% by independent radiology assessment and 39.5% in centrally confirmed HER2-
positive patients [Krop et al. 2009]. Patients on study had received a median of seven prior agents for metastatic
disease (range 1–15). T-DM1 was generally well tolerated, with the most common toxicities being fatigue,
nausea, and reversible thrombocytopenia.
A randomized phase II trial of T-DM1 in patients receiving first-line treatment for metastatic breast cancer
compared T-DM1 with trastuzumab plus docetaxel [Perez et al. 2010]. There were 137 patients with newly
diagnosed metastatic disease who were randomized to one of the two study arms. After a median follow up of 6
months, the ORR in the T-DM1 arm was 48%, compared with 41% in the trastuzumab/docetaxel arm. Most
importantly, the rates of clinically adverse events were 37% in the T-DM1 arm compared with 75% in the
chemotherapy-containing arm. The development of therapies such as T-DM1, which provide significant benefit
while reducing toxicity, is of utmost importance in patients with metastatic disease. T-DM1 is now being
evaluated in early-stage breast cancer and in combination with chemotherapy and with other targeted agents as
discussed below.
Pertuzumab
Pertuzumab (Omnitarg, Genentech, San Francisco, CA) is a humanized monoclonal antibody that binds to an
epitope in the dimerization domain of the HER2 receptor that is different from the binding site of trastuzumab
and prevents signaling secondary to heterodimerization with HER3. In a phase II study of patients with HER2-
positive metastatic breast cancer progressing on trastuzumab, the combination of trastuzumab and pertuzumab
showed an ORR of 24% and a clinical benefit rate (CBR) of 50%, with five patients (7.6%) experiencing a
complete response [Baselga et al. 2010b]. This combination was extremely well tolerated with diarrhea, fatigue,
and nausea being the most common adverse events. Only four patients experienced grade 3 treatment-related
adverse events, including diarrhea, which was controlled with medication in two patients, one central line
infection, and one episode of pruritic rash after injection of contrast prior to pertuzumab. All of the adverse
events resolved and treatment was continued. The concept of treating breast cancer through the use of two
targeted therapies was verified with trastuzumab and lapatinib, but this study is the first to show a benefit for
combining two monoclonal antibodies without affecting toxicity.
Building on the success of the pertuzumab/trastuzumab study, a phase III study of pertuzumab and trastuzumab
with docetaxel versus trastuzumab/docetaxel, known as CLEOPATRA (Clinical Evaluation of Pertuzumab and
Trastuzumab), met its primary endpoint of PFS benefit for the pertuzumab/trastuzumab/docetaxel arm [Baselga
et al. 2011]. CLEOPATRA was a randomized, placebo-controlled study which included 808 patients with
HER2-positive metastatic breast cancer from 19 countries in their first line of treatment for metastatic disease.
The median PFS was 18.5 months in the pertuzumab group compared with 12.4 months in the control group
(HR 0.62, 95% CI 0.51–0.75, p < 0.001). Final OS results are pending, but an interim analysis did show a
strong trend in favor of the pertuzumab group. No new safety signals were noted and adverse events were
consistent with prior studies combining trastuzumab and pertuzumab. Importantly, no increase in cardiac toxic
events was noted with the combination of the two antibodies.
Pertuzumab has also been evaluated in the neoadjuvant setting in patients with HER2-overexpressing cancer
whose primary tumors were larger than 2 cm. NeoSphere (Efficacy and Safety of Neoadjuvant Pertuzumab and
Trastuzumab in Women with Locally Advanced, Inflammatory, or Early HER2-positive Breast Cancer Trial)
was a four-arm phase II study of 417 patients designed to compare neoadjuvant docetaxel given concurrently
with trastuzumab, or pertuzumab, or the combination of trastuzumab and pertuzumab, or trastuzumab and
pertuzumab without chemotherapy [Gianni et al. 2010b]. The primary endpoint was pCR rate, and secondary
endpoints included CBR, DFS and breast conservation rate. The combination of
docetaxel/trastuzumab/pertuzumab yielded a pCR rate of 46% compared with 29% for docetaxel/trastuzumab,
24% for docetaxel/pertuzumab, and 17% for trastuzumab/pertuzumab. The CBR rate was similar between all
four arms. The primary grade 3 and higher toxicities occurred in the docetaxel arms and included neutropenia,
febrile neutropenia, leucopenia, and diarrhea. These appeared to be due to docetaxel as the toxicities among the
three docetaxel arms were similar and the addition of a second biological drug did not change the adverse
effects. The only grade 3 and higher toxicity reported in the trastuzumab/pertuzumab arm was a 1% rate of
neutropenia. This study confirmed the activity of the two monoclonal antibodies in combination, but suggested
that chemotherapy is still necessary in at least a subset of the population to achieve maximum response.
The MARIANNE study, a phase III randomized study of T-DM1 with or without pertuzumab compared with
trastuzumab plus a taxane for first-line treatment of HER2-overexpressingmetastatic breast cancer is an ongoing
study which is the first to evaluate the efficacy of a targeted antibody and an antibody–drug conjugate[Ellis et
al. 2011]. The primary endpoint is PFS, and target enrollment is ahead of schedule. Ifpositive, this study may
change treatment paradigms completely for HER2-overexpressing metastatic breast cancer by eliminating
nontargeted cytotoxic chemotherapy in the first line. T-DM1 is also being explored in the second-line setting in
a randomized phase III study comparing it with lapatinib and capecitabine. This study (EMILIA) will again
serve to potentially challenge a standard treatment in HER2-overexpressing breast cancer.
Table 1 includes a list of ongoing phase III clinical trials with novel agents for patients with HER2-
overexpressing metastatic breast cancer.
Table 1. Ongoing randomized phase III trials in human epidermal growth factor receptor
2 overexpressing metastatic breast cancer.
Clinical trial Study arms Trial endpoint Data expected
NEFERTT Neratinib + Paclitaxel PFS, OS 2012
(N = 1200)
First-line metastatic Trastuzumab + Paclitaxel

Herceptin + taxane PFS 2012

BO22589
(N = 1092) T-DM1
First-line metastatic
T-DM1 + pertuzumab
T-DM1 PFS, OS, ORR 2013
EMILIA
(N = 580) Capecitabine + lapatinib
Locally advanced or metastatic
Docetaxel + trastuzumab + pertuzumab
PHEREXA Capecitabine + trastuzumab PFS, TTP, TTF, ORR, CBR 2015
(N = 450)
Second-line after trastuzumab Capecitabine + trastuzumab + Pertuzumab

BOLERO-1 Pertuzumab + trastuzumab PFS, OS, ORR, CBR, TTR 2012

(N = 717)
First-line metastatic Pertuzumab + trastuzumab + everolimus

BOLERO-3 Vinorelbine + trastuzumab PFS, OS, ORR, CBR 2012

(N = 572)
Resistant to trastuzumab Vinorelbine + trastuzumab + everolimus
CBR, clinical benefit rate; ORR, overall response rate; OS, overall survival; PFS, progression-free survival;
TTF, time to treatment failure; TTP, time to progression; TTR, time in treatment range.
Conclusion
In the case of treatment targeted against HER2-positive breast cancers, there are no biomarkers reliably
predicting lack of benefit from trastuzumab that can be used for either clinical trial development or individual
therapeutic decisions. Although there are many drugs (such as phosphoinositide 3-kinase/Akt pathway
inhibitors, antiangiogenics, cell cycle regulators, or insulin-like growth factor 1 inhibitors) that might be
rationally combined with trastuzumab or any other HER2 inhibitor, we do not have a formal process that allows
prioritization or triaging of those combinations in a way that will accelerate the approval of the most effective
ones.
The study of biomarkers of drug exposure and sensitivity in metastatic tumors, although feasible, is not easy
due to the inherent difficulty of obtaining sequential tumor samples only for research purposes. One approach to
circumvent this difficulty consists of the administration of novel therapies in the neoadjuvant setting. The
incorporation of presurgical targeted-development clinical trials that focus on extensive agent characterization
and target-assay development in a limited number of patients could yield results that would optimally inform
and expedite subsequent development and approval of molecularly targeted agents, providing a platform for
prioritization of novel combinations [Kummar et al. 2007]. By allowing the collection of both diagnostic and
surgical tumor material, these studies have the added benefit of providing paired pre- and post-therapy tumor
tissues with pharmacodynamic endpoints in 100% of subjects enrolled, hence providing a goldmine for
discovery of resistance mechanisms and a platform for better identification of patients who may do well with
less toxic treatment.
The results of recent neoadjuvant clinical trials for patients with HER2-overexpressing breast cancer
(summarized in Table 2) show that the combination of chemotherapy and dual HER2 blockade (i.e. trastuzumab
plus lapatinib or trastuzumab plus pertuzumab) clearly promotes higher rates of pCR, whereas the combination
of chemotherapy and single-agent lapatinib or single-agent pertuzumab in general performs worse than
chemo/single agent trastuzumab-containing regimens. Furthermore, lapatinib single-agent arms (1500 mg) tend
to be more toxic, and result in inability to complete a full course of treatment. Subset analysis of pCR rates in
HER2+/ER− and HER2+/ER+ breast cancers consistently show higher pCR rates in HER2+/ER− tumors.
However, long-term follow up supports that HER2+/ER+ tumors may have similar (if not better) prognosis.
Table 2. Pathological complete responses (pCRs) in neoadjuvant clinical trials for patients
with human epidermal growth factor receptor 2 (HER2)-overexpressing breast
cancer.
Clinical trial Study arms pCR (%)
NeoSphere (Gianni et al. 2010b) (N ~ Trastuzumab + docetaxel 29
400)
Pertuzumab + docetaxel 24
Pertuzumab + trastuzumab + docetaxel 46
Trastuzumab + pertuzumab 17
NeoALTTO (Baselga et al. 2010a) (N ~ Trastuzumab → trastuzumab + paclitaxel 30
450)
Lapatinib → lapatinib + paclitaxel 25
Trastuzumab + lapatinib → lapatinib + trastuzumab +
51
paclitaxel
GeparQunito (Untch et al. 2010) (N ~ EC + trastuzumab → trastuzumab + docetaxel 31
600)
EC + lapatinib → lapatinib + docetaxel 22
TBCRC006 (Chang et al. 2011) (N ~ 60) Trastuzumab + lapatinib (ER−) 46
Trastuzumab + lapatinib + letrozole (ER+) 21
EC, epirubicin + cyclophosphamide; ER, estrogen receptor; NeoSphere, Efficacy and Safety of Neoadjuvant
Pertuzumab and Trastuzumab in Women with Locally Advanced, Inflammatory, or Early HER2-positive Breast
Cancer Trial; NeoALTTO, neo-Adjuvant Lapatinib and/or Trastuzumab Treatment Optimization Trial.
Overall, the addition of anthracyclines and/or longer duration of neoadjuvant treatment did not significantly
increase pCR rates. This was to be expected following the results of the Breast Cancer International Research
Group 006 (BCIRG006) multicenter phase III randomized trial. This trial compared doxorubicin and
cyclophosphamide followed by docetaxel (ACT) with doxorubicin and cyclophosphamide followed by
docetaxel and trastuzumab (ACTH) and with docetaxel, carboplatin and trastuzumab (TCH) in the adjuvant
treatment of node-positive and high-risk node-negative patients with operable HER2-overexpressing breast
cancer [Slamon et al. 2009]. The results showed that the benefit of trastuzumab addition to an anthracycline-
based (ACTH) and a non-anthracycline-based (TCH) chemotherapy regimen was very similar in terms of DFS
and OS at 65 months of follow up, with much less cardiac toxicity seen in the nonanthracycline-based (TCH)
arm.
The similarities in the direction of the outcomes of certain 'paired' adjuvant/neoadjuvant clinical trials are
certainly intriguing, and suggest the possibility that neoadjuvant studies with cellular and molecular endpoints
in addition to clinical endpoints can 'predict' the outcome of larger clinical studies in the adjuvant or metastatic
setting and thus provide a novel platform for the prioritization of new drugs and/or combinations. This was
certainly the case in the adjuvant ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial [Howell et al.
2005] and the neoadjuvant IMPACT (Immediate Preoperative Anastrozole, Tamoxifen, or Combined with
Tamoxifen) trial [Dowsett et al. 2003, 2005; Smith et al. 2005], both of which compared the use of tamoxifen
with the third-generation aromatase inhibitor, anastrozole, and the combination. In the neoadjuvant NOAH
(Neo-Adjuvant Herceptin) trial [Gianni et al. 2010a] and the adjuvant NSABP (National Surgical Adjuvant
Breast and Bowel Project) B-31/NCCTG N9831 trial [Romond et al. 2005], survival benefit was shown from
the addition of trastuzumab to chemotherapy. More recently, the NeoALTTO study [Baselga et al. 2010a]
showed that the single-agent lapatinib arm had a lower pCR rate than the trastuzumab and combination arms,
which seem to have accurately predicted the outcome of the lapatinib only arm in the ALTTO study.
However, as tempting as it is to speculate, due to variable outcomes, pCR rate may not be a 100% reliable
surrogate in all cases (i.e. HER2+/ER+ breast cancer), and validation in the adjuvant setting may still be
required. Despite its small sample size, the TBCRC006 trial, in which patients with stage II and III HER2-
overexpressing breast cancers were treated with a trastuzumab and lapatinib combination, showed that
neoadjuvant treatment without a chemotherapy backbone is feasible and potentially sufficient for a selected
patient population. Such neoadjuvant studies, in which tissue is collected prior to treatment and at surgery, new
molecular markers can be investigated to identify subsets of patients who are the best candidates for
chemotherapy-free regimens. Confirmatory studies addressing length of therapy duration, the superiority and
side-effect profile of the different biological drug combinations (i.e. trastuzumab plus lapatinib, trastuzumab
plus pertuzumab, T-DM1) and determination of biomarkers of HER2 therapy resistance will be instrumental in
decreasing morbidity and mortality for patients with HER2-overexpressing breast cancer.
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(n = 949), with 6-year median follow-up and 313 events, revealed 5-year DFS rates of 80.1% and 84.4%,
respectively. There was an increase in DFS with concurrent trastuzumab and paclitaxel relative to sequential
administration (arm C/arm B HR, 0.77; 99.9% CI, 0.53 to 1.11), but the P value (.02) did not cross the
prespecified O'Brien-Fleming boundary (.00116) for the interim analysis. CONCLUSIONDFS was significantly
improved with 52 weeks of trastuzumab added to adjuvant chemotherapy. On the basis of a positive risk-benefit
ratio, we recommend that trastuzumab be incorporated into a concurrent regimen with taxane chemotherapy as
an important standard-of-care treatment alternative to a sequential regimen.

Trastuzumab (Herceptin) May Work Better With Anthracyclines

By David Douglas
NEW YORK (Reuters Health) Oct 31 - In HER2+ breast cancer patients, neoadjuvant therapy with trastuzumab
(Herceptin) plus an anthracycline might be more effective than trastuzumab alone, new research shows.
"Significantly more patients who had the anthracycline regimen had complete eradication of tumor in their
breast and axillary nodes -- pathological complete response. Patients who had anthracyclines also had a lower
rate of recurrence," Dr. Funda Meric-Bernstam told Reuters Health.
Dr. Meric-Bernstam, who headed the new study, also noted that "there has been a growing trend away from the
use of anthracyclines, especially with the increased utilization of trastuzumab," in women with breast tumors
that express human epidermal growth factor receptor 2 (HER2).
In a phase III trial reported in 2001, giving anthracyclines with trastuzumab produced a 27% rate of
cardiotoxicity, she and her colleagues recalled in paper published online September 27th in Cancer. But in that
2001 study and others, "Although cardiotoxicity was more frequent with sequential
doxorubicin/cyclophosphamide and taxane-trastuzumab than nonanthracycline-based trastuzumab regimens, the
majority of patients who received therapy displayed neither acute nor delayed cardiac dysfunction," the
researchers write.
And in three studies published since 2005, "trastuzumab plus anthracycline-based neoadjuvant systemic therapy
was both effective and well tolerated," they add.
In the article published last month, Dr. Meric-Bernstam and colleagues at The University of Texas MD
Anderson Cancer Center review data on 235 patients with HER2-positive breast cancer who received sequential
paclitaxel and trastuzumab, with 5-fluorouracil, epirubicin and cyclophosphamide in combination with
trastuzumab (PH-FECH), and 65 patients managed with the non-anthracycline-based regimen of docetaxel,
carboplatin, and trastuzumab (TCH).
Excluded were patients with metastatic disease, bilateral breast cancer, or more than one primary tumor.
At three years, the PH-FECH group had a significant advantage in recurrence-free survival (83% vs. 71%) and
overall survival (95% vs. 86%). Hazard ratios for recurrence and death were 0.27 and 0.37, respectively, with
PH-FECH.
The 235 patients who received PH-FECH were 1.45 times more likely to have a pathological complete
response, according to the authors.
There were no significant differences between the groups in non-laboratory adverse events or cardiotoxicity.
However, one patient on PH-FECH developed congestive heart failure that led to sudden cardiac death. This
example "further highlights the importance of careful patient selection and close cardiac monitoring," the
researchers said.
Researchers are currently conducting a trial to see whether trastuzumab can be withheld until after anthracycline
therapy, without any decrease in efficacy.
"Our study has limitations as it was retrospective and not randomized," Dr. Meric-Bernstam said. "However, we
had minimal cardiac toxicity in carefully selected patients."
She concluded, "Anthracycline based regimens should continue to be strongly considered for HER2+ patients
without cardiac risk factors as there may be oncologic benefits."
SOURCE: http://bit.ly/uxVmsd
Cancer 2011.

Oncotype DX Assay for HER2 Status Has High False-Negative Rate

NEW YORK (Reuters Health) Oct 24 - The Oncotype DX test (Genomic Health Inc) for HER2 gene
amplification in breast cancers has an "unacceptable" false-negative rate, according to a report in the Journal of
Clinical Oncology online October 11.
But the Oncotype DX is "increasingly used to help make chemotherapy decisions for patients diagnosed with
estrogen-receptor (ER)-positive breast cancer," according to Dr. Rohit Bhargava at Magee-Womens Hospital of
the University of Pittsburgh and colleagues.
The U.S. Food and Drug Administration has approved five assays for assessing HER2 status: two use
immunohistochemistry and three use fluorescent in situ hybridization (FISH).
The Oncotype Dx test, in contrast, uses a reverse transcription polymerase chain reaction (RT-PCR).
"On the basis of our data, we suggest that oncologists be careful not to take into account (the) GHI HER2 assay
in selecting patients for trastuzumab therapy and continue to rely on validated IHC and/or FISH assays," Dr.
Bhargava and her coauthors write.
The human epidermal growth factor receptor 2 gene (HER2 or ERBB2), a marker of aggressive disease, is
amplified in 15% to 20% of breast cancers. The Oncotype DX assay looks for DNA overexpression associated
with HER2 gene amplification.
Using tumor samples from 843 patients from three centers, the research team compared results reported by
Oncotype DX to results of immunohistochemistry (IHC) and FISH.
The Oncotype test gave 816 negative results, but 14 of these were positive and 23 were equivocal on IHC/FISH
testing, the authors report.
The PCR-based test also classified 17 results as equivocal, of which 12 were positive on IHC/FISH.
In fact, of 36 cases identified as positive by IHC/FISH, the GHI test found only 10. It reported 12 as equivocal
and 14 as negative.
"There was an unacceptable false-negative rate for HER2 status with GHI HER2 assay in this independent
study," Dr. Bhargava and colleagues conclude. "This could create confusion in the decision-making process for
targeted treatment and potentially lead to mismanagement of patients with breast cancer if only GHI HER2
information is used."
GHI's Oncotype DX website notes that the assay is included in the 2007 American Society of Clinical Oncology
Clinical Guidelines on Use of Tumor Markers in Breast Cancer as well as in the National Comprehensive
Cancer Network (NCCN) Breast Cancer Treatment Guidelines.
So where does this leave clinicians? In an editorial, Drs. John M. S. Bartlett and Jane Starczynski with the
Ontario Institute for Cancer Research in Toronto write, "Simply stated, there is insufficient evidence to support
qRT-PCR as a substitute for in situ methods (IHC/FISH)."
SOURCE: http://bit.ly/rFRzEK
J Clin Oncol 2011.

Targeted Chemo Shows Promise in Metastatic Breast Cancer

September 26, 2011 (Stockholm, Sweden) — The first randomized trial to compare the novel agent trastuzumab
emtansine (T-DM1) with standard therapy shows that it significantly increased progression-free survival in
women with metastatic breast cancer.
"First-line treatment with T-DM1 was associated with a statistically significant improvement in progression-free
survival, and was also associated with a reduction in the risk of toxicity," said lead author Sara Hurvitz, MD,
director of the breast oncology program, division of hematology/oncology, University of California, Los
Angeles.
"These results validate the hypothesis that the unique targeted delivery of chemotherapy through T-DM1 may
lead to an improved therapeutic index," she said.
Dr. Hurvitz presented the results of the study here at the 2011 European Multidisciplinary Cancer Congress.
Median progression-free survival was 14.2 months for women who received T-DM1, and 9.2 months for those
who received standard therapy with trastuzumab (Herceptin) plus docetaxel. The hazard ratio was 0.59,
indicating that treatment with T-DM1 reduced the probability of disease progression or death by 41%, compared
with standard therapy, noted Dr. Hurvitz.
Longer Duration
T-DM1 is a novel HER2-targeted antibody–drug conjugate, developed by Genentech, for the treatment of
HER2-positive cancer. Dr. Hurvitz emphasized that it provides intracellular delivery of the cytotoxic agent
DM1, while maintaining the antitumor activities of trastuzumab and sparing normal cells.
Trastuzumab targets the product to the cancer cell, she explained, while the attached emtansine acts as a
"bullet", she said.
In this study, Dr. Hurvitz and colleagues randomized 137 patients with metastatic breast cancer to either T-DM1
or to the combination of trastuzumab 75 or 100 mg/m2 plus docetaxel (control group) to evaluate the safety and
efficacy of the experimental agent. In the majority of patients in the control group (74.2%), trastuzumab was
initiated at 75 mg/m2.
The median durations of follow-up were 13.5 months for the control group and 13.8 months for the T-DM1
group. The primary end point was progression-free survival.
Patient characteristics were balanced between the 2 groups, and the majority of patients were enrolled outside of
the United States. Dr. Hurvitz pointed out that relatively few patients received adjuvant trastuzumab. "This is
likely due to the international nature of the study and the lack of availably at some centers," she said.
The majority of patients who discontinued treatment did so because of disease progression, but the rate was
much lower in the T-DM1 group than in the control group (61% vs 42%).
The overall response rates were similar in the T-DM1 and control groups (64% vs 58%).
In the control group, the duration of response was 9.5 months; in the T-DM1 group, the duration of response has
not been reached. "This suggest that it will be durable, but we will need further follow-up to know what it will
be," said Dr. Hurvitz.
There was a difference in toxicity — a measure that is "clinically meaningful" to patients, she said.
Lower Rate of Toxicity
Patients in the T-DM1 group had significantly fewer common and grade 3 or higher adverse events. The T-DM1
group had approximately half the incidence of severe adverse events as the control group (46.4% vs 89.4%).
Discontinuation of treatment because of toxicity was markedly lower in the T-DM1 group than in the control
group (7.2% vs 28.8%).
The majority of serious events were related to neutropenia, and the rate was much higher in the control group
than in the T-DM1 group (60.6% vs 5.8%). In addition, 13.6% of patients in the control group experienced
febrile neutropenia; there were no cases in the T-DM1 group.
Also, said Dr. Hurvitz, the rate of alopecia — an adverse effect that is very important to patients — was much
lower in the T-DM1 group than in the control group (4.0% vs 66.7%).
The median duration of treatment was longer in the T-DM1 group (10.0 vs 5.5 months), most likely because of
the toxicity in the control group. There were 2 deaths in the study not related to disease progression — 1 in each
group.
Overall survival data are not mature and are, therefore, not available.
Phase 3 Results Coming
"This is the first study to evaluate an antibody–drug conjugate for HER2-positive metastatic breast cancer,
compared with standard therapy," she said.
"These results validate the hypothesis that the unique targeted delivery of chemotherapy through T-DM1 may
lead to an improved therapeutic index," Dr. Hurvitz concluded.
She added that the drug is currently being evaluated in phase 3 clinical trials; the first results will be available in
2012.
Martine Piccart-Gebhart, MD, PhD, the discussant of the paper, noted that these results are exciting. Perhaps
this is the "magic drug, the one we have been waiting for," she said, cautioning that this is an open-label study
and the data are still early.
"This is an important study with exciting results, but we need validation in the phase 3 setting," said Dr. Piccart-
Gebhart, who is from the Jules Bordet Institute in Brussels, Belgium.
She pointed out that there is a very comprehensive phase 3 program ongoing, so the drug might soon be
available to patients.
2011 European Multidisciplinary Cancer Congress (EMCC): Abstract 5001. Presented September 25, 2011.

EMCC News: New cancer drug combination significantly delays breast cancer progression
25.09.11
Category: EMCC 2011
The first randomised trial to investigate the use of trastuzumab emtansine (T-DM1) – an
antibody-guided drug – for the initial treatment of HER2- (human epidermal
growth factor receptor-2) positive metastatic breast cancer has shown that it makes
a significant difference to the time women live without their disease worsening.
European Multidisciplinary Cancer Congress 2011 [1]: Dr Sara Hurvitz, one of the trial investigators: “Our
results showed that patients with metastatic breast cancer who received T-DM1 had a 41% improvement in the
time they lived without their breast cancer worsening compared to those who received standard docetaxel
chemotherapy plus trastuzumab. These provocative Phase II data illustrate that first-line treatment with T-DM1
provides a longer time for patients to live without cancer progression and with fewer side effects than standard
chemotherapy plus trastuzumab.”
Trastuzumab emtansine (T-DM1) is a novel type of cancer therapy known as an antibody drug conjugate
(ADC). It combines the monoclonal antibody, trastuzumab, with a potent cytotoxic agent DM1 [2] through a
stable linker and uses the HER2 targeting properties of trastuzumab to deliver the cell-killing agent DM1 into
the cancer cells.
Dr Hurvitz, Director of the Breast Oncology Program for the Division of Hematology/ Oncology at The
University of California, Los Angeles (UCLA), USA, has said that “T-DM1 is unique because it retains the
cancer fighting properties of trastuzumab and delivers the DM1 agent directly to the tumour cell for destruction,
while limiting exposure of the free DM1 drug to normal cells. This explains why patients who received T-DM1
had fewer side effects compared to those assigned to the chemotherapy-containing control arm in this study.”
T-DM1 is specifically designed to attach trastuzumab to DM1 using a stable linker. The bound DM1 has little
toxicity, but when it is delivered to the HER2-positive cancer cells, DM1 is released and its potent cytotoxic
effect is enabled. The trastuzumab monoclonal antibody delivers its anti-cancer effects after targeting T-DM1 to
the cancer cell.
About one in five breast cancer tumours are HER2-positive, meaning that the cancer cells overproduce the
protein called HER2, which plays an important role in promoting cancer growth. This type of breast cancer is
often more aggressive and difficult to treat than other types of breast cancer. HER2-positive tumours are usually
treated with targeted therapy.
Dr Hurvitz: “The majority of patients with HER2-positive metastatic breast cancer will face resistance to the
currently available HER2-directed therapies. Therefore, dealing with resistance to HER2-targeted therapy
remains an unmet need and new, effective therapies for HER2-positive breast cancer are still necessary.”
Dr Hurvitz and her colleagues enrolled 137 patients, who had never received chemotherapy or HER2-targeted
therapy for locally advanced or metastatic HER2-positive breast cancer, in the open-label, randomised, Phase II
clinical trial. Patients were randomly assigned to receive treatment with either T-DM1 or standard therapy
(trastuzumab plus the chemotherapy drug docetaxel).
The median progression-free survival (time that elapses before the cancer worsens) was 14.2 months for women
who received T-DM1 compared to 9.2 months for those who received trastuzumab plus docetaxel. Two deaths
that were not due to disease progression occurred in the study, one in each treatment arm. The percentage of
women who discontinued treatment due to side-effects was 7.2% in the T-DM1 arm and 28.8% in the standard
therapy arm of the study.
“T-DM1 is unique in that it allows the targeted delivery of chemotherapy to cancer cells. Based on the results of
this Phase II study, T-DM1 appears to be not only safer than the docetaxel/trastuzumab combination, but it may
allow patients to live without disease progression for a significantly longer period of time. A safer, more
effective treatment is likely to enhance patient quality of life and it may ultimately translate into fewer
hospitalisations for complications more commonly reported with docetaxel/trastuzumab use.”
“It is important to realise that while the current data are encouraging, results from the ongoing Phase III studies
(EMILIA and MARIANNE) [3] will be needed to more fully characterise the efficacy and safety profile of T-
DM1 compared to the current therapy regimens used to treat HER2-positive metastatic breast cancer.”
Professor Michael Baumann, president of ECCO said: “This is a very important trial which indicates that the
more selective delivery of anticancer drugs, by conjugating them to antibodies which dock to cancer cells, bears
considerable promise for personalised cancer treatment.”
Commenting on the study, which he was not involved with, ESMO member Dr Angelo Di Leo from the
Hospital of Prato, Istituto Toscano Tumori, Italy, said: “These promising data do not yet allow us to consider T-
DM1 as a new standard of care for the first-line treatment of HER-2 positive breast cancer. The results from
ongoing Phase III trials are eagerly awaited. Ongoing studies are also exploring the possibility of combining T-
DM1 with other biological agents targeting receptors belonging to the HER family. It is expected that
combining T-DM1 with these agents will further improve the level of care for women affected by HER-2
positive breast cancer.”
Abstract no: 5001. Breast cancer proffered papers session, Sunday 09.00-11.05 hrs CEST (Hall A1).

HER3 Overexpression and Survival in Solid Tumors

A Meta-analysis
Alberto Ocana, Francisco Vera-Badillo, Bostjan Seruga, Arnoud Templeton, Atanasio Pandiella, Eitan Amir
J Natl Cancer Inst. 2013;105(4):266-273.
Abstract and Introduction
Abstract
Background The human epidermal growth factor receptor 3 (HER3) is an ErbB/HER family member that
dimerizes with other ErbB receptors such as HER2. Numerous agents against HER3 are in clinical development
despite variable data for the prognostic impact of HER3 expression. Here we report a meta-analysis of the
association of HER3 expression and survival in solid tumors.
Methods PubMed was searched for studies evaluating expression of HER3 (as measured by
immunohistochemistry) and overall survival (OS) in solid tumors. Published data were extracted and computed
into odds ratios (ORs) for death at 3 and 5 years. Data were pooled using the Mantel–Haenszel random-effect
model. All statistical tests were two-sided.
Results Analysis included 12 studies: three that evaluated colorectal cancer, two that evaluated gastric cancer,
two that evaluated breast cancer, and one each that evaluated melanoma, ovarian cancer, head and neck cancer,
pancreatic cancer, and cervical cancer. The median percentage of cancers with HER3 overexpression was
42.2%. HER3 was associated with worse OS at both 3 years (OR = 2.24, 95% confidence interval [CI] = 1.77 to
2.83, P < .001) and 5 years (OR = 2.20, 95% CI = 1.75 to 2.76, P < .001). Among studies with common HER2
overexpression (breast, gastric, and ovarian cancers), the magnitude of effect of HER3 on OS was statistically
significantly greater for both 3-year OS (OR = 3.12, 95% CI = 2.24 to 4.37) and 5-year OS (OR = 2.84, 95% CI
= 2.09 to 3.88).
Conclusions Expression of HER3 is associated with worse survival in solid tumors. The influence of HER3
may be greater in those tumors where HER2 is commonly overexpressed.
Introduction
The human epidermal growth factor receptor (HER or ErbB) family of receptor tyrosine kinases plays a central
role in different physiological functions mediating the transmission of extracellular signals to intracellular
downstream pathways.[1]
The ErbB family includes four members, the epidermal growth factor receptor (EGFR; HER1 or ErbB1), HER2
(ErbB2), HER3 (ErbB3), and HER4 (ErbB4).[2] The abnormal activation of these receptors has been linked with
different pathological processes including malignant transformation.[3] For instance, overexpression of HER2
has been observed in breast, ovarian, and gastric cancer, and mutations of the EGFR have been described in
non-small-cell lung cancer.[3] Strategies targeting these proteins, including the use of trastuzumab and lapatinib
for the treatment of HER2 overexpressing breast cancer, trastuzumab for the treatment of HER2-amplified
gastric cancer,[3,4] and EGFR tyrosine kinase inhibitors in non-small-cell lung cancer,[5] have become routine
clinical practice.
Activation of ErbB receptors causes stimulation of intracellular signaling cascades, which promote migration,
invasion, proliferation, or survival, among others.[1] In pathological situations, such as in cancer, ErbB receptors
can be activated by ligand binding, receptor overexpression, or structural alterations, including truncations and
mutations.[6]
The HER3 receptor is a key member of the ErbB family and preferentially signals through the
phosphatidylinositol 3-kinase pathway.[7] Formation of dimers between HER3 and HER2 seems to be crucial for
the HER2-driven signals in those tumors with overexpression of HER2.[8] Oligomerization of HER3 with other
HER family receptors appears critical for its signaling function because HER3 lacks tyrosine kinase activity.[3]
Given the fact that HER2–HER3 is considered the most active signaling dimer of the ErbB system, agents
targeting this dimerization have been developed.[9,10] This was the case for the antibody pertuzumab, which
prevents the formation of HER2–HER3 dimers upon ligand binding.[10,11]
Recent attention has focused on strategies to inhibit the activity of HER3.[12] The rationale for targeting this
receptor is based on the mentioned preclinical data and the increasing interest in the role of HER3-activating
ligands such as neuregulin in cancer.[11,13] Furthermore the positive results from clinical trials in HER2-positive
breast cancer, in which pertuzumab was added to trastuzumab, have reinforced the interest in this receptor and
led to the approval of pertuzumab for the first-line treatment of patients with HER2-positive, metastatic breast
cancer.[14] In addition to pertuzumab, which binds the domain 2 of HER2, preventing its dimerization with
HER3, other antibodies targeting HER3 are currently under development. These include those designed
specifically against the ectodomain of HER3 and bivalent antibodies that target both HER2 and HER3.[15]
Despite the clinical development of anti-HER3 therapies, the prognostic value of HER3 overexpression across
different solid tumors remains unclear. It would be desirable to explore whether tumors in which HER3 is
overexpressed are associated with worse outcome.
Here, we present a meta-analysis evaluating the prognostic impact of HER3 overexpression. The primary aim of
this study was to evaluate the role of HER3 in relation to survival in solid tumors, thereby allowing more
rational development of therapeutic strategies against this receptor.
Discussion
ErbB receptors have been implicated in the etiology of a substantial number of solid tumors. Because HER3 is
thought to play a key role in signaling, proliferation agents against this receptor are currently under
development.[12] In this study, we meta-analyzed the published data about the expression of HER3 in solid
tumors and their association with survival for studies that evaluated HER3 by IHC. We selected only studies
that evaluated HER3 by IHC because this is the standard method for the evaluation of other ErbB-family
proteins (eg, HER2 and EGFR) and there was consistency in the evaluation process among studies.
Results show that overexpression of HER3 was associated with worse survival for all studies analyzed except
for two studies of colorectal cancer.[21,22] These results can be observed at both 3 and 5 years. Among the tumor
types evaluated, gastric cancer was the tumor type most linked with a worse outcome for patients who
expressed high levels of HER3.[23,25] That this tumor commonly overexpresses HER2 suggests that the family of
ErbB receptors and ligands may have an important role in this tumor type. In this disease site, the cutoff for
overexpression of HER3 varied from 35% to 60% of cells.[23,25]
This effect was maintained when other disease sites frequently associated with HER2 expression (breast and
ovarian cancers) were added.[19,23, 25,27] This suggests that interaction between HER2 and HER3 may be important
in these tumors. Unfortunately, differential survival rates by individual HER2 and HER3 overexpression were
not reported; therefore, this hypothesis cannot be tested using available data. The impact of HER3
overexpression in both HER2-normal and HER2-overexpressing tumors, therefore, requires further assessment.
Interestingly, overexpression of HER3 in colorectal studies was not associated with a worse outcome. HER2 has
not been identified as a key element in the oncogenesis of colon cancer, and data about the role of HER3-
activating ligands in this tumor type is also weak.[11,30]
We observed that overexpression of HER3, ranging from 20% to 60% depending on the tumor type, is present
in a substantial number of tumors; most studies used a combined evaluation of HER3 staining in the cytoplasm
and membrane. However, the pooled analyses of studies that evaluated HER3 in the cytoplasm or in the
membrane did not showed statistically significant differences.
A consistent and reproducible method to evaluate HER3 should be developed to better identify patients who
may be more responsive to anti-HER3 therapies currently under clinical evaluation. Furthermore, evaluation of
ligands that activate this receptor should help in the identification of those tumors that have activated HER3 and
that would be sensitive to these therapies. This process should mirror that for HER2, for which the development
of trastuzumab occurred synchronously with an accurate technique to evaluate the biomarker.[31,32]
These analyses have several important implications. First, they show that overexpression of HER3 is associated
with worse outcome, which suggests that this protein may be a useful druggable therapeutic target. This is
important because the lack of kinase activity of HER3 raised doubts about the clinical relevance of targeting
HER3.[33] However, several recent findings support the targeting of HER3 in cancer.[12] Thus, expression and
signaling by HER3 has been described in tumors from patients resistant to anti-HER therapies.[34] Moreover,
expression of HER3 ligands, with establishment of autocrine loops that favor tumor growth, have been reported
in certain tumors[35,36]
Second, it identifies a subtype of tumors with worse outcome potentially those in which other ErbB receptors
are also overexpressed. Third, it identifies a subgroup of tumors. Fourth, it highlights the importance of the
development of an accurate biomarker for its assessment. Finally, the analyses emphasize the value of
identifying surrogate markers of HER3 activation. We and others have suggested the HER3 ligand neuregulin as
a potential key marker.[11,15,35,36] Following this approach, some phase I trials of HER3-targeting antibodies are
selecting patients based on heregulin expression (a type of the HER3-ligands termed neuregulins) (Clinical
Trial: NCT00911898, NCT0109746033; http://www.clinicaltrials.gov),[37] or enriching populations with patients
with certain disease sites (eg, breast and ovarian cancers; see ).
Table 4. Ongoing studies evaluating anti-human epidermal growth factor receptor 3
(HER3) therapeutic strategies*
Study/sponsor
NCT01482377Hoffmann–La
Roche
NCT01451632Merrimack
Pharmaceuticals
NCT01447225Merrimack
Pharmaceuticals
NCT01209195Merrimack
Pharmaceuticals
NCT00734305Merrimack
Pharmaceuticals
NCT01436565Sanofi-
AventisMerrimack
Pharmaceuticals
NCT01151046Merrimack
Pharmaceuticals
NCT01421472Merrimack
Pharmaceuticals
NCT00994123Merrimack
Pharmaceuticals
NCT01447706Merrimack
Pharmaceuticals
NCT01097460Merrimack
Pharmaceuticals
NCT01603979AVEO
Pharmaceuticals
NCT01479023Washington
University School of
Phase/setting Experimental arm(s)
Phase I, 3-part dose escalating
RO5479599RO5479599 +
studyMalignant/locally advanced
cetuximabRO5479599 + erlotinib
HER3-positive solid tumors
MM-121 (SAR256212) + cetuximab +
Phase IAdvanced cancers
irinotecan
MM-121(SAR256212) + gemcitabineMM-
Phase IAdvanced-stage solid 121 (SAR256212) + carboplatin MM-121
tumors (SAR256212) +pemetrexed MM-121
(SAR256212) + cabazitaxel
Phase IAdvanced gynecological
cancers or HER2-negative breast MM-121+ paclitaxel
cancers
Phase IAdvanced solid tumors
MM-121
resisting ordinary treatment
Phase ILocally advanced or
metastatic solid tumors (PI3K MM-121(SAR256212) + SAR245408
mutation present)
Phase IILocally advanced or
metastatic estrogen receptor–
Arm A: MM-121 (SAR256212) +
positive and/or progesterone
exemestaneArm B: placebo+ exemestane
receptor–positive HER2-negative
breast cancer
Arm A: MM-121 (SAR256212) +
paclitaxel→doxorubicin,
Phase IIEarly HER-2 negative
cyclophosphamide→surgeryArm B:
breast cancer
paclitaxel→doxorubicin,
cyclophosphamide→surgery
Phase I–IIAdvanced non-small- Arm A: MM-121 (SAR256212) + erlotinib
cell lung cancer Arm B: erlotinib
Phase IIPlatinum-resistant or
Arm A: MM-121 (SAR256212) +
refractory recurrent/advanced
paclitaxelArm B: paclitaxel
ovarian cancers
Phase IAdvanced HER2-
amplified, heregulin-positive MM-111 + trastuzumab
breast cancer
Phase IMetastatic or advanced
AV-203
solid tumors
Phase IAdvanced solid tumors U3-1287
Medicine
* RO5479599, MM-121(SAR256212), MM-111, AV-203, and U3-1287 are monoclonal antibodies against
HER3. XL-147 (SAR245408) is an oral PI3K inhibitor.
These analyses have limitations. First because this is a literature-based analysis, it is compromised by the
potential for publication bias, whereby predominantly positive results were published, thus inflating our
estimate for the association between HER3 and poor outcome. Second, there is no accepted and validated
method for assessment of HER3 expression. Therefore, there may be substantial heterogeneity, which may not
be fully accounted for by our use of random-effects modeling. An internationally accepted and validated method
for HER3 testing is warranted. Finally, we were unable to pool hazards of death because time-to-death data
were not reported. Instead, we reported the odds of death at two fixed time points. This measure is less robust
because it does not take into account the duration of survival until death. However, this was the only feasible
method with the data available.
In conclusion, our analyses show that overexpression of HER3, as measured by IHC, is associated with a worse
prognosis in different tumor types, which suggests that the development of strategies against this receptor could
be a reasonable therapeutic approach. Further data are required about the potential for greater impact in tumors
with overexpression of both HER2 and HER3.

Pertuzumab Approved in Europe for HER2 Breast Cancer

Nick MulcahyMar 05, 2013
The European Medicines Agency has approved pertuzumab (Perjeta, Roche/Genentech) for patients with
HER2-positive metastatic breast cancer, the company announced today.
Specifically, pertuzumab is approved in combination with trastuzumab (Herceptin, Roche/Genentech) and
docetaxel for patients with HER2-positive metastatic or locally recurrent unresectable breast cancer who have
not received previous anti-HER2 therapy or chemotherapy for their metastatic disease.
"The combination of [pertuzumab], [trastuzumab], and chemotherapy is the first to significantly extend
survival, compared with the previous standard of care — [trastuzumab] and chemotherapy alone," said Hal
Barron, MD, chief medical officer and head of global product development at Roche, in a press statement.
In 2012, pertuzumab was approved for the same indication in the United States, where trastuzumab plus
pertuzumab reportedly costs about $188,000 for an 18-month course of treatment.
The European approval comes after the phase 3 CLEOPATRA (Clinical Evaluation of Pertuzumab and
Trastuzumab) trial showed that survival was a median of 6.1 months longer with the triple-drug combination of
pertuzumab, trastuzumab, plus docetaxel than with trastuzumab plus docetaxel alone, with no disease worsening
or death.
The CLEOPATRA results were first presented at the San Antonio Breast Cancer Symposium in 2011, as
reported at the time by Medscape Medical News, and simultaneously published in the New England Journal of
Medicine (2012;366:109-119).
The pertuzumab combination also improved overall survival and objective response rate, compared with
trastuzumab plus chemotherapy.
In CLEOPATRA, median overall survival was 37.6 months for trastuzumab plus chemotherapy. At the time of
the analysis, median overall survival had not been reached for the pertuzumab combination; more than half of
that group continued to survive.
As a single agent, pertuzumab has been described as having only "modest antitumor activity." However,
preclinical studies have shown that pertuzumab and trastuzumab have a synergistic effect.
Because pertuzumab and trastuzumab have complementary mechanisms of action and bind at different epitopes,
the combination of the 2 agents provides a "more comprehensive blockade of HER2 signaling, and results in
greater antitumor activity than either agent alone," the CLEOPATRA investigators wrote in 2011.
The most common (>30%) adverse reactions observed with pertuzumab in combination with trastuzumab plus
docetaxel were neutropenia, nausea, fatigue, rash, and peripheral neuropathy. The most common (>2%)
grade 3/4 adverse reactions were neutropenia, febrile neutropenia, leukopenia, diarrhea, peripheral neuropathy,
anemia, asthenia, and fatigue.
The CLEOPATRA investigators also pointed out that the triple therapy did not result in an increase in left
ventricular systolic dysfunction.

Vinorelbine 'Preferred' Chemo in HER2-Positive Advanced Breast Cancer

Toxicity, not efficacy, is key
January 26, 2011 — What's the best chemotherapy to use in combination with trastuzumab in women with
HER2-positive metastatic and locally advanced breast cancer?
The answer is not found in the efficacy data; instead, it is found in toxicity results, according to the
Scandinavian authors of a new study on the subject.
On that score, the investigators found, in a phase 3 trial of first-line therapies, that vinorelbine (Navelbine) had
significantly fewer adverse effects than docetaxel (Taxotere) when each was combined with trastuzumab
(Herceptin). Efficacy, measured by time to progression, was comparable between the 2 regimens.
Results from the Herceptin Plus Navelbine or Taxotere (HERNATA) trial, which comprised 284 women from
Denmark, Sweden, and Norway, were first presented at the European Breast Cancer Conference in 2010 and
have now been published in the January 20 issue of the Journal of Clinical Oncology.
The results reflect what medical oncologists have been finding out on their own in clinical practice, suggest the
authors of an editorial that accompanies the study.
"Many clinicians choose to partner trastuzumab with vinorelbine or, less frequently, capecitabine" in this first-
line setting because the taxane alternatives are generally more toxic, say 2 breast cancer oncologists, Nancy U.
Lin, MD, and Eric Winer, MD, from the Dana-Farber Cancer Institute in Boston, Massachusetts, who wrote the
editorial.
This study firmly establishes . . . trastuzumab plus vinorelbine as an acceptable, and even preferred,
option.
"Given the more favorable toxicity profile and the failure to conclude that docetaxel is superior to vinorelbine,"
they write, "we believe this study firmly establishes the role of trastuzumab plus vinorelbine as an acceptable,
and even preferred, option for the first-line treatment of patients with HER2-positive metastatic breast cancer."
The study authors, led by Michael Andersson, MD, from Rigshospitalet in Copenhagen, Denmark, are less
definitive. They conclude their paper by saying that "vinorelbine plus trastuzumab should be considered as an
alternative first-line option with a favorable risk/benefit balance."
But they also write that "the choice of a first-line chemotherapy drug . . . may not be important . . . regarding
treatment efficacy, but it certainly is important in terms of toxicity." In other words, the authors indirectly
champion vinorelbine over taxanes, including docetaxel.
According to Dr. Lin and Dr. Winer, only the taxane paclitaxel is currently approved by the US Food and Drug
Administration for use in combination with trastuzumab in HER2-positive metastatic breast cancer. Docetaxel is
approved for use in combination therapy by the European Medicines Agency. Vinorelbine is approved by
neither agency in this setting at this point. However, the National Comprehensive Cancer Network lists
vinorelbine — along with paclitaxel (with or without carboplatin), docetaxel, and capecitabine — as preferred
first-line agents in this setting.
The editorialists believe that more research studies are not needed to further define which chemotherapy is
optimal in this setting. "In our view, little will be gained by playing musical chairs with chemotherapeutic
agents," they write.
Trastuzumab is the "great equalizer," they add, "rendering the specific choice of chemotherapy secondary."
What is needed in research is an expansion of investigations into "individualized and targeted" therapies; they
need to "claim the limelight," say Dr. Lin and Dr. Winer.
Study Findings
The study, which was supported by Roche and Sanofi-Aventis, enrolled patients with HER2-positive metastatic
or locally advanced breast cancer who had not received previous chemotherapy or HER2-targeted therapy for
the treatment of their advanced disease.
A total of 284 patients were randomized to treatment with either docetaxel 100 mg/m2 once every 3 weeks (n =1
43) or vinorelbine (30 mg/m2 or 35 mg/m2, according to institutional predefined preference) on days 1 and 8 of
a 21-day cycle (n = 141). Trastuzumab was administered to all patients once every 3 weeks.
Treatment was continued until progression, intolerable toxicity, or patient withdrawal.
The primary study end point was time to progression, which was not statistically significantly different: the
median for docetaxel was 12.4 months and for vinorelbine was 15.3 months (hazard ratio [HR], 0.94; 95%
confidence interval [CI], 0.71 to 1.25; P = .67).
This efficacy outcome favoring vinorelbine was surprising, explain the study authors.
"At the time of conception of the study, it was believed that the vinorelbine plus trastuzumab combination was
inferior to docetaxel plus trastuzumab in terms of efficacy," they write.
There was no difference in most of the secondary end points, including overall survival. Median overall survival
was 35.7 months for docetaxel and 38.8 months for vinorelbine (HR, 1.01; 95% CI, 0.71 to 1.42; P = .98).
The one exception to this — time to treatment failure — cast docetaxel in a negative light. Median time to
treatment was significantly shorter for docetaxel than for vinorelbine (5.6 vs 7.7 months; HR, 0.50; 95% CI,
0.38 to 0.64; P < .0001).
Toxicity is where the 2 agents were most different, say both the authors and the editorialists. More patients in
the docetaxel group than in the vinorelbine group discontinued therapy because of toxicity (20.1% vs 6.5%;
P < .001).
With docetaxel, compared with vinorelbine, there were also significantly more treatment-related grade 3 to 4
febrile neutropenia (36.0% vs 10.1%), leucopenia (40.3% vs 21.0%), infection (25.1% vs 13.0%), fever (4.3%
vs 0.0%), neuropathy (30.9% vs 3.6%), nail changes (7.9% vs 0.7%), and edema (6.5% vs 0.0%).
Dr. Andersson reports receiving honoraria from Roche and Sanofi-Aventis, the 2 companies that sponsored the
study. Some of the study coauthors reported financial ties to these companies and others. Dr. Lin reports
receiving research funding from Genentech, GlaxoSmithKline, Boehringer Ingelheim, and Infinity
Pharmaceuticals. Dr. Winer reports receiving research funding from Genentech.
J Clin Oncol. 2010;29:251-253, 264-271. Abstract, Abstract

Systemic Treatment of Brain Metastases in HER2-positive Breast Cancer

Current Status and Future Directions
Hamdy A Azim; Hatem A Azim Jr
Posted: 03/14/2012; Future Oncology. 2012;8(2):135-144. © 2012 Future Medicine Ltd.
Abstract and Introduction
Abstract
In recent years, brain metastases have emerged as a main challenge affecting the morbidity and mortality of
patients with HER2-positive metastatic breast cancer. In the era following trastuzumab, approximately 30% of
these patients develop brain metastases. Trastuzumab does not cross the blood–brain barrier, hence its role is
limited to controlling extra-CNS metastases. Lapatinib emerged as a potential candidate; however, its use as a
single agent was associated with modest responses. Combination with capecitabine was associated with good
results, particularly in patients with newly diagnosed brain metastases. In this article, we discuss the role of
trastuzumab and lapatinib in patients with HER2-positive breast cancer with brain metastases. We also highlight
the complex structure of the blood–brain barrier and elucidate different potential strategies that could be useful
in improving drug delivery.
Introduction
Breast cancer (BC) is the second most common source of brain metastases (BM), being only preceded by lung
cancer.[1] The incidence of BM among patients with advanced BC is approximately 10–15%[2,3] and reaches up
to 30% in autopsy studies.[4] Although treatment by whole-brain radiotherapy (WBRT) is associated with tumor
regression and clinical improvement in the majority of patients, these responses are classically short-lived,
ranging from 3 to 6 months.[5] Historically, this was not a major challenge as progression in other visceral sites
was the dominant source of mortality and thus, the development of novel strategies to manage BM was not
considered of high priority. However, the introduction of novel chemotherapeutics and targeted agents has
substantially prolonged survival of patients with metastatic disease, despite the fact that they have limited
efficacy in dealing with BM. Therefore, there is a real concern that the incidence of BM will be more frequently
encountered – given the improvement in survival – particularly in HER2-positive patients. Hence, BM could
considerably impact survival at a time when many of these patients have extra-CNS disease control. In this
article, we describe the different available systemic treatment strategies in managing BM in patients with
HER2-positive BC. We also elaborate on potential approaches that we believe hold some promise in improving
outcomes of such patients in the years to come.
BM & its Relation to HER2 Expression
Several groups, including ours, have shown a higher predisposition of BM in patients with HER2-positive BC.
[6–9]
However, in our opinion, the most convincing evidence comes from a large study involving 3726 patients
with early-stage BC, who were followed for 15 years, in which patients with HER2-enriched BC had the
highest incidence of BM (14.7%) compared with 2.2, 4.7, 10.9 and 7.2% for patients diagnosed with luminal-A,
luminal-B, triple-negative basal-like and triple-negative nonbasal BC, respectively.[8] This has also been
observed in preclinical models. HER2 overexpression was found to increase the metastatic outgrowth of BC
cells in the brain, suggesting that HER2-positive BC cells have a great affinity to colonize in the brain compared
with HER2-negative cells.[10] However, the reason behind such predisposition is not very clear. Some have
suggested a potential role for certain chemokines, such as CXCR4, which is upregulated in HER2-positive
tumors and was shown to facilitate the invasion of cancer cells into the brain by increasing the permeability of
brain endothelial cells.[11] However, other studies have also linked CXCR4 expression with metastasis to other
sites and not necessarily to the brain.[12,13] Hence, the potential role of chemokines in BM remains speculative
and requires further validation.
Trastuzumab & the Risk of BM
With the establishment of trastuzumab as a standard therapy for managing patients in metastatic BC,[14] the
problem of BM has become more clinically evident. Given that trastuzumab resulted in an improvement in
survival and BM typically develops later in the disease course,[15] there has been an apparent increase in the
incidence of BM with approximately 30% of patients treated with trastuzumab developing BM.[16–18] The
combination of a tumor type that has a high potential for CNS spread and a treatment that improves clinical
outcomes, but with limited CNS penetration – owing to its large molecular weight (˜145 kDa) – has resulted in
observing this apparent increase in BM.[19]
A literature-based meta-analysis of six large Phase III clinical trials has recently addressed this question in the
adjuvant setting.[20] The results showed that CNS metastases were significantly increased in the trastuzumab-
containing treatment arms compared with the nontrastuzumab-containing arms (odds ratio: 1.57; 95% CI: 1.08–
2.3; p = 0.018). Furthermore, trastuzumab treatment was associated with a higher incidence of the brain being
the first site of relapse. In the HERA, NCCTG N9831 and NSABP b-31 trials, the incidence was marginally
higher in the trastuzumab arm (26 [2%] vs 22 [1%], 12 [1.5%] vs 4 [0.5%] and 21 [2.4%] vs 11 [1.7%] patients,
respectively).[21,22] Data from a large population-based study involving 1458 patients further confirmed that the
brain is more frequently the first site of relapse in patients treated with trastuzumab, whether in the adjuvant or
metastatic setting.[6]
Is There a Role for Trastuzumab in Managing HER2-positive Breast Cancer With BM?
Given its limited ability to cross the blood–brain barrier (BBB), it is plausible to suppose that trastuzumab has a
limited role in patients with established BM. However, this does not appear to be entirely true. To gain more
insight, Dawood et al. have recently reported the outcome of 223 patients with BC and BM who received
WBRT.[23] Patients were grouped into three groups; estrogen receptor-positive/HER2-negative (30.2%), HER2-
positive (45.5%) and triple-negative (24.3%) BC. All three groups were treated with routine systemic therapy
following WBRT, including trastuzumab in all patients with HER2-positive disease. Median survival was found
to be significantly longer in the HER2-positive group compared with the two other groups (9 vs 5 vs 5 months,
respectively; p = 0.006). In the multivariate model, the HER2-positive group had a significant (37%) reduction
in the risk of death compared with the other groups. The same results were recently reported by other groups as
well.[24,25] This highlights that trastuzumab improves the prognosis of these patients.
To understand the role of trastuzumab within patients with HER2-positive BM, Brufsky et al. have recently
published the results of the first and only prospective study addressing the role of trastuzumab in these patients.
[16]
This observational study included 1023 newly diagnosed metastatic BC patients, of whom 377 (37%)
developed CNS metastasis at a median time of approximately 1 year after developing metastatic disease.
Following the development of CNS metastasis, 71, 69 and 68% received radiotherapy, chemotherapy and
trastuzumab, respectively. In a multivariate model, the latter two were significantly associated with overall
survival (hazard ratio: 0.64; 95% CI: 0.48–0.85; p = 0.002 for chemotherapy and hazard ratio: 0.33; 95% CI:
0.25–0.46; p < 0.001 for trastuzumab). Surgery and radiotherapy were not significantly associated with survival
in this study. This confirms the results of several older retrospective studies that addressed the same question.[26–
33]
The later ones, however, suffered some limitations being retrospective and small in size. In addition,
inconsistency was observed in the way overall survival was calculated. Some of these studies dated survival
from the date of metastasis development[26,33] while others used the date of BM development.[27–32] We believe
the latter method better reflects the potential role of trastuzumab in these patients (Table 1). However, it should
be noted that the later method could be a subject of lead-time bias, as imaging screening for asymptomatic BM
is widely adopted nowadays, despite the lack of evidence to support an impact on patient outcome.
Table 1. Retrospective studies addressing the role of trastuzumab in metastatic breast
cancer with brain metastases.
Understanding the Magnitude of Benefit of Lapatinib in BM
Lapatinib was approved in the metastatic setting following the results of a pivotal trial showing an improvement
in response rate and progression-free survival to its combination with capecitabine compared with capecitabine
alone.[34,35] In this study, the CNS, as the site of first progression, was reported in 13 women treated with
capecitabine and four patients treated with the combination (p = 0.045). Despite the low number of events, such
observation was met with considerable interest. This was running in line with preclinical experiments that
showed that lapatinib inhibits colonization of brain-seeking HER2-positive BC cell lines and decreases the
amount of phosphorylated HER2 in established BM.[36] In addition, acknowledging that lapatinib – unlike
trastuzumab – is a small molecule (˜1 kDa) with a higher potential to cross the BBB, further suggested that
lapatinib is the drug that would overcome the limitations of trastuzumab in this setting.
To unveil the role of lapatinib in BM, Lin and colleagues reported the results of two Phase II studies in which
lapatinib at 1500 mg/day was given to patients with progressive BM following trastuzumab and WBRT.[37,38]
The first study included 39 patients while the second included 242 patients. Both studies had a similar design
and eligibility criteria, with CNS response being the primary end point. However, they differed in the way that
response was assessed. In the first study, CNS response was assessed using the response evaluation criteria in
solid tumors (RECIST) with partial response defined as ≥30% decrease in size using MRI. In the second study,
they used a cutoff of 50% in volumetric reduction of brain lesions on MRI to define partial response. However,
in both studies, lapatinib showed modest efficacy with objective responses reported in 2 and 6% of patients,
respectively, using the formerly mentioned criteria. Minor responses were reported in a further 18 and 21% of
patients, respectively. Interestingly, responding patients (including minor responses) had an improved time-to-
progression compared to nonresponding patients. This highlighted that lapatinib could have some activity, yet
the results remain below expectations and certainly do not encourage its administration as a single agent against
BM.
Combining lapatinib with chemotherapeutics that have the potential for crossing the BBB and with known
activity in BC appears to be a more attractive approach as it could potentially augment the activity of lapatinib
against BM. To the best of our knowledge, apart from capecitabine, only topotecan was tested in combination
with lapatinib in this setting, with no responses and severe toxicity that resulted in study closure.[39] In fact,
capecitabine emerged as a good candidate to combine with lapatinib given its established role in metastatic BC,
as well as its potential activity against BM.[40,41] The studies that have explored the combination of lapatinib and
capecitabine in this setting are summarized in Table 2.[38,39,42–45] The studies are generally small in size, ranging
from 13 to 138 patients. In nearly all studies, 85–100% of patients received prior trastuzumab and WBRT. CNS
response ranged from 20 to 30%, which appears to be an improvement over responses observed with lapatinib
alone.
Table 2. Studies combining lapatinib and capecitabine in patients with HER2-positive
metastatic breast cancer with brain metastases.
Only one study addressed the role of the capecitabine and lapatinib combination prior to WBRT.[45] In this study,
45 patients with newly diagnosed BM were enrolled, of which 36 (80%) patients had two or more BM and 42
(93%) patients received prior trastuzumab. This study showed an impressive (67%) CNS response rate, defined
as 50% volumetric reduction of CNS lesions. Median time to progression was 5.5 months (95% CI: 3.9–5.9)
and median time to whole-brain irradiation was 8.3 months (95% CI: 5.1–11.7). Several points could be drawn
from the results obtained in this study: first, it demonstrates, clearly, the synergy and additive effect of lapatinib
and capecitabine in BM. The higher response rate compared with the other studies could be justified by the fact
that these patients are less refractory, being newly diagnosed with BM on initiation of therapy. Also, it opens the
door for adopting effective systemic strategies that could potentially delay the need for WBRT. Combining
lapatinib or its combination with capecitabine with WBRT could also be an appealing approach. However,
careful safety consideration regarding dosing during WBRT should be made. In this regard, a recent Phase I
study combined lapatinib at different doses with WBRT.[46] Lapatinib, at a dose of 1250 mg/day, was the
maximum tolerated dose and a total of 24 patients received the drug at this dose in combination with WBRT.
Approximately 21% of patients experienced a dose-limiting toxicity (n = 5) including two patients who
developed a pulmonary embolism. The combination was associated with 83% CNS response at least 8 weeks
following WBRT. However, the combination did not meet the predefined criteria for feasibility for safety
reasons.
Novel Strategies
Targeting the BBB
The main challenge in managing BM remains in the limited ability of most of – if not all – the investigated
agents to cross the BBB. Figure 1 illustrates a simplified diagram of the BBB. Being an almost impermeable
structure, it limits the free diffusion of polar solutes allowing only particles with a diameter less than 20 nm to
cross to the brain.[47] In addition, it expresses a wide variety of active efflux transporters that further restrict drug
access to the brain. This includes p-glycoprotein (P-gp), BC resistance protein, multidrug resistance-associated
proteins and organic anion transporter 3.[48] Furthermore, the endothelial cells within the BBB are equipped with
a limited array of transport systems that supply the brain with nutrients, but also eliminate byproducts of brain
metabolism.[47] Taken together, these characteristics provide an effective protective shield against not only the
high-molecular weight agents, but also small molecules.
Figure 1. The blood–brain barrier.
The blood–brain barrier is a complex vascular system consisting of highly specialized endothelial cells,
pericytes, a basement membrane and the endfeet of astrocytes. Endothelial cells are linked by tight junctions
that interconnect the adjacent endothelial cells. A thin basement membrane – in which a large number of
pericytes are embedded – surrounds the endothelial cells and provides both structural support and a dense
physical barrier between the circulation and the microenvironment of the brain. Astrocytes that form the blood–
brain barrier extend cellular processes (endfeet) to cover the basement membrane and enclose the capillaries on
all sides, adding further restriction to the ability of macromolecules to gain access to the brain parenchyma.
On the other hand, the observed contrast enhancement of metastases on computed tomography and MRI would
suggest that the BBB is at least partially disrupted in metastasis. It has been shown that, as a result of a
macroscopic brain tumor (>4 mm), the tight junctions between the endothelial cells become stretched out with
evident formation of gaps, which leads to increased vascular permeability.[49] This altered structure of the BBB
is termed the blood–brain tumor barrier (BTB), which also includes the microvessels supplying brain tumors.[49]
To gain more insight into the permeability of the BTB in relation to the BBB, Lockman et al. found that the
uptake of paclitaxel and doxorubicin in BM was significantly greater than normal brain tissue, but it was less
than 15% of that of other metastases.[50] The drug concentrations within the BM showed significant
heterogeneity and only reached cytotoxic levels in a small subset of lesions (˜10%). More interestingly, neither
drug could significantly decrease BM in HER2-positive BC, suggesting that the BBB/BTB is less disrupted in
this subtype.[50] This could possibly be related to the relatively high expression of P-gp at the BBB in patients
with HER2-positive metastatic BC, compared with those with other BC subtypes.[51] Thus, while BTB is more
permissive than the BBB, it remains a significant impediment to standard chemotherapy, particularly in HER2-
positive BC.
Having elucidated the principle physiological aspects of the BBB and the BTB, we will highlight three potential
strategies that would possibly overcome the resistance observed at the BBB and the BTB levels in the following
section.
Increasing the BTB Permeability
The difference in vascularity between the BBB and the BTB may provide a therapeutic window where certain
drugs can selectively increase the permeability in brain tumor capillaries, without causing a significant change
in normal brain capillaries permeability, thereby enhancing drug delivery to brain tumors while sparing the
normal brain parenchyma.
cGMP is an important intracellular secondary messenger that has been implicated in the regulation of vascular
permeability and is selectively degraded by phosphodiesterases enzyme (PDE).[52,53] Thus, inhibition of PDE
activity, would subsequently lead to intracellular cGMP accumulation, which may result in increased capillary
permeability, including microvessels in brain tumors. Sildenafil (Viagra®) and vardenafil (Levitra®) are
selective inhibitors of type 5 PDE (PDE5)[54] and are approved for erectile dysfunction in men. In a brain tumor-
bearing animal model, vardenafil and sildenafil selectively increased BTB permeability and enhanced antitumor
efficacy of doxorubicin.[55] In this study, rats treated with doxorubicin in combination with vardenafil survived
significantly longer than rats treated with doxorubicin alone.[55] While this study was conducted in glioblastoma-
bearing mice, it also provides proof of concept that could be explored in BM models. To address the latter point,
the same group examined the effect of PDE5 inhibitors in nude mice on the delivery of trastuzumab to
intracranially implanted human HER2-positive BC.[56] This was preceded by an in vivo study to check the
permeability of trastuzumab through the BTB. Interestingly, the administration of vardenafil doubled the uptake
of trastuzumab (p < 0.01) and their coadministration significantly improved survival compared with
administration of each drug alone (p < 0.01). On the other hand, Ding et al. have reported that vardenafil can
also block the drug efflux function of P-gp and increase the intracellular accumulation of paclitaxel.[57]
Collectively, these preclinical models highlight the potential of developing strategies incorporating PDE5
inhibitors.
Maximizing Drug Influx
P-gp (encoding the gene ABCB1) is the most important mediator of multidrug resistance and is responsible for
chemotherapeutic drug resistance to a wide variety of agents active in BC, including vinca-alkaloids,
anthracyclines, taxanes and lapatinib.[58] Developing drugs that target P-gp, or efflux pump inhibitors in general,
have been extensively explored. The discussion of this topic is beyond the scope of this article, but the results
were generally disappointing.[59–61]
P-gp is involved in the efflux of lapatinib at the BBB, yet the latter has been implicated in inhibiting the
function of several transporters by binding to their ATP-binding sites.[62] In experimental models, lapatinib
reversed P-gp, and strongly enhanced the effect of paclitaxel and liposomal doxorubicin on the inhibition of
growth of the ABCB1-overexpressing cancer cells.[62] These findings may suggest that the use of lapatinib in
combination with chemotherapy is a more rational approach compared with its monotherapy use, as
demonstrated earlier with capecitabine.[38] De Azambuja and colleagues recently reported the results of a Phase I
study involving 17 patients who were treated with lapatinib in combination with temozolomide.[63] The latter is
known to cross the BBB and is effective against primary brain tumors,[64] with few small reports showing
potential activity when given to treat BM, particularly with WBRT.[65–67] The study showed that both drugs can
be combined at a dose of 1500 mg/day for lapatinib and 200 mg/day day 1–5 for temozolamide with acceptable
toxicity. However, the study suffered slow accrual and responses were seldom reported. Nearly all patients were
pretreated with anthracyclines, taxanes, trastuzumab and WBRT. In addition, 50% were also pretreated with
lapatinib. The median time to progression was 2.7 months and median survival was 10.9 months. Another
interesting combination could be with pegylated liposomal doxorubicin (Caelyx®) given its higher penetration
of the BBB, which is 10–30-fold higher than doxorubicin.[68] Currently, this combination is being explored in
the Phase II setting.[101]
Manipulate the Drug Formulation
Another attractive approach is to utilize the specific transporters that are localized within the brain capillary
endothelium that mediate endogenous substrate transport from the circulation into the brain. Among these
transporters, LRP-1 has been reported to possess the ability to mediate effective transport of ligands across
endothelial cells of the BBB (Figure 2).[69] This receptor is involved in BBB transcytosis of several proteins and
peptides. Importantly, LRP-1 is highly expressed at the BBB[70] and is also upregulated in brain tumors.[71]
Angiopep-2 is a 19-amino acid peptide that was developed to bind to LRP-1 receptors at the BBB, with
enhanced transcytosis capacity. Hence, angiopep could be used as a peptide-based delivery technology that
provides a platform for transporting drugs into the brain.[72] In other words, it could ferry the chemotherapeutic
drugs via the LRP. ANG1005 is a peptide–paclitaxel conjugate with three molecules of paclitaxel linked to
angiopep-2. Preclinical studies in BC BM demonstrated that the brain's uptake of ANG1005 is up to 54-times
that of paclitaxel.[73] Recently, a Phase I trial was presented testing ANG1005 in 48 patients with heavily
pretreated BM.[74] Overall disease control, including responses plus stable disease, was achieved in 71% of
patients. Median time to progression was 18 weeks in responders (≥standard deviation). The drug was well
tolerated and no CNS toxicity was observed, with thrombocytopenia being the dose-limiting toxicity. It is not
possible to draw conclusions on the role of this drug in HER2-positive BM from this study as it was a Phase I
study and enrolled different types of solid tumors. However, the biological rationale and preliminary safety and
efficacy data warrant further evaluation in the Phase II setting, focusing on a more homogenous patient
population.

Figure 2. A simplified schematic layout of the molecular composition of the blood–brain barrier.
(A & B) The cerebrovascular endothelium, in addition to restricting passive diffusion for polar solutes, also
expresses a wide variety of active efflux transporters, which further restrict drug access to the brain.
Transporters that are localized on the apical (luminal) side of the brain capillary endothelium restrict brain
uptake of drugs, while transporters at the abluminal side enhance the extrusion of drugs from the brain. (C) The
blood–brain barrier endothelial cells are characteristically equipped with a limited array of transport systems
 that supplies the brain with nutrients and eliminates byproducts of brain metabolism. Among these transporters,
LRP-1 has been reported to possess the ability to mediate effective transport of endogenous larger molecules.
Ligands on the luminal side of the endothelium, are endocytosed and transported across the cell for release into
the brain parenchyma at the abluminal side.
BCRP: Breast cancer resistance protein; Oatp: Organic anion-transporting polypeptide; MRP: Multidrug
resistance-associated protein; P-gp: P-glycoprotein.
Future Perspective
Currently, several strategies exist for managing patients with BM secondary to HER2-positive BC; however, the
results remain unsatisfactory. WBRT remains the standard of care, yet we aim to identify strategies that would
prolong CNS response beyond that achieved by radiation. We believe that patients who are sensitive to
trastuzumab should still be offered the drug even with developing BM, despite its poor crossing to the brain.
Recently, Chargari and colleagues have combined trastuzumab with WBRT in 31 patients with very good
tolerance, and an interesting 74.2% response rate with complete responses in 19%.[75] Median time-to-
progression and survival was 10 and 18 months, respectively. The validation of these results in a randomized
trial would elucidate the magnitude of benefit of such an approach compared with WBRT alone. In patients who
have already received WBRT, combining trastuzumab to lapatinib and capecitabine could be an interesting
strategy that is worth exploring. Currently, we have evidence that the combination of trastuzumab and lapatinib
improves survival compared with lapatinib alone even in patients with trastuzumab refractory disease.[76]
However, we have no data on adding capecitabine to the combination. Such a combination could be effective
against BM as well as maintaining an adequate extra-CNS control. Yet, careful consideration should be made
regarding the doses of lapatinib and capecitabine used in the triplet combination, and should be investigated in a
Phase I/II setting. Another strategy for trastuzumab-sensitive patients is giving the drug in the combination with
PDE5 inhibitors. Such combination was associated with better drug delivery in the preclinical setting but we are
not aware of any ongoing clinical trials with this strategy.
In patients refractory to WBRT and trastuzumab, offering lapatinib in combination with capecitabine is the
current standard of care; however, responses remain short-lived. In this setting, one would argue that combining
lapatinib and capecitabine with upfront WBRT could be an interesting approach, although recent safety
consideration emerged when lapatinib was combined with WBRT at a dose of 1250 mg. Investigating the
transporters at the BBB emerges as a very interesting approach that is worth exploring, perhaps in combination
with lapatinib.
Sidebar
Executive Summary
 Brain metastasis (BM) are increasingly observed in patients with metastatic HER2-positive breast cancer
owing to the improved survival rate following the introduction of HER2-targeted agents.
 Trastuzumab appears to improve outcomes in patients with BM secondary to controlling extra-CNS
disease, which remains the main cause of cancer-related mortality.
 The single-agent lapatinib has a limited role in managing BM, while its combination with capecitabine
appears to deliver better results, particularly in patients who are not refractory to whole-brain radiotherapy.
 Better understanding of the physiology of the blood–brain barrier and changes exerted, secondary to
developing BM by means of formation of the blood–brain tumor barrier, would help in identifying strategies
that would possibly advance research development in this field.
 Several strategies are worth exploring to improve delivery of drugs to the brain. These include
investigating the vascularity of the blood–brain tumor barrier and utilizing transporters at the blood–brain
barrier.
References

British Journal of Cancer (2010) 103, 249–255. doi:10.1038/sj.bjc.6605735 www.bjcancer.com

Published online 15 June 2010
Significance of E-cadherin expression in triple-negative breast cancer
S Kashiwagi1, M Yashiro1,2, T Takashima1, S Nomura1, S Noda1, H Kawajiri1, T Ishikawa1, K Wakasa3 and
K Hirakawa1
Purpose:
Triple-negative breast cancer (TNBC), a subtype of breast cancer that is oestrogen receptor (ER) negative,
progesterone receptor (PR) negative, and human epidermal growth factor receptor 2 (HER2) negative, has a
poor prognosis. Although a correlation between E-cadherin expression level and outcome has been
demonstrated among all types of breast cancer, little is known about the significance of E-cadherin expression
levels in TNBC.
Methods:
A total of 574 patients who had undergone a resection of a primary breast cancer except for invasive lobular
carcinomas were enrolled in this study. Expressions of ER, PR, HER2, and E-cadherin were assessed by
immunohistochemistry. We examined the association between TNBC and other clinicopathological variables
and evaluated the significance of the E-cadherin expression.
Results:
Among the 574 breast cancer cases, 123 (21.4%) revealed a triple-negative phenotype. Patients with TNBC
experienced more frequent lymph node metastasis (P=0.024) and a poorer prognosis (P<0.001) in comparison
with non-TNBC patients. Triple-negative breast cancer was an independent prognostic factor. Reduced levels of
E-cadherin were observed in 238 (41.5%) of the 574 breast cancer cases. E-cadherin reduction was significantly
frequent in cases of TNBC (P<0.001) and lymph node metastasis (P=0.032). Furthermore, in the 123 TNBC
cases, the prognosis of patients with an E-cadherin-negative expression was significantly worse than that of E-
cadherin-positive patients (P=0.0265), especially for those in clinical stage II (P=0.002). A multivariate logistic
regression analysis showed a reduction of the E-cadherin expression to be an independent prognostic factor
(P=0.046).

Platinum-Based Adjuvant Treatment for Triple-Negative Breast Cancer:

Are We There Yet?
Eric P. Winer, MD
Posted: 04/05/2010
Question
On the basis of recently reported data, should we now be considering carboplatin or cisplatin in the adjuvant setting for our
patients with triple-negative breast cancer?
Triple-negative breast cancer is distinct from other breast cancer subtypes in that the tumor cells lack estrogen and progesterone
receptors and are also negative for HER2. Practically, these features of triple-negative breast cancer mean that hormonal therapy
is ineffective and that patients with triple-negative disease are not candidates for anti-HER2 treatment with trastuzumab.
Approximately 10%-15% of all breast cancer diagnoses are characterized as triple negative, and it appears to be more common
in young women, particularly young African American women.[1-3] Triple-negative disease is also commonly seen in BRCA1-
related breast cancer.[1-3]
Although targeted therapy with hormonal agents or trastuzumab is not effective, women with triple-negative breast cancer can
derive substantial benefit from adjuvant and neoadjuvant chemotherapy.[4] Standard adjuvant chemotherapy regimens for women
with triple-negative disease generally include both an anthracycline and a taxane.[4,5] Although some very early clinical trials
suggest that the platinum salts, either cisplatin or carboplatin, may be quite effective in this setting, [6-9] we do not know whether
these agents are more effective than standard treatment. Outside of a clinical trial, women with triple-negative breast cancer
should receive a standard chemotherapy regimen as adjuvant treatment, which generally consists of an anthracycline and/or a
taxane. These regimens are often also administered with agents such as cyclophosphamide.
Although women with triple-negative breast cancer have a higher recurrence rate during the first few years after diagnosis than
women with other breast cancer subtypes, the majority are effectively treated and remain free of recurrence. [2,5] The size of the
tumor and the number of involved lymph nodes influence the chance that the cancer will recur, but even women with multiple
positive lymph nodes can remain free of recurrence for years or even decades. [3]
Ongoing clinical trials[10] are trying to determine whether adding a platinum salt, such as cisplatin or carboplatin, to standard
adjuvant chemotherapy will lower recurrence rates. Studies are also evaluating the anti-vascular endothelial growth factor
monoclonal antibody bevacizumab in this setting,[11] and early clinical trials are beginning to evaluate the PARP (poly [ADP-
ribose] polymerase) inhibitors in women with early-stage triple-negative disease. [12] At this point, however, these approaches are
considered investigational and should not be applied outside of a clinical trial.

Lapatinib Effective When Breast Tumors Express HER2 and P95HER2

NEW YORK (Reuters Health) May 07 - Lapatinib (Tykerb) is effective against breast cancers that express human epidermal
growth factor receptor 2 (HER2), whether or not the tumors also express a truncated HER2 receptor called p95HER2, new
studies show.
Tumor xenografts coexpressing p95HER2 are resistant to the HER2 inhibitor trastuzumab (Herceptin), the researchers said.
They say p95HER2 is expressed in about 30% of HER2-positive breast cancers. It is associated with increased nodal
metastasis and a shorter disease-free survival compared to patients who overexpress full-length HER2.
The studies, done in two animal models and then in tissues from clinical trial subjects, were reported in a single paper
published online April 20th in Clinical Cancer Research.
Dr. Jose Baselga from Vall d'Hebron University Hospital, Barcelona, Spain and colleagues first studied the antitumor activity
of lapatinib in two mouse models of p95HER2-positive tumors. Lapatinib -- an HER2 tyrosine kinase inhibitor -- markedly
reduced tumor growth compared with placebo in trastuzumab-refractory breast tumors that coexpressed both full-length
HER2 and p95HER2 and in p95HER2-dependent tumors.
Then the investigators analyzed the relationship between p95HER2 expression and response to lapatinib in HER2-positive
patients who received the agent either as monotherapy or in combination with capecitabine (Xeloda).
Altogether, 20.5% of women in the monotherapy trial (14/68) and 28.5% of women in the capecitabine-plus-lapatinib study
(45/156) had tumors that were p95HER2 positive. In both studies, progression-free survival did not differ significantly between
p95HER2-positive and p95HER2-negative subgroups.
Moreover, the presence of p95HER2 did not alter the impact of lapatinib on clinical benefit rate or overall response rate in the
2 clinical trials.
"Taking in consideration that p95HER2 tumors are resistant to trastuzumab, our results suggest that lapatinib, as well as
other tyrosine kinase inhibitors, may be a preferred therapeutic option for these tumors," the researchers conclude. "Hence,
the presence of p95HER2 could determine the choice of anti-HER2 therapy if the results are further validated."
The current studies were supported in part by GlaxoSmithKline, the manufacturer of lapatinib.
Clin Cancer Res 2010;16:2688-2695.

Potential Therapeutic Target Revealed for Triple-Negative Breast Cancer

September 30, 2010 — Triple-negative breast cancer accounts for only a small proportion of breast cancer
cases, but it is difficult to treat and might have a more aggressive clinical course than other forms of the disease.
According to data presented at the 4th American Association for Cancer Research International Conference on
Molecular Diagnostics in Cancer Therapeutic Development, in Denver, Colorado, insulin-like growth-factor 1
receptor (IGF-1R) is overexpressed and amplified in a subset of triple-negative breast cancer patients.
This finding suggests that IGF-IR is a potential therapeutic target, explained study coauthor Agnieszka K.
Witkiewicz, MD, associate professor of pathology at Thomas Jefferson University Hospital in Philadelphia,
Pennsylvania.
The researchers found that IGF-1R was overexpressed in 25% of cases, and a significant association was
observed between IGF-1R protein expression and IGF1R gene amplification (P < .001). In patients 55 years and
younger, a high IGF-1R score was associated with prolonged survival (hazard ratio, 0.13; 95% confidence
interval, 0.02 - 1.00; P = .050).
During a presscast, Dr. Witkiewicz explained that even though triple-negative breast cancer accounts for only
15% to 20% of patients with the disease, it leads to half of all breast cancer deaths. Estrogen-receptor-positive
breast cancer mortality has declined over the past decade, but the same is not true for triple-negative disease.
"This is one of the subsets that is most challenging to treat," said Dr. Witkiewicz. "It is more common in young
women, more common in African American women, and is characterized by an aggressive course."
Therefore, there is a significant need for a better understanding of the pathogenesis of triple-negative breast
cancer and a need to identify new molecular targets for treatment, she added.
IGF-1R has been known to play a major role in cancer cell proliferation, survival, and resistance to treatment in
a number of human malignancies, including breast cancer, the authors write. It is also a target of several
investigational drugs, both in clinical and preclinical development.
However, the authors note, there have been no systematic studies of IGF-1R expression in triple-negative breast
cancer.
High Expression Equated the Better Survival
In the current study, Dr. Witkiewicz and colleagues evaluated IGF-1R expression in 99 women with triple-
negative breast cancer. Immunohistochemistry was used to evaluate IGF-1R protein expression, which was
scored according to standardized criteria originally developed for HER2 disease. In addition, chromogenic
in situ hybridization for the IGF1R gene was performed on 35 cases.
A tumor was interpreted as positive for gene amplification when the ratio of the IGF1R gene signal to the
chromosome 15 signal was 2.2 or higher; for the purpose of statistical analysis, the expression of IGF-1R was
classified as low (0 to 2) or high (3).
The authors observed that IGF-1R expression was high in 29 of 99 (29%) cases and correlated with negative
lymph nodes (P = .03). Gene amplification was seen is 8 of 35 cases (23%). Low IGF-1R expression was
associated with lymph node metastases (P = .033); conversely, high IGF-1R expression was associated with a
tumor size that was borderline significantly smaller (P = 0.080).
The authors note that there was no statistically significant association between IGF-1R expression and grade or
race.
However, patient age played a role, Dr. Witkiewicz pointed out. "In patients older than 65 years, there was no
difference in survival between patients with low and high IGF-1R expression," she said. "But in patients
younger than 65, those with high IGF-1R expression had longer survival than those with low expression."
The longest survival was seen in younger patients with high IGF-1R expression, and the poorest survival was
seen in older patients (>55 years) with low IGF-1R expression.
"For now, we know that it is there and we know it is a marker of better prognosis," said Dr. Witkiewicz. "The
next step is to learn if triple-negative breast cancer patients benefit from targeting IGF-1R."
Program chair Gordon B. Mills, MD, PhD, from the Department of Systems Biology at the University of Texas
M.D. Anderson Cancer Center, in Houston, noted that, based on earlier iterations of this conference and the
contributions of many members of the community, "we have developed a pathway to the development of
molecular diagnostics and biomarkers."
"Importantly, we have a much better concept of the limitations, challenges, and hurdles that need to be
overcome for the implementation of molecular diagnostics," he told Medscape Medical News.
"Currently, the outcome for triple-negative breast cancer is poor, at least in part because of the lack of novel
targets for therapy," he told Medscape Medical News. Dr. Witkiewicz and colleagues have demonstrated that
IGF-1R is overexpressed in triple-negative breast cancer, warranting studies to validate IGF-1R as a target for
therapy," he said.
4th American Association for Cancer Research International Conference on Molecular Diagnostics in Cancer
Therapeutic Development (AACR-MDCTD): Abstract A29. Presented September 28, 2010.

FDA Approves New Treatment for Metastatic HER2 Breast Cancer

Nick MulcahyFeb 22, 2013
The US Food and Drug Administration (FDA) today approved ado-trastuzumab emtansine (Kadcyla,
Genentech), also known as T-DM1, for the treatment of patients with HER2-positive metastatic breast cancer.
T-DM1 is indicated for patients who were previously treated with the anti-HER2 therapy trastuzumab
(Herceptin, Genentech) and a taxane chemotherapy.
This product offers a new twist on an older product; it is an antibody–drug conjugate in which the HER2-
targeted antibody trastuzumab is chemically linked to the cytotoxin mertansine (DM1). The antibody homes in
on HER2 breast cancer cells, delivering the chemotherapy directly to the tumor, which reduces the risk for
toxicity.
T-DM1 "delivers the drug to the cancer site to shrink the tumor, slow disease progression, and prolong
survival," said Richard Pazdur, MD, director of the Office of Hematology and Oncology Products at the FDA
Center for Drug Evaluation and Research, in a press statement.
It is the fourth drug approved that targets the HER2 protein, he noted. The first was trastuzumab, which was
followed by lapatinib (Tykerb) and pertuzumab (Perjeta). Apart from lapatinib, which is marketed by
GlaxoSmithKline, all the other HER2-targeted products have been developed and are marketed by
Genentech/Roche. For T-DM1, the proprietary technology involved in the DM1 portion of the product was
developed by ImmunoGen, working in collaboration with Genentech/Roche.
In the pivotal phase 3 EMILIA study, patients receiving T-DM1 survived nearly 6 months longer than patients
receiving the standard therapy of lapatinib (Tykerb) plus capecitabine (Xeloda) (median overall survival, 30.9 vs
25.1 months). Also, there were fewer grade 3 or higher (severe) adverse events with TDM-1 than with standard
therapy (43.1% vs. 59.2%), according to the company.
The approval represents a "momentous" day in breast cancer, said Kathy Miller, MD, from Indiana University
in Indianapolis, in her Miller on Oncology Medscape blog.
"Our HER2-positive patients with metastatic disease have another very powerful therapy that offers the real
hope for prolonged disease control with less toxicity," she said.
"This is the classic light-beer scenario; it's less filling and tastes great," she summarized, adding that T-DM1
was more effective in EMILIA than standard therapy on every outcome: overall response rate, disease-free
survival, progression-free survival, and overall survival.
However, another expert sees T-DM1 in a less dramatic light.
Steve Vogl, MD, a private practitioner and former academic who practices in the Bronx, New York, called T-
DM1 a "nice" drug when he discussed the product in an online essay last year.
T-DM1 causes "no alopecia, little neutropenia, and only moderate thrombocytopenia. It requires only a short
infusion every 3 weeks, lacks cumulative toxicity, and has a response rate as first-line chemotherapy that is
about the same as that of docetaxel and trastuzumab, with apparently longer remissions," he wrote.
However, Dr. Vogl called the EMILIA control regimen (lapatinib and capecitabine) "distinctly suboptimal" and
not a standard of care, even though it is an FDA-approved treatment option in this setting.
"TDM-1 does not meet [the] goals of a major advance," wrote Dr. Vogl, who explained that such an advance
must cure some patients, increase the rate of clinical complete remission, or produce a high rate of very long
partial response.
TDM-1 does not provide a "major change in prognosis" for women with metastatic disease who have
progressed on trastuzumab treatment, he wrote, adding that it is likely to be "very expensive."
Study Data and Boxed Warning
The international open-label EMILIA study involved 991 patients with HER2-positive locally advanced breast
cancer or metastatic breast cancer who had previously been treated with trastuzumab and a taxane
chemotherapy. The study met the coprimary efficacy end points of overall survival and progression-free
survival (assessed by an independent review committee).
Median progression-free survival was longer with TDM-1 than with lapatinib plus capecitabine (9.6 vs 6.4
months). In addition, patients treated with TDM-1 lived significantly longer without their disease getting worse
(hazard ratio [HR], 0.65; reduction in risk of disease worsening or death, 35%; P < .0001).
The risk of dying was 32% lower with TDM-1 than with lapatinib and capecitabine (HR, 0.68; P = .0006).
For patients receiving TDM-1, the most common adverse events (occurring in more than 2% of participants) of
grade 3 or higher were low platelet count (14.5%), increased levels of enzymes released by the liver and other
organs (8%), low red blood cell count (4.1%), low levels of potassium in the blood (2.7%), nerve problems
(2.2%), and tiredness (2.5%).
T-DM1 was reviewed under the FDA's priority review program, which provides for an expedited 6-month
review of drugs that might provide safe and effective therapy when no satisfactory alternative exists, or that
offer significant improvement over comparable products on the market.
T-DM1 is being approved with a boxed warning that alerts patients and healthcare professionals that the drug
can cause liver toxicity, heart toxicity, and death. The drug can also cause severe life-threatening birth defects,
so pregnancy status should be verified prior to starting T-DM1 treatment.
About 25% of all breast cancers are HER2-positive. The current data support the use of T-DM1 only as a
second-line treatment in women with HER2-positive metastatic breast cancer who have already received
trastuzumab and who have progressed. The companies are currently conducting a study (known as
MARIANNE) to explore its use in the first-line setting.

HER2 Therapy Could Be Useful in More Than 20% of Breast Cancers

Zosia ChusteckaFeb 26, 2013
Therapies targeted at HER2, such as trastuzumab (Herceptin), have revolutionized the treatment of HER2-
positive breast cancer in recent years, but this accounts for only 20% of all breast cancers.
However, new research suggests that these drugs may play a role in other breast cancers, because HER2 has
been found in cancer stem cells (CSCs), the clump of "mother" cells that drives the disease. Although this small
nest of cells accounts for only 1% to 5% of all breast cancer tissue, it is a crucially important driver that fuels its
growth and spread.
Even if a breast tumor tissue sample tests negative for HER2, indicating that a patient is not a candidate for
HER2-targeted therapies, the drugs could be useful because they would target the HER2 found in the little
clump of CSCs.
This theory is supported by experimental data published online today in Cancer Research.
"If this is confirmed in clinical trials, it could alter our approach to breast cancer treatment," said senior author
Max Wicha, MD, distinguished professor of oncology and director of the University of Michigan
Comprehensive Cancer Center in Ann Arbor.

The idea of using drugs that cause tumors to shrink...is flawed.

The implication of this finding is that a 2-pronged approach to treatment is needed, the researchers suggest. One
treatment approach would target the small cluster of CSCs, perhaps with HER2 therapy; the other, likely
traditional therapy, would target the bulk tumor cells.
"This work has very significant implications," Dr. Wicha said in a statement. "The idea of using drugs that cause
tumors to shrink, which has been the accepted paradigm for developing therapies, is flawed."
"Our work suggests that adjuvant therapies will need to target the cancer stem cell population," he explained.
Eliminating the CSCs should prevent tumor recurrence and ultimately result in more cures.
Molecular Explanation for Clinical Findings
In their study, Dr. Wicha and colleagues report findings from laboratory research on breast cancer cell lines,
human breast cancer tissue samples, and animal studies using xenograft models. Their results show that HER2
is selectively expressed in the CSC population of luminal estrogen-receptor-positive breast cancers that are
negative for HER2 (i.e., show no HER2 gene amplification).
"These observations extend previous studies linking HER2 expression and CSC phenotypes in cell lines," the
researchers write.
The findings also "provide a molecular explanation for the surprising finding" that some patients with breast
cancer who tested negative for HER2 nevertheless benefited from adjuvant therapy with the targeted drug
trastuzumab, Dr. Wicha noted.
He was referring to a "provocative" report that challenges the conventional wisdom that only patients with
HER2-amplified breast tumors benefit from trastuzumab (N Engl J Med.2008;358:1409-1411).
That report details a pivotal trial showing the effectiveness of trastuzumab, and notes that 174 cases originally
classified as HER2-postitive actually lacked HER2 gene amplification when they were reanalyzed in a central
laboratory. Surprisingly, Dr. Wicha explained that the patients who turned out to be HER2-negative benefited
from adjuvant trastuzumab to an extent similar to that seen in patients who displayed classic HER2
amplification.
Although there were questions about the reliability of the HER2 analyses in that study, similar results were
reported by another group (J Clin Oncol. 2010; 28:4307-4315), which "makes it less likely that these results are
due to chance or laboratory error," the researchers write.
"These studies have important implications for the development of clinical trials using HER-targeting agents by
suggesting that a much larger group of women with breast cancer may benefit from HER2 blockade in the
adjuvant setting than currently receive these treatments," Dr. Wicha and colleagues conclude.
The good news is that there are a number of HER2-targeted therapies already available. Trastuzumab, first
approved in 1998, has since been joined by lapatinib (Tykerb), pertuzumab (Perjeta), and T-DM1 (Kadcyla),
which was approved just last week.
Dr. Wicha reports receiving a commercial research grant from Dompe, having an ownership interest (including
patents) in Oncomed Pharmaceuticals, and serving on the consultant/advisory board of Verastem and Paganini.
Coauthor Hasan Korkaya, PhD, from the University of Michigan, reports receiving a com

Unique Profile of Adenoid Cystic Carcinoma: A Triple Negative Breast Tumor

with Paradoxical Features, a Case Report and Review of Literature
Dana Jaggessarsingh, MD; Talia M. Muram-Zborovski, MD; Lynne Bemis, PhD; William A. Robinson, MD,
PhD; Christina Finlayson, MD; Meenakshi Singh, MD
Posted: 12/12/2010; Laboratory Medicine. 2010;41(12):713-717. © 2010 American Society for Clinical
Pathology
Abstract
Adenoid cystic carcinomas (ACC) of the breast are uncommon tumors that are not well characterized and have
seemingly paradoxical features. We report the case of a deceptively well circumscribed adenoid cystic
carcinoma with multiple additional foci of invasive tumor. Immunohistochemical studies revealed an estrogen
receptor (ER), progesterone receptor (PR), Human epidermal growth factor Receptor 2 (HER2/neu) negative
tumor (triple negative tumor) with immunoreactivity for p63 and, CD 117 (c-kit). p53 was not over expressed.
Gene studies did not reveal mutations in the commonly mutated exons of the TP53 and KIT genes. The unique
and paradoxical features of this tumor are presented along with a review of the literature.
Introduction
Adenoid cystic carcinomas (ACC) of the breast are rare tumors with unique histopathologic features. In contrast
to other estrogen receptor (ER), progesterone receptor (PR), and HER2/neu negative breast carcinomas, or triple
negative breast carcinomas (TNBCs), ACCs have a relatively good prognosis. High proliferation indices (Ki-
67) are also usually indicative of higher-grade breast carcinomas with a poorer prognosis; however, for ACCs
this has no correlation with prognosis.[1] Insight into the molecular phenotype of this uncommon tumor may
provide clues to increase our understanding of why some breast carcinomas, particularly certain triple negative
tumors, behave less aggressively than others and possibly identify new potential therapeutic targets.
Case Report
A 43-year-old female with a strong family history of breast carcinoma presented with a palpable breast mass.
An excisional biopsy revealed a 1.5 cm deceptively circumscribed tumor. Hematoxylin and eosin sections
revealed a strikingly varied histology with cribriform, solid, and tubular growth patterns in a lobular and ductal
distribution (Image 1A). Cytologically, tumor cells appeared low grade. Intra-luminal basement-membrane-like
material was abundant (Image 1B), and a minimal low-grade carcinoma in situ component was identified
(Image 1C). A diagnosis of ACC was rendered. A simple mastectomy was subsequently performed.
Image 1. (A) A tumor nest with solid ductal and cribriform lobular components. H+E stain. (×100). (B) Back-
to-back acinar arrangement with low-grade tumor cells and prominent intra-luminal basement membrane-like
material. H+E stain. (×100). (C) A focus of low-grade ductal carcinoma in situ in the excisional biopsy. Intra-
luminal basement membrane-like material is present in this component too. (D) Multiple foci of invasive tumor
without significant stromal desmoplasia. H+E stain. (×100). (E) An immunohistochemical stain reveals intense
nuclear immunoreactivity for p63 by the tumor cells. (×200). (F) An immunohistochemical stain reveals CD117
overexpression in the tumor cells. (×100).
Gross examination of the simple mastectomy revealed a biopsy site without identifiable residual tumor in the
upper outer quadrant. Microscopic examination of breast tissue outside of the biopsy cavity revealed 3
additional foci of invasive ACC measuring 1.5 cm, 0.8 cm, and 0.4 cm, respectively. At low-power examination,
infiltration was difficult to identify since no stromal response was evident (Image 1D). The tumor itself
appeared identical to the excisional biopsy with variable growth patterns and prominent intra-luminal basement-
membrane-like material. Cytologically, tumor cells remained low grade. Vascular invasion was not identified,
and all margins were free of tumor. There was no involvement of the breast by Paget's disease or dermal
lymphatic infiltration. Immunohistochemistry (IHC) was performed for diagnosis and prognostication.
Immunohistochemistry for p63 showed nuclear staining at the periphery of the tumor nodules and focally within
the nodules (Image 1E). Additional IHC for ER, PR, and HER2/neu were negative. p53 protein was not over
expressed, however, c-kit protein (CD117) did show over expression (Image 1F). The patient did not receive
any adjuvant therapy and is reported to be doing well without evidence of recurrence 2 years postoperatively.
Gene sequencing studies were performed for the commonly mutated exons of the TP53 and KIT genes. These
included exons 5, 6, 7, 8, and 9 for TP53 and exons 9–13 and 17 for KIT. All gene studies were negative and did
not reveal mutations within these exons.
Materials and Methods
Formalin-fixed paraffin embedded tissue blocks of tumor and benign tissue (control) were sectioned into 10
micron thick scrolls. TP53 exons 5–9 and KIT exons 9–13 and 17, previously shown to harbor mutations in
other breast cancer types, were amplified and directly sequenced from both samples. TP53 mutation analysis
was conducted following methods previously described by Franklin and colleagues.[2] Briefly, genomic DNA
was extracted from formalin-fixed sections using the DNeasy Tissue kit produced by Qiagen (Duesseldorf,
Germany). Genomic DNA was then purified, and 50 nanograms of DNA were amplified for p53 exons 5–9 by
hemi-nested PCR using the primers described by Franklin and colleagues.[2]
Polymerase chain reaction (PCR) amplification for c-kit mutations was not hemi-nested; however, PCR primers
previously described by Tayal and colleagues[3] were used for amplification. All PCR reactions used 2X Master
Mix (Promega, Madison, WI) and touch down PCR conditions starting with denaturation at 95°C for 10 minutes
followed by denaturation at 94°C for 1 minute, annealing starting at 10 degrees above optimal and reducing the
temperature 0.5°C with each cycle until reaching 55°C. Twenty cycles were followed by an additional 15 cycles
at 55°C for 1 minute and extension at 72°C for 2 minutes at each cycle.
Polymerase chain reaction amplicons were separated on 1.5% agarose gel and visualized by ultra-violet
transillumination of the gels stained with ethidium bromide. Amplicons were then subjected to gel purification
using a Qiagen gel purification kit and submitted for sequence analysis at the University of Colorado at
Denver's sequencing core laboratory. Bidirectional sequencing was performed by the dye-terminator fluorescent
method (Sanger sequencing) followed by interrogation on an ABI 3730 DNA Sequence Analyzer (Applied
Biosystems, Carlsbad, CA). Sequencing was analyzed using GenBank reference sequences NW_001838913 for
KIT and NM x 54156 for TP53.
Discussion
Adenoid cystic carcinomas are relatively uncommon primary breast tumors accounting for approximately 0.1%
to 1% of all breast tumors. While ACCs are seen affecting organs other than the breast, ACCs of the breast are
unlike their salivary gland counterparts. In fact, ACCs of the salivary gland are characterized as aggressive
tumors with a poor prognosis distinctly converse to the indolent behavior and good prognosis associated with
ACCs of the breast. Breast ACCs typically present as a mass, while some ACCs have been associated with
breast tenderness and pain. The etiology behind the clinical presentation in these cases remains unclear.[4]
Histologically, ACCs of the breast, like their counterparts in other locations, are composed of glandular
elements (adenoid component) and basement-membrane material (the cylindromatous component).[4] Ro and
colleagues divide ACCs into 3 grades based on the percent solid growth pattern: grade 1=no solid growth, grade
2=less than 30%, and grade 3=greater than 30%. The authors found that Grade 2 and Grade 3 tumors were more
likely to be larger compared to Grade 1 ACCs.[5]
The differential diagnoses of breast ACCs include both benign and malignant entities, such as collagenous
spherulosis and invasive cribriform carcinoma. Collagenous spherulosis also has a cribriform architecture and
central eosinophilic material composed of acellular spherules, thereby creating an adenoid cystic-like pattern.
The lumens in collagenous spherulosis may be irregular compared to that in ACC. Although myoepithelial cells
around the spherules may not be readily identified on H&E stained sections, these are highlighted by IHC stains
for myoepithelial cells.[6] Cribriform carcinoma and ACC share some features such as low nuclear grade and a
cribriform pattern. Cribriform carcinoma is differentiated from ACC by positivity for ER and PR and a negative
PAS/Alcian blue stain. In addition, a desmoplastic stromal reaction may be identified in invasive cribriform
carcinoma, but this is absent in ACC.[7] No stromal response was identified in the case we report here.
Nicholson and colleagues[8] state regional lymph node involvement is rare in ACCs, suggesting that lymph node
sampling is not necessary. However, local recurrences and distant metastasis have been reported. These
contradicting reports for this uncommon tumor suggest additional studies and perhaps longitudinal studies are
needed to better understand the natural history of this entity.
Immunohistochemical staining has become invaluable in the diagnosis of unusual variants of invasive breast
carcinoma. For most common types of breast carcinoma, absence of myoepithelial cells is indicative of
invasion. In these tumors, myoepithelial immunohistochemical markers such as p63 are negative in tumor cell
nests of invasive breast carcinoma. Peripheral uninvolved breast lobules and in situ carcinomas retain
myoepithelial cells and therefore positive p63 staining. These areas act as good internal controls for
myoepithelial marker stains. Invasive ACCs do lose the myoepithelial layer encircling the ducts, but the tumor
cells themselves (the myoepithelial/basaloid component) express p63, while the epithelial component expresses
CK7. These epithelial/myoepithelial dual components are typical of the salivary-gland type of tumors.
Therefore, this immunostain must be interpreted carefully to help distinguish an in situ component from an
invasive focus. Alternative histologic features such as irregular infiltrative tumor nests and the mass like
replacement of breast parenchyma are useful clues in identifying invasive foci. When available, comparison of
the histology of the initial resection with the simple mastectomy and the immunohistochemical features of both
may be helpful in confirming the presence of invasion in additional tumor foci. This was true for the case
presented here. McLaren and colleagues report that collagenous spherulosis, adenomyoepithelioma, ACC, and
low-grade adenosquamous carcinoma may be examples of epithelial-myoepithelial interactions and could
represent a spectrum of metaplastic lesions/tumors in the breast.[9] This could be an explanation for the positive
immunoreactivity for p63 observed in this case.
While ACCs retain immunoreactivity for p63, these tumors belong to the group of TNBCs. Triple negative
breast carcinomas are a group of carcinomas that show negative staining for ER, PR, and HER2/neu receptors.
This is a histologically and molecularly heterogenous group of tumors.[10] However, many TNBCs fall under the
molecular category of basal-like breast carcinomas. Weigelt and colleagues[11] attempted to refine breast cancer
classification by examining 11 different histologically special types of breast carcinomas using IHC and gene
expression profiling. One poor prognostic group identified by this study is the basal-like breast carcinomas.
Adenoid cystic carcinomas and medullary carcinomas of the breast have basal-like transcriptomes, however,
both types are associated with favorable outcomes. This provides strong evidence of the heterogeneity within
this group of basal-like cancers. The authors further identified that ACCs, medullary carcinomas, and
metaplastic carcinomas have similar immunohistochemical profiles characterized by low levels of CK19,
androgen receptor, CK8/18, and PR expression and high levels of CD117 (c-kit), vimentin, S100, CK14, and
CK5/6 expression compared to other tumor subtypes, suggesting that these similar protein expression patterns
may reflect a common etiological/genetic pathway in tumorigenesis.[11] CD117 (c-kit) over expression was
identified in the tumor presented; however, this over expression was not accompanied by gene mutations within
the commonly mutated exons. Gene mutations were also not identified within the commonly mutated exons of
p53. While these exons have been shown to be commonly mutated in other types of breast carcinomas, it is
possible that an alternative exon is altered in ACCs or a different molecular driving force leads to over
expression of c-kit (CD117).
C-kit expression has also been reported in ACCs of the salivary gland ranging from 89%[12] to 97%[13] of
reported cases. Freier and colleagues[12] found higher immunostaining for c-kit in cribriform and tubular but
none in solid subtypes of ACCs of the salivary gland. Immunohistochemistry for c-kit has been used to
differentiate ACC from polymorphous low-grade adenocarcinoma of the salivary gland. Mino and colleagues[14]
found that certain head and neck neoplasms, including pleomorphic adenoma, basal cell adenoma,
polymorphous low-grade adenocarcinoma, and basal cell carcinoma, that can show histologic overlap with
adenoid cystic carcinoma, had significantly less c-kit immunoreactivity than did ACC (P<.001). In contrast, in
their experience c-kit expression did not reliably distinguish ACC from basal cell adenocarcinoma and basaloid
squamous carcinoma (P>.05). Absence of c-kit has been associated with poor prognosis in salivary gland
carcinomas.[15] Non-salivary ACCs such as thymic ACCs have been reported to not express c-kit protein.[16] Pan
and colleagues,[17] on the other hand, found that c-kit is frequently over expressed in thymic carcinomas (86%)
but not in thymomas or normal thymus. Tracheobronchial ACCs showed c-kit immunoreactivity in 100%
(13/13) of cases reported by Albers and colleagues.[18]
Clinical trials with single agent Imatinib have yielded variable results. Milano and colleagues[19] and Hotte and
colleagues[20] report negative results or no objective response. In contrast, Faivre and colleagues[21] had an
objective response in ACCs of the salivary gland that were clinically progressing and expressed high levels of c-
kit. Additional studies are therefore necessary to provide answers for whether anti-kit therapy can be efficacious
in ACCs at various sites.
There is no consensus on a precursor lesion for ACC at present. Acs and colleagues[22] reported 17 cases in
which ACC coexisted with microglandular adenosis (MGA), an entity not considered to be a definite precursor
for carcinoma. They performed immunocharacterization with a panel of myoepithelial antibodies and suggested
that ACC may develop in a background of, and in continuity with, MGA. In their opinion, altered myoepithelial
cells appeared to be the major neoplastic element in ACC and "atypical MGA." They hypothesize that such
lesions might be best interpreted as ACC in situ, that MGA and ACC of the breast grow in an expansile and
diffusely infiltrative pattern, and that their stromal interactions may play a role in their non-metastasizing
biologic behavior. Da Silva[23] compared the molecular genomic alterations in ACCs with those in areas of
coexisting tubular adenosis to determine if the latter was a precursor of ACC. Focusing on copy number
alterations, Da Silva found alterations in ACC were restricted to small deletions on 16p and 17q, whereas
tubular adenosis showed gains on 1q, 5p, 8q, 10q, 11p, and 11q and losses on 1p, 10q, 11q, 12q, 14q, 15q, and
16q. The authors concluded that while ACC of the breast arising simultaneously with tubular adenosis does
have genetic instability, there was no molecular evolutionary link predisposing tubular adenosis to the
development of ACC. No tubular adenosis was identified in the case reported here. The precursor lesion for
ACC is still unknown.
Weigelt and colleagues[11] used pathway analysis to report that in ACCs there is a downregulation of the antigen
presenting pathway genes affiliated with mounting an immune response. They suggest the favorable prognosis
in ACCs of the breast, despite them being ER negative and harboring the poor molecular signature of basal
tumors, may be related to these modulations.
To summarize, ACCs are breast tumors with a unique histology, immunohistochemical profile, and a
paradoxically good prognosis. Studies to date have been unable to identify the molecular mechanisms or
precursor lesion for ACC. This information is critical to enhance our understanding of this triple negative tumor
and add to our insight into the more aggressive basal type breast carcinomas, ultimately identifying possible
therapeutic targets.

SABCS Wrap-up: A Chemotherapy-Free Future for HER2-Positive Patients?

Kathy D. Miller, MD; José Baselga, MD, PhD; George W. Sledge, Jr., MD
Posted: 12/17/2010
Introduction
Kathy D. Miller, MD: Hello. I'm Kathy Miller, Associate Professor of Medicine at Indiana University School
of Medicine in Indianapolis. This is the Medscape Oncology Wrap-Up of the 2010 San Antonio Breast Cancer
Symposium. It's my pleasure to welcome 2 truly notable colleagues. First, Dr. José Baselga, Associate Director
of the Massachusetts General Hospital Cancer Center, Chief of Hematology and Oncology, and Professor of
Medicine at the Harvard Medical School in Boston, and Dr. George Sledge, Professor of Medicine at the
Indiana University Simon Cancer Center in Indianapolis and the current President of ASCO® [American
Society of Clinical Oncology]. Welcome to both of you.
George W. Sledge, Jr., MD: Thank you.
Dr. Miller: As the 2010 San Antonio Breast Cancer Meeting winds down, I'd like to talk to both of you about
what you consider to be the highlights of this year's meeting. José, when you think about this year, what stands
out for you?
José Baselga, MD: Kathy, it was a very prolific meeting. We had a lot of new information. To me, perhaps, the
most important data have been the demonstration in the neoadjuvant trials that dual blockade of HER2 is quite
active. The studies combining pertuzumab and trastuzumab, the NEOSPHERE [Neoadjuvant Study of
Pertuzumab and Herceptin in an Early Regimen Evaluation] and then the Neo-ALTTO [Neoadjuvant Lapatinib
and/or Trastuzumab Treatment Optimisation combining lapatinib and trastuzumab] showing a doubling of
pathologic complete response (CR) rates -- so that's something that is truly novel and that I thought was
exciting.
Perhaps the other important news is some negative data that are going to help us better choose our therapies. We
had the AZURE Does Adjuvant Zoledronic acid redUce REcurrence in patients with high-risk localised breast
cancer?] trial[1] that showed the lack of benefit of bisphosphonates in early disease in terms of preventing
recurrence, so I think that was also an important piece of information.
AZURE Trial: Negative Results
Dr. Miller: George, let's take the AZURE trial in a little bit more detail. There had been a lot of enthusiasm
after the results of the ABCSG-12 [Austrian Breast and Colorectal Cancer Study Group 12] trial that found
improvement with the addition of zoledronic acid. A pretty narrowly defined group of patients: premenopausal;
ER-positive; by and large not treated with chemotherapy. We were reminded by Martine Piccart-Gebhart's
ASCO presentation that we needed the results of other trials in a wider group, and we've all been waiting for the
results of the AZURE trial.
Dr. Sledge: Waiting, and waiting, and waiting, and now it's here.
Dr. Miller: Could have been still waiting, I understand.
Dr. Sledge: Yes. In fact, there was a redo of the statistics to allow this to be presented. This was an
exceptionally large trial -- and a well-conducted trial -- that looked at the broad population of breast cancer
patients, rather than the much more narrow premenopausal ER-positive population that had been looked at in
the ABCSG trial. Now this trial, in terms of its primary endpoint, was a negative trial. I've always believed that
you should, in general, judge trials by their primary endpoint.
There was a subset analysis looking at postmenopausal women suggesting (in contrast, curiously enough, to the
ABCSG trial) a benefit in the postmenopausal women. Now whether that's a statistical artifact is difficult to say.
But this is certainly not something that would excite one overall about the use of bisphosphonate therapy as an
adjuvant therapy in breast cancer, although it may suggest that, as with other therapy, we need to be thinking of
bisphosphonate therapy perhaps as a more targeted therapy for particular subgroups.
Dr. Miller: The numbers got pretty small, right?
Dr. Sledge: In a hurry.
Dr. Miller: When they looked at the subgroup most comparable to the ABCSG population, premenopausal
patients with ER-positive disease didn't look encouraging.
Dr. Sledge: It did not. When you roll the dice twice, sometimes you get different results, just through the play
of chance, but this is certainly the largest trial that we have to date. I think, as the largest trial, it probably
deserves the greatest amount of respect of all the trials that we've seen to date.
Dr. Miller: What does this mean for the folks at home who are treating patients?
Dr. Sledge: It certainly suggests that the use of adjuvant bisphosphonate therapy is not the standard of care at
this point. I think many of us, when the ABCSG trial came out, wondered whether we should be treating more
women with bisphosphonates in the adjuvant setting. After this meeting you'd certainly have to say that it's not
the standard of care.
Of course, we still have one large adjuvant bisphosphonate trial -- that of the NSABP -- that hopefully will be
coming out sometime in the next few years and will further inform us in terms of whether bisphosphonate
therapy is a benefit.
Neo-ALTTO Trial
Dr. Miller: Let's turn back to some of those neoadjuvant studies that you mentioned, José. This, in my mind,
goes down as the San Antonio of adjuvant and neoadjuvant therapy. That's really where the biggest news came
from. The ALTTO [Adjuvant Lapatinib and/or Trastuzumab Treatment Optimisation] trial is still going on. It's a
huge effort of over 8000 patients. The Neo-ALTTO trial, though, may give us some hints or predictions of the
ALTTO results. Tell us about the design of the Neo-ALTTO trial and what differences you saw.
Trial description
Dr. Baselga: The Neo-ALTTO[2] is a neoadjuvant trial that had 3 arms. This was for patients who were HER2-
positive, who had tumors that were 2 cm or larger in diameter, and inflammatory disease was ruled out. These
patients (450) were randomly assigned to 3 arms. One of them had lapatinib. The second arm had trastuzumab.
The third arm had a combination of both lapatinib and trastuzumab. Therapy with anti-HER2 therapy alone was
given for 6 weeks, and then at week 6, paclitaxel was added on a weekly basis for 12 additional weeks. Then at
week 18, patients underwent surgery. After surgery, patients received 5-fluorouracil, epirubicin, and
cyclophosphamide chemotherapy times 3, and then they continued on the same anti-HER2 therapy that they
were on before for up to a year.
Results: dual blockade effective
What we presented was the initial component until surgery. The study's primary endpoint was pathologic CR
rate. What we observed is that the pathologic CR (PCR) rate with the combination of lapatinib and trastuzumab
was much larger than with either lapatinib or trastuzumab alone. The numbers are quite remarkable. We are
talking about a 51% PCR rate, as compared to 29% with trastuzumab. Clearly, it's an indication that with this
combination there is something there.
Now are these data going to be confirmed in the ALTTO trial? We don't know. But to me, it's an indication that
this concept of dual blockade is, perhaps, what we should be focusing on in the near future.
Dr. Miller: I was impressed with Eric Winer's discussion in which he reminded us of the sobering fact that
while patients who achieve a PCR do very well -- and that has been a very consistent finding -- it has not been
as consistent in the neoadjuvant trials that an improvement in PCR always translates to a difference in disease-
free and overall survival.
Dr. Baselga: I agree with Eric that you have to be careful when you interpret the PCR, but we have to realize
Eric was referring to the B27 study, which is a very good study, but B27 was not HER2-positive. In all the
HER2-positive trials to date -- I think the newer study that was cochaired by Luca Gianni and myself that we
published this year in The Lancet is a good example -- in HER2-positive disease, PCR has always correlated
with improvement in disease-free survival.
Is this an indication that we should start doing this tomorrow? Absolutely not. What this is an indication of is to
get the ALTTO study finished. We are 200 patients away. The ALTTO study, which is the large adjuvant study,
has enrolled over 8200 patients. We are only 200 patients short of starting that. But for the question that you're
asking, I think in HER2-positive disease, PCR does correlate very well with disease-free survival
Dr. Miller: In a way the adjuvant and neoadjuvant settings are very complementary.
Dr. Baselga: Yes.
Dr. Miller: You will have much greater assurance of those disease-free and overall survivals with the strength
of the numbers of the large adjuvant trial. But the neoadjuvant setting is a biomarker goldmine because you can
get that information on everyone. That had to be one of the goals of the Neo-ALTTO trials.
Dr. Baselga: Absolutely, and it was designed with that intention. The intention of Neo-ALTTO was to be the
translational research companion, if you wish, of ALTTO. I think that's the way clinical trials should be done in
the future. Neo-ALTTO had mandatory tumor biopsies, brief therapy on week 2, and then at the time of surgery.
In addition, we had a cohort of patients who underwent PET/CT scan because functional imaging is going to be
very important. We also had a subgroup of patients in whom we analyzed circulating tumor cells. Altogether,
what we have in our tumor bank today for the Neo-ALTTO study is 11,000 biological samples. More than 90%
of all the desired samples are already in our bank, so that will be a tremendous resource to study translational
endpoints.
The hope and the idea is that Neo-ALTTO will be like the engine of hypothesis where we will check potential
mechanisms of resistance or sensitivity, and whatever we find in Neo-ALTTO, we will be able to translate into
ALTTO. We cannot underestimate the potential strength of this type of approach in which you have companion
neoadjuvant and adjuvant studies.
NEOSPHERE Trial
Dr. Miller: George, another major neoadjuvant study in this population of HER2-positive patients is the
NEOSPHERE trial.[3]
Trial description
Dr. Miller: NEOSPHERE is similar in that it looked at a combined blockade of the pathway, although this time
with trastuzumab and the antibody pertuzumab, but somewhat uniquely including an arm that didn't receive any
chemotherapy -- just the dual blockade.
Dr. Sledge: Yes. And while the results in that arm were not quite as good as the combination with
chemotherapy, they certainly suggested that a significant percentage of the population probably -- if we believe
the PCR rates -- could get by without chemotherapy.
Consistency of HER2+ Trial Results
I agree with my colleague that these 3 presentations were the height of this meeting. What impressed me about
all of these, first, is the consistency of the results. Sometimes, when you see 3 different presentations, one will
say one thing and one will say another thing. They all pointed us in the same direction: that combination anti-
HER2 therapy is something that is going to increase the PCR rate, and certainly, as one pointed out, it suggests
that we're likely to see that in the adjuvant setting. They appear to increase the PCR almost regardless of which
HER2 drugs we combine -- which I also find quite fascinating -- and suggests that we're probably going to have
multiple tools.
A question I wanted to ask: Do the results of the Neo-ALTTO trial suggest to us that single-agent lapatinib is
not something that we should be using in this setting?
Dr. Baselga: No, I don't think so. The differences in our study -- the Neo-ALTTO -- between the lapatinib arm
and the trastuzumab arm were not statistically significant. They were very similar. But I think the era of
questioning whether lapatinib is better than trastuzumab is over.
Dr. Baselga: I saw the lapatinib arm as a control arm that was required just to make sure that we could interpret
the data, because if we did not have that arm, the interpretation of the study would have been very difficult. But
now that we have these data, we just have to move on.
Future Therapies With Less Toxicity
Dr. Miller: It also begs looking at triplets in a HER2-positive group, whether it's with trastuzumab, pertuzumab,
and lapatinib, substituting -- perhaps some would say -- a better trastuzumab with TDM1 and using
trastuzumab, both to target the receptor and to deliver chemotherapy. So there are a lot of places and directions
that this could go, and I expect that we're going to see several studies in the future.
Dr. Baselga: Kathy, in this direction, I want to point you to a phase 1 study with TDM1 and pertuzumab that
was reported. A phenomenal response rate, although you cannot overrate it -- I think that it's in support of your
proposal that maybe triplets or maybe combinations with hormonal therapy would also be indicated. One
question that occurred to me, looking at the NEOSPHERE data, is that in the arm that had no chemotherapy,
there were a proportion of patients who were ER-positive. Had they added an antihormone at the same time,
based on the models of Kent Osborne and Rachel Schiff?
Dr. Sledge: Indeed. Do we need chemotherapy for everyone who's HER2-positive?
Dr. Miller: In the NEOSPHERE trial, although in aggregate, the no-chemotherapy-just-dual-antibody approach
was inferior. Despite that, I was struck by the fact that between 10% and 20% of patients achieved a PCR with
no chemotherapy whatsoever. So even if most patients may still need some traditional cytotoxic chemotherapy,
if we could identify the subset, that would be phenomenally important for them.
Dr. Sledge: A question that's raised by these data concerns the adjuvant setting. Let's say that the ALTTO trial
shows results similar to Neo-ALTTO - I'm certainly encouraged that it will do so. Trastuzumab got us to
somewhere in the 80%-90% long-term, disease-free survival range. If we see a similar reduction in ALTTO as
we've seen in Neo-ALTTO, then probably somewhere north of 90% of patients will be long-term, disease-free
 survivors in the HER2-positive population in the adjuvant setting. Where do we go from here? Because we're
now talking about much, much larger trials to get much smaller benefits.
Dr. Miller: There actually is a model for that, though. It almost becomes testes cancer.
Dr. Baselga: Indeed.
Dr. Miller: If you look at the history of testes cancer trials, the early studies were looking at moving the bar in
efficacy. Once efficacy was north of 90%-95%, then the goal of the clinical trials became how do we preserve
that efficacy while minimizing exposure to therapy and exposure to the toxicities? I think we are -- perhaps with
the results of ALTTO, if Neo-ALTTO really does properly foreshadow them -- potentially in that range where
that will become every bit as much our goal.
Dr. Baselga: Yes. An essential part of this is in the same session that Neo-ALTTO and NEOSPHERE was
presented: a German study, GeparQuinto. They had very intensive chemotherapy, followed by docetaxel with
trastuzumab. The PCR rate was 50%, so it was identical to the response rate with nontoxic therapy with a
combination of lapatinib and trastuzumab. This is to your point.
The next direction will be to develop therapies that are less toxic. We could start in HER2-positive disease. The
direction that we are taking with HER2-positive disease is one with less toxic chemotherapy. Actually, I just
wrote an editorial for Journal of Clinical Oncology that will be coming out. The title of that editorial talking
about neoadjuvant HER2 therapies is "The Road to Chemotherapy-Free Therapy in HER2-Positive Disease."
That's very exciting. I think that if we wisely use TDM1, pertuzumab, lapatinib, and hormone therapy down the
line, we may get by with a very limited amount of chemotherapy.
Closing Remarks
Dr. Miller: That's a wonderful, forward-thinking, and optimistic way for us to end. Thank you for joining us,
José, and thank you, George. Thanks to our listening audience for joining us for this edition of Medscape
Oncology Insights. This is Dr. Kathy Miller at the 2010 San Antonio Breast Cancer Symposium in San Antonio.
[ CLOSE WINDOW ]
References
1. Coleman RE, Thorpe HC, Cameron D, et al. Adjuvant treatment with zoledronic acid in stage 2/ 3 breast
cancer. The AZURE trial (BIG 01/04). Program and abstracts of the 33rd Annual San Antonio Breast Cancer
Symposium; December 8-12, 2010; San Antonio, Texas. Abstract S4-5.
2. Baselga J, Bardbury I, Eidtmann H, et al. First results of the NeoALTTO trial (BIG 01-06/EGF 106903):
A phase 3, randomized, open label neoadjuvant study of lapatinib, trastuzumab, and their combination plus
paclitaxel in women with HER2-positive primary breast cancer. Program and abstracts of the 33rd Annual San
Antonio Breast Cancer Symposium; December 8-12, 2010; San Antonio, Texas. Abstract S3-3.
3. Gianni L, Pienkowski T, Im YH, et al. Neoadjuvant pertuzumab (P) and trastuzumab (H): Antitumor and
safety analysis of a randomized phase 2 study ('NeoSphere'). Program and abstracts of the 33rd Annual San
Antonio Breast Cancer Symposium; December 8-12, 2010; San Antonio, Texas. Abstract S3-3.

Combination Tx for HER2+ Breast Cancer Excites SABCS

December 11, 2010 (San Antonio, Texas) — Combination targeted therapy appears to be more effective than
using a single agent in the treatment of stages 1 to 3 HER2-positive breast cancer, according to 3 new clinical
trials presented here at the 33rd Annual San Antonio Breast Cancer Symposium.
After meeting participants saw these promising data, however, one prominent expert questioned the
affordability of the strategy, given the high cost of these drugs.
The clearest proof of the combination concept at the meeting was a neoadjuvant trial comparing the targeted
agents trastuzumab (Herceptin; Genentech/Roche) and lapatinib (Tykerb; GlaxoSmithKline), given both alone
and together before breast cancer surgery in women with primary HER2-positive breast cancer.
The combination of trastuzumab and lapatinib completely wiped out tumor cells in the breast, and thus achieved
a pathological complete response (pCR) in 51.3% of women — about twice the response seen with either drug
alone. The difference was statistically significant (P =.001).
These results from the Neo-ALLTO trial were presented by Jose Baselga, MD, who was at the Vall d'Hebron
University Hospital in Barcelona, Spain, at the time of the trial start and is now at the Massachusetts General
Hospital Cancer Center, in Boston. "Dual antiHER2 blockade is a valid concept," summarized Dr. Baselga.
"The combination is a lot better than either single agent," said Edith Perez, MD, from the Mayo Clinic, about
Neo-ALLTO results.
An expert in targeted therapies, Dr. Perez was asked by Medscape Medical News to comment on the new trials.
"We are not curing everybody with HER2-positive disease," said Dr. Perez about the need to improve on
treatment with trastuzumab.
In the second of the presentations at the meeting session on targeted therapies, use of a trastuzumab and
pertuzumab (Genentech/Roche) doublet showed, "most importantly," that "a proportion of HER2-positive
tumors can be eradicated without the need for chemotherapy," said lead author Luca Gianni, MD, from the
Istituto Nationale Tumori, in Milan, Italy. "Our study is the only study that indicates there is a subset of women
who can do without chemotherapy," said Dr. Gianni at a meeting press conference.
However, Dr. Gianni's 4-group, phase 2, neoadjuvant trial, known as NeoSphere, also showed that the
combination of trastuzumab, pertuzumab, and docetaxel was most effective, producing a pCR rate of 45.8% —
the clear winner over the other 3 treatment groups, including the trastuzumab and pertuzumab doublet, which
had a pCR rate of 17%.
In the third trial, the combination of neoadjuvant trastuzumab and chemotherapy achieved pCR in 31.3% of
women with primary breast cancer compared with 21.7% in women treated with lapatinib and chemotherapy;
the difference was statistically significant (P < .05). The definition of pCR used in the German study, known as
GeparQuinto, was the "most stringent" used in medicine, pointed out lead author Michael Untch, MD, from
Helios Klinikum Berlin-Buch in Germany. Trastuzumab and lapatinib were only used in combination with
chemotherapy in this trial, and not alone or in combination with each other.
The exact efficacy of lapatinib in GeparQuinto was clouded by the fact that about a third of the patients
receiving lapatinib discontinued treatment because of adverse effects, including, most prominently, diarrhea.
"We have to be prepared to teach patients how to deal with this side effect," said Dr. Untch.
Pathological Complete Response and Its Critics
Targeted therapy combinations for the treatment of early breast cancer are investigational at this point.
However, the pCR results in the trials were seen by a number of experts to be signs of likely eventual regulatory
approval. The pCR measure, which was evaluated at the time of surgery, is a good surrogate for longer-term
efficacy, said Dr. Untch, citing the other research. "All those patients [in the study] who had a pCR were, after 5
years, still alive," he said about another German study.
However, Eric Winer, MD, from the Dana-Farber Cancer Institute, in Boston, Massachusetts, said that pCR was
"not ready for prime time" as a measure to be used for drug approval or practice change, as it is not always
correlated with improved disease-free and overall survival. "We need further data," said Dr. Winer about the
various targeted therapy combinations. He made his comments while acting as discussant of the 3 trials
presented at the meeting.
Another expert agreed with Dr. Winer about the value of pCR and the targeted therapy studies presented at the
meeting. "This data is promising, but it cannot be used to change clinical practice, because complete
pathological response is not a perfect surrogate for long-term survival," said Leif Ellisen, MD, PhD, from the
Gillette Center for Breast Cancer at Harvard Medical School, in Boston, Massachusetts.
"It's predicted survival in some trials of breast cancer, but not in all," he told Medscape Medical News. "And the
[US Food and Drug Administration] has said that it will not allow pCR to be used as an endpoint."
However, these comments were in stark contrast to those of another presenter at the meeting: Michael Spector,
MD, from the Duke Comprehensive Cancer Center in Durham, North Carolina. "I envision the next trial to be
lapatinib plus trastuzumab plus pertuzumab," he said at a meeting press conference. "I've always believed total
HER2 blockade is optimal," said Dr. Spector, who developed lapatinib while working at GlaxoSmithKline.
"People are starting to talk about curing the disease," said Dr. Spector, referring to nonmetastatic HER2-positive
breast cancer.
Money, Money, Money
What are the possibilities for anti-HER2 agents in improving the most important measure in medicine, overall
survival?
"With new therapies, we could easily go over curing 90% of patients at 5 years," said Dr. Baselga, noting that
trastuzumab's 5-year survival rate is about 87% in an early trial.
Dr. Baselga also noted that before targeted therapy for HER2-positive disease, the 5-year survival rate was 40%
to 50%.
"Remarkable," summarized Dr. Spector about the actual and possible improvements in survival.
After speaking so enthusiastically for targeted therapy, however, Dr. Spector then doused the high spirits with a
strong dose of economic reality: What good are the therapies if they are not accessible to all HER2-positive
women? he asked.
He also presented a slide to the symposium audience that listed the 3 targeted therapies — lapatinib,
trastuzumab, and pertuzumab — and their possible combinations. The slide also listed corresponding dollar
signs to signify approximate costs. The slide read:
T + L $$
T + P $$$
T + P + L [Image of a piggy bank being smashed; accompanied by the verbal comment from Dr. Spector, "We
are going to bust the economy!"]
Dr. Untch offered a strategy that, although unproven, could lower future targeted therapy costs. "We can
probably lower the cost if, after 12 weeks of very effective treatment, we achieve 50% or more eradication of
tumor cells. Do we really need to treat for 12 more months?" he asked, referring to trastuzumab treatment
schedules.
Dr. Baselga, Dr. Untch, and Dr. Spector have disclosed no relevant financial relationships. Dr. Gianni is on the
advisory board of Roche, Genentech, Boehringer Ingelheim, and Pfizer.
33rd Annual San Antonio Breast Cancer Symposium: Abstracts S3-1, S3-2, S3-3, and S3-4. Presented
December 10, 2010.

Novel Agent Trastuzumab-DM1 Shows Efficacy in Metastatic Breast Cancer

October 9, 2010 (Milan, Italy) (UPDATED October 12, 2010) — Results of the first-ever phase 2 study of an
anti-Her2 antibody-drug conjugate, trastuzumab-DM1 (T-DM1), as first-line therapy in patients with Her2-
positive metastatic breast cancer, confirm good efficacy and lower toxicity than standard therapy.
These findings were presented by principal investigator Edith Perez, MD, from the Mayo Clinic, Jacksonville,
Florida, here at the 35th European Society for Medical Oncology Congress.
This is the first randomized phase 2 study on efficacy and safety of T-DM1 in this population. T-DM1 was
compared with trastuzumab (Herceptin; Genentech/Roche) plus docetaxel (Taxotere; Sanofi-Aventis) in patients
with Her2-positive metastatic breast cancer who had not received prior chemotherapy for metastatic disease.
"So far our results are really very encouraging," Dr. Perez told Medscape Medical News. "T-DM1 provides
efficacy with lower toxicity in patients with Her2-positive metastatic breast cancer. The results are early, but the
response data are solid, and we want to follow-up with progression-free survival.
"It's not only the response rate which is indeed numerically much higher, but it is the lower toxicity of this drug
compared to traditional chemotherapies and Herceptin," she added.
T-DM1 is the first of a novel class of antitumor therapy known as antibody–drug conjugates. It consists of 2
existing cancer drugs bound together so that both are delivered to the cancer cells. Trastuzumab is a monoclonal
antibody, which targets cells that overproduce the protein HER2, whereas DM1 is a chemotherapy agent that
targets microtubules.
"This coupling means that chemotherapy is not found free floating but is delivered inside the tumor cells per
se," explained Dr. Perez. "With T-DM1, we target delivery far better by coupling chemotherapy with
Herceptin."
Thus, when trastuzumab binds to the Her2 protein in the cell, the whole trastuzamab-DM1 molecule is
internalized and the chemotherapy is released inside the cell — where it is supposed to be — not in the blood,
circulating, causing adverse effects, she pointed out.
Response Rates Similar
In this ongoing phase 2 trial, 67 women received T-DM1 (3.6 mg/kg intravenously every 3 weeks), and 70
received treatment with trastuzumab (6 mg/kg intravenously; 8 mg/kg in cycle 1) plus docetaxel (75 or 100
mg/m2 intravenously on day 1 every 3 weeks). Patients remained on treatment until disease progression or
unacceptable toxicity.
Progression-free survival and safety were primary endpoints, whereas secondary endpoints included overall
response rate, clinical benefit rate, and overall survival.
After a median of 6 months' follow-up, the percentage of patients in the T-DM1 group who showed objective
response (complete or partial response based on RECIST 1.0) was 48% (95% confidence interval [CI], 35.4% -
60.3%) compared with 41% (95% CI, 30.2% - 53.8%) in patients in the trastuzumab-plus-docetaxel group.
The percentage of patients showing clinical benefit (objective response or maintained stable disease for at least
6 months from treatment start) was similar between the 2 groups: 55.2% (95% CI, 43.1% - 67.2%) in the T-
DM1 group and 57.1% (95% CI, 44.8% - 68.9%) in the comparator group.
Dr. Perez explained that they wanted to determine whether T-DM1 delays overall progression of breast cancer.
"We can shrink tumors, but now we want to know for how long we can shrink these tumors, as compared to
older standard treatments," she said. "We have very mature data related to response in this study, but it will take
another year to consolidate our data regarding progression-free survival."
Toxicity Lower in Experimental Group
Most notably, rates of clinically relevant adverse events (grade > 3) were significantly lower in the T-DM1
group (37.3%) compared with the rate in patients given trastuzumab plus docetaxel (75.0%).
The most common adverse events of any grade were alopecia (1.5% vs 66.2%), neutropenia (7.5% vs 57.4%),
and diarrhea (10.4% vs 45.6%) for T-DM1 and trastuzumab plus docetaxel, respectively.
"Even if the response had been the same with this level of lower toxicity, then it is something to pay attention
to. We want to both improve response in our patients but also to improve their lives," said Dr. Perez.
Replace Systemic Chemotherapy?
Jose Baselga, MD, chief of hematology and oncology, Massachusetts General Hospital, Boston, commented that
T-DM1 was a wonderful addition to the treatment of Her2-positive disease. "The concept is very appealing. A
very important cytotoxic agent is linked to trastuzumab, and clinical trials have shown a very high response rate
with minimal toxicity," he said.
"Why is it that the response rate is so good in patients who have received so many therapies previously, as if
they were patients treated first-line?" he questioned, adding that in his opinion, the answer to that question lies
in the biology.
"Her2 tumors are extremely sensitive, and they continue to respond to second-line plus treatments," he said.
"We shouldn't give up on treating this disease."
In conclusion, he speculated that in the future, this might replace systemic chemotherapy in Her2-positive breast
cancer. "It is provocative data. If T-DM1 is even equal to trastuzumab plus chemotherapy, then that is a big win
because we have highly efficacious therapy, which is nontoxic.
"I think this is phenomenal," he added.
Progression-free survival, 1-year overall survival rates, mature overall response rates, and duration of response
data are expected in 2011. A phase 3 trial, called MARIANNE, has now begun that assesses trastuzumab plus
taxane vs T-DM1, with a third option of T-DM1 plus pertuzumab.
Genentech supported the study. L. Dirix, J. Kocsis, L. Gianni, J. Lu, J. Vinholes, and S. Hurwitz received
research/contract funding from Roche/Genentech covering costs associated with the conduct of this study. V.
Ng, C. Linehan, and S. Agresta are employees and stockholders of Roche. All other authors have disclosed no
relevant financial relationships. Dr. Perez does not own any stock in Genentech or Roche. Genentech and
Roche supply research support for the breast cancer program at the Mayo Clinic. Dr. Baselga has disclosed no
relevant financial relationships.
35th European Society for Medical Oncology Congress: Abstract LBA3. Presented October 11, 2010.

Potential Therapeutic Target Revealed for Triple-Negative Breast

Cancer
September 30, 2010 — Triple-negative breast cancer accounts for only a small proportion of breast cancer
cases, but it is difficult to treat and might have a more aggressive clinical course than other forms of the disease.
According to data presented at the 4th American Association for Cancer Research International Conference on
Molecular Diagnostics in Cancer Therapeutic Development, in Denver, Colorado, insulin-like growth-factor 1
receptor (IGF-1R) is overexpressed and amplified in a subset of triple-negative breast cancer patients.
This finding suggests that IGF-IR is a potential therapeutic target, explained study coauthor Agnieszka K.
Witkiewicz, MD, associate professor of pathology at Thomas Jefferson University Hospital in Philadelphia,
Pennsylvania.
The researchers found that IGF-1R was overexpressed in 25% of cases, and a significant association was
observed between IGF-1R protein expression and IGF1R gene amplification (P < .001). In patients 55 years and
younger, a high IGF-1R score was associated with prolonged survival (hazard ratio, 0.13; 95% confidence
interval, 0.02 - 1.00; P = .050).
During a presscast, Dr. Witkiewicz explained that even though triple-negative breast cancer accounts for only
15% to 20% of patients with the disease, it leads to half of all breast cancer deaths. Estrogen-receptor-positive
breast cancer mortality has declined over the past decade, but the same is not true for triple-negative disease.
"This is one of the subsets that is most challenging to treat," said Dr. Witkiewicz. "It is more common in young
women, more common in African American women, and is characterized by an aggressive course."
Therefore, there is a significant need for a better understanding of the pathogenesis of triple-negative breast
cancer and a need to identify new molecular targets for treatment, she added.
IGF-1R has been known to play a major role in cancer cell proliferation, survival, and resistance to treatment in
a number of human malignancies, including breast cancer, the authors write. It is also a target of several
investigational drugs, both in clinical and preclinical development.
However, the authors note, there have been no systematic studies of IGF-1R expression in triple-negative breast
cancer.
High Expression Equated the Better Survival
In the current study, Dr. Witkiewicz and colleagues evaluated IGF-1R expression in 99 women with triple-
negative breast cancer. Immunohistochemistry was used to evaluate IGF-1R protein expression, which was
scored according to standardized criteria originally developed for HER2 disease. In addition, chromogenic
in situ hybridization for the IGF1R gene was performed on 35 cases.
A tumor was interpreted as positive for gene amplification when the ratio of the IGF1R gene signal to the
chromosome 15 signal was 2.2 or higher; for the purpose of statistical analysis, the expression of IGF-1R was
classified as low (0 to 2) or high (3).
The authors observed that IGF-1R expression was high in 29 of 99 (29%) cases and correlated with negative
lymph nodes (P = .03). Gene amplification was seen is 8 of 35 cases (23%). Low IGF-1R expression was
associated with lymph node metastases (P = .033); conversely, high IGF-1R expression was associated with a
tumor size that was borderline significantly smaller (P = 0.080).
The authors note that there was no statistically significant association between IGF-1R expression and grade or
race.
However, patient age played a role, Dr. Witkiewicz pointed out. "In patients older than 65 years, there was no
difference in survival between patients with low and high IGF-1R expression," she said. "But in patients
younger than 65, those with high IGF-1R expression had longer survival than those with low expression."
The longest survival was seen in younger patients with high IGF-1R expression, and the poorest survival was
seen in older patients (>55 years) with low IGF-1R expression.
"For now, we know that it is there and we know it is a marker of better prognosis," said Dr. Witkiewicz. "The
next step is to learn if triple-negative breast cancer patients benefit from targeting IGF-1R."
Program chair Gordon B. Mills, MD, PhD, from the Department of Systems Biology at the University of Texas
M.D. Anderson Cancer Center, in Houston, noted that, based on earlier iterations of this conference and the
contributions of many members of the community, "we have developed a pathway to the development of
molecular diagnostics and biomarkers."
"Importantly, we have a much better concept of the limitations, challenges, and hurdles that need to be
overcome for the implementation of molecular diagnostics," he told Medscape Medical News.
"Currently, the outcome for triple-negative breast cancer is poor, at least in part because of the lack of novel
targets for therapy," he told Medscape Medical News. Dr. Witkiewicz and colleagues have demonstrated that
IGF-1R is overexpressed in triple-negative breast cancer, warranting studies to validate IGF-1R as a target for
therapy," he said.
4th American Association for Cancer Research International Conference on Molecular Diagnostics in Cancer
Therapeutic Development (AACR-MDCTD): Abstract A29. Presented September 28, 2010.

A Review of Triple-negative Breast Cancer

Roohi Ismail-Khan, MD; Marilyn M. Bui, MD, PhD
Posted: 09/30/2010; Cancer Control. 2010;17(3):173-176.
Abstract
Background: An estimated 1 million cases of breast cancer are diagnosed annually worldwide. Of these, more
than 170,000 are described as triple-negative. Triple-negative breast cancer (TNBC) is defined by the lack of
protein expression of estrogen receptor (ER) and progesterone receptor (PR) and the absence of HER2 protein
overexpression. TNBC is a subtype of breast cancer that overlaps with the "basal-like" breast cancer. TNBC has
significant clinical implications.
Methods: The epidemiology, diagnosis, clinical course, prognosis, and pathology of this subtype of breast
cancer are reviewed. The authors compare the "triple-negative" and "basal-like" definitions of breast cancer. A
discussion of both standard and experimental treatments for TNBC is included.
Results: The poor prognosis of high-grade TNBC relates to poor disease-free interval in the adjuvant setting,
shortened progression-free survival in the metastatic setting, and the lack of targeted therapy. However, not all
TNBCs are associated with a poor prognosis.
Conclusions: Although chemotherapy is the main current treatment of this subtype of breast cancer, new agents
such as PARP inhibitors, which show promise in the treatment of TNBC, are currently in clinical trials.
Introduction
Breast cancer is the most common cancer among women in the United States, the second most common cause
of cancer death, and the main cause of death in women ages 45 to 55 years. In 2009, approximately 192,370
American women were diagnosed with breast cancer, and an estimated 40,170 women died of the disease.[1]
Triple-negative breast cancer (TNBC) accounts for approximately 15% of breast cancers.[2] Although recently in
the limelight and frequently discussed, TNBC is not a new type of breast cancer. In fact, the term has recently
been coined to describe a subtype of breast cancer that lacks expression of the estrogen receptor (ER) and
progesterone receptor (PR) and does not overexpress human epidermal growth factor 2 receptor (HER2)
protein. TNBC is an important area of research for both researchers and clinicians alike because (1) TNBC is a
poor prognostic factor for disease-free and overall survival, (2) no effective specific targeted therapy is readily
available for TNBC, (3) there is a clustering of TNBC cases in premenopausal women and in women of African
descent, and (4) the overlap of BRCA1-associated breast cancers with the TNBC phenotype is significant.
Epidemiology
An estimated 1 million cases of breast cancer are diagnosed annually worldwide.[3] Of these, approximately
170,000 are of the triple-negative (ER–/PR–/HER2–) phenotype.[3] Of these TNBC cases, about 75% are "basal-
like."[4] The prevalence of TNBC is highest in premenopausal African American women; a recent report notes
that 39% of all African American premenopausal women diagnosed with breast cancer are diagnosed with
TNBC.[5] The prevalence of TNBC in this same age group in non–African American women is much less, at
approximately 15%. These ethnic or menopausal differences are not seen in either the ER+/HER2+ breast
cancer subgroup or the ER+/HER2− subgroup.[5]
Multiple other studies and abstracts have confirmed that TNBC occurs in a higher percentage of African
American women. Of these TNBC cases, about 75% are also of the basal-type molecular classification. As
presented initially in 2006 at the San Antonio Breast Cancer Symposium in a study of racial differences in the
prevalence of triple-negative invasive breast tumors, researchers found that the incidence of triple-negative
disease among African American women was more than twice that among white women. They also reported
that 47% of tumors in African American women were "triple-negative" compared with 22% in white women.
After adjusting for age and stage at diagnosis, African American women were almost 3-fold more likely than
white women to have triple-negative tumors.[2]
These disparities in incidence among different racial groups leads us to question whether genes or mutations
predispose women, particularly premeno pausal African American women, to TNBC. Studies have shown that
breast cancers in women with germ-line BRCA1 mutations are more likely to be triple-negative and high-grade.
[6]
Gene expression studies have confirmed this phenomenon and also that BRCA1-associated breast cancer
appears to cluster in the basal-like subtype.[7]
Pathologic and Molecular Features
Although the terms basal-like breast cancer and TNBC are often used interchangeably, they are not
synonymous. TNBC refers to the immunophenotype of the breast cancer that is immunologically negative to
ER, PR, and HER2. These immunological studies are done on formalin-fixed and paraffin-embedded tumor
sections. Basal-like breast cancer refers to the molecular phenotype of the tumor that has been defined by cDNA
microarrays. Of these TNBCs, about 75% of them are of the basal-like type.
Perou et al[8] were the first to describe the various molecular subtypes or molecular profiles of breast cancers.
They described four subtypes based on cDNA micro arrays, including a basal-like subtype of breast cancer, and
noted that most TNBCs clustered in the basal-like subtype.[8] Since then, multiple studies of gene expression
profiling have advanced the understanding of the molecular diagnosis of breast cancer, thus providing the
background for oncologists to use the triplenegative phenotype to describe the basal-like molecular subtype.[7,9–
11]

The luminal subtypes of breast cancers express high amounts of luminal cytokeratins and express genetic
markers of luminal epithelial cells and normal breast cells.[12,13] In contrast, basal-like breast cancers tend to ex
press cytokeratins associated with basal types of cancers, as they arise from the outer basal layer.
Basal-like breast cancers are typically high-grade and poorly differentiated when examined morphologically.
While the TNBC phenotype is defined by immunohistochemistry, no established diagnostic criteria have been
identified for basal-like breast cancer on a morphological basis. In general, basal-like breast carcinomas are
morphologically consistent with a high nuclear grade, high mitotic count, and necrosis (Fig 1), such as a grade 3
invasive ductal carcinoma, not otherwise specified (Fig 1). Some have the histomorphology of medullary
carcinoma or metaplastic carcinoma. It has also been reported that almost 82% of basal-like breast cancers
express p53 compared with 13% in the luminal A subgroup.[10]

Figure 1. This high-grade breast cancer (invasive ductal carcinoma, not otherwise specified, grade 3) is an
example of a triple-negative breast cancer, basallike carcinoma (hematoxylin-eosin, ×400).
A subset of TNBC and basal-like breast cancer that is of low histological grade includes secretory, adenoid
cystic, acinic cell, and apocrine breast carcinoma. Useful immunohistochemical markers for characterizing
basallike carcinomas are CK5 (Fig 2), CK6, CK14, CK8/CK18, p63, P-cadherin, vimentin, epidermal growth
factor receptor 1 (EGFR1 [or HER1]), c-kit, and other growth factors such as insulin-like growth factor receptor
(IGFR).[4,13,14]
Figure 2. This tumor shows CK5 positivity, which is typical for a basal-like cancer (immunohistochemical
CK5 stain, ×400). The insert is a CK5 stain of a normal control slide highlighting the basal cells (hematoxylin-
eosin, ×200).
Not all basal-like carcinomas are HER2−. A study found that 23% of basal-like tumors, which are defined by
gene expression study, were HER2+.[15] Therefore, HER2 immunoreactivity should not be used to rule out a
basal-like carcinoma.
It is important to realize that TNBC and basal-like breast cancer are not all of high histological grade. For the
above-mentioned low-grade tumors, the clinical management strategies outlined in this article are not
applicable. Therefore, oncologists need to be aware of this when using triple-negative to define a potentially
aggressive group of breast cancers. Although the majority of TNBCs are basal-like and the majority of basal-
like breast cancers are triple-negative, there is approximately a 25% discordance between the two descriptive
subgroups.[4] However, for the remainder of this article, the TNBC phenotype is used to represent this molecular
subtype.
Clinical Course and Prognosis
TNBCs are biologically aggressive; although some reports suggest that they respond to chemotherapy better
than other types of breast cancer, prognosis remains poor.[16] This is due to two factors: shortened disease-free
interval in the adjuvant and neoadjuvant setting and a more aggressive clinical course in the metastatic setting.
Triple-negative tumors have a good initial response to chemotherapy, particularly anthracycline and
taxanebased therapy. Although these tumors are initially sensitive to standard neoadjuvant chemotherapy, they
continue to exhibit a short disease-free survival.[17] Recently published neoadjuvant studies have clarified the
fact that patients who have a good pathologic outcome from surgery also have a good clinical response.
However, within the group of patients who have residual disease after completing neoadjuvant chemotherapy, a
worse prognosis is seen in the triple-negative subgroup.[18]
Carey et al[18] examined the relationship of neoadjuvant chemotherapy response to clinical outcome among three
breast cancer subtypes. They used immunohistochemical profiles to represent molecular subtypes of breast
cancer. The three groups compared were the HER2+/hormone receptor-negative (HER2 overexpressed)
subtype, the hormone receptor-negative and HER2– (basal-like) subtype, and the hormone receptor-positive
(luminal) subtype. They followed a prospectively maintained data set of patients with breast cancer treated with
neoadjuvant anthracyclinebased chemo therapy — doxorubicin plus cyclophosphamide (AC). They then
analyzed each subtype for clinical and pathologic response to neoadjuvant chemotherapy and examined the
relationship of this response to distant disease-free and overall survival. After neoadjuvant AC, 75% received
subsequent chemotherapy, and all patients who were hormone receptor-positive received endocrine therapy.
The chemotherapy regimen and the pretreatment stage did not differ by subtype. The clinical response to AC
neoadjuvant therapy was higher in the HER2+/ER− (70%) and basal-like (85%) subtypes than in the luminal
subtype (47%; P < .0001). Pathologic complete response occurred in 36% in the HER2+/ER− group, 27% in the
basal-like group, and 7% in the luminal subtype (P = .01). Of interest, despite displaying initial
chemosensitivity, patients with the basal-like and HER2+/ER− subtypes had worse distant disease-free survival
(P = .04) and overall survival (P = .02) than those with the luminal subtype. This worse outcome among the
basal-like and HER+/ER− subtypes was due to higher relapse among those patients with residual disease after
completing neoadjuvant chemotherapy (P = .003).
In another study, TNBC was associated with increased risk for visceral metastases (P = .0005), lower risk for
bone recurrence (P = .027), and shorter postrecurrence survival (P < .0001).[19] If pathologic complete response
(pCR) was achieved, patients with TNBC and non-TNBC had similar survival (P = .24). In contrast, patients
with residual disease had worse overall survival if they had TNBC compared with non-TNBC (P < .0001). This
study concluded that patients with TNBC have increased pCR rates compared with those without TNBC and
that those with a pCR have excellent survival. However, patients with residual disease after neo adjuvant
chemotherapy have significantly worse survival if they have TNBC compared with those without TNBC,
particularly in the first 3 years.
Even in early-stage TNBC, early relapse is common. There is a predilection for visceral metastasis, including
lung, liver and, notably, brain metastasis. Current estimates are that approximately 15% of TNBC patients
develop brain metastasis. The risk for developing brain metastasis is higher for patients with TNBC than with
other types of breast cancer. Studies show have shown that even in patients with cerebral metastasis, TNBC
patients have a poor prognosis, as metastasis to the brain occurred earlier.[20]
According to NCCN guidelines, treatment of T1N0 breast cancer is based on both tumor size and cellular
characteristics. Oncologists tend to treat patients with T1N0 TNBC with more aggressive chemotherapy, in both
the neoadjuvant and adjuvant setting. When examining the number of patients treated and also the type of
adjuvant chemotherapy administered, triple-negative T1N0 patients have greater recurrence risk despite this
more aggressive therapy.[21] In 2007, researchers from the Swedish Cancer Institute from Seattle, Washington,
reported that patients with T1N0 TNBC have twice the risk of recurrence, despite receiving more aggressive
treatment.[17]
In addition to having a short disease-free survival, triple-negative breast tumors are aggressive in the metastatic
setting, significantly contributing to the shortened overall survival.[3] Progression-free survival is estimated to be
4 months at best in TNBC for first-line therapy, even with bevacizumab-based therapy.[22]
Future Directions in Research
Although TNBC is sensitive to chemotherapy, early relapse is more likely in patients with TNBC than with
other subtypes, and visceral metastasis, including brain metastasis, is commonly seen. Targeted agents that are
currently being investigated include EGFR, vascular endothelial growth factor (VEGF), poly(adenosine
diphosphate [ADP]-ribose) polymerase (PARP) inhibitors.
The antiangiogenic agent bevacizumab (Avastin), a monoclonal antibody targeting VEGF, is active in many
solid tumors including breast cancer. Miller et al[22] demonstrated a significant improvement in progression-free
survival (11.8 vs 5.9 months, hazard radio [HR] = .60; P < .001) when adding bevacizumab to paclitaxel
chemotherapy compared with single-agent paclitaxel alone in first-line treatment of metastatic disease.
Examining the TNBC subset of patients in this study confirmed the same improvement (HR = .53; 95%
confidence interval, 0.40–0.70).[22,23] Most oncologists would strongly consider an Avastin combination for first-
line therapy when treating patients with metastatic TNBC.
The fact that the majority of BRCA1-associated breast cancers are also triple-negative and basal-like has led
researchers to question the extent to which the BRCA1 pathway contributes to the behavior of sporadic basal-
like breast cancers. It has been shown that basal-like breast carcinomas frequently harbor defects in DNA
doublestrand break repair through homologous recombinations such as BRCA1 dysfunction. The DNA-repair
defects characteristic of BRCA1-deficient cells confer sensitivity to poly(ADP-ribose) polymerase 1 (PARP1)
inhibition.[24]
The PARP1 gene encodes a chromatin-associated enzyme that modifies various nuclear proteins. This gene is
involved in the molecular events leading to cell recovery from DNA damage. When PARP1 is inhibited, breaks
in double-strand DNA accumulate that, under normal conditions, would be repaired via homologous
recombination. Both BRCA1 and BRCA2 are required for the homologous recombination pathway to function
properly. Therefore, cells deficient in either BRCA1 or BRCA2 are sensitive to PARP1 inhibition, resulting in
cell death and apoptosis. Intuitively, inhibition of the PARP pathway should benefit patients with BRCA-
associated malignancies.[25] However, as stated above, not all TNBC cases are associated with BRCA mutations.
Several PARP1 inhibitors are currently in clinical development and hold promise in TNBC and basal-like breast
cancers. As presented in a plenary session in 2009,[26] the results of a randomized phase II study with BSI-201 (a
PARP inhibitor) showed benefit in patients with TNBC who had two or fewer previous lines of chemotherapy.
When BSI-201 was combined with gemcitabine and carboplatin, the clinical benefit rate improved to 62%
compared with 21% in the gemcitabine and carboplatin alone arm (P < .0002).[26] Clinical benefit rate is defined
as complete response plus partial response plus stable disease for at least 6 months. In addition, the overall
response rate was notably improved in the BSI-201 arm at 48% compared with the control arm at 16%.
Progression-free survival was improved to 6.9 months in the BSI-201 arm vs 3.3 months in the gemcitabine and
carboplatin alone arm.[26] Currently, many initial trials on targeted therapy with PARP inhibitors are underway to
study their use in the treatment of TNBC. In addition, several new agents are being investigated that may be
beneficial for patients with this subgroup of breast cancer.

PARP inhibitor increases survival in triple-negative breast cancer

10.10.10 Category: Milan 2010 News

The basic structure of PARP

The final results of a phase II study of the PARP inhibitor iniparib in combination with gemcitabine/carboplatin
are presented by Dr. Joyce O'Shaughnessy and colleagues. The results of this study, which enrolled 123 patients
with triple-negative breast cancer, confirm that iniparib improves the outcome of this particularly aggressive
subtype of breast cancer, without important associated toxicity. This improved outcome includes an increase in
median survival, a rare finding in advanced disease. "While results from this relatively small phase II study add
to currently available data on this new therapeutic option, any enthusiasm must be balanced with some degree
of caution until data are confirmed by large randomized phase III studies" comments Dr. Fatima Cardoso, Chair.
Such studies are currently ongoing in the metastatic setting, evaluating combinations with taxanes and
platinums. Additionally, studies in the neoadjuvant setting are in an advanced stage of planning and will include
treatment combinations with anthracyclines. Together these studies will provide the evidence needed to confirm
if PARP inhibitors are indeed the much needed breakthrough in the treatment of triple-negative breast cancer.
Until then, these promising drugs can only be used within the context of a clinical trial.
2013 Top Stories in Oncology: Breast Cancer
Lee S. Schwartzberg MD, FACP
This is Dr. Lee Schwartzberg for PracticeUpdate. Today, I want to talk about the top story of 2013 for breast
cancer.
In my opinion, this was the FDA approval of pertuzumab in the neoadjuvant setting for HER2-positive breast
cancer. And why do I consider this to be the top story? Because it was a paradigm shift for the regulatory
authority to approve a drug in the treatment of breast cancer prior to surgery. What we’re talking about is adding
pertuzumab to a standard treatment of chemotherapy plus trastuzumab.
Pertuzumab has already been approved for advance breast cancer. It had not been approved, up until now, for
the treatment of patients who have early-stage breast cancer. However, the FDA decided that a surrogate marker,
which is pathologic complete response, was good enough to potentially predict for long-term outcome in breast
cancer, and, of course, drugs are approved based on their efficacy, or what they're going to do long-term for
patients, as well as their safety.
Pertuzumab has been studied in a variety of relatively small randomized trials that looked at adding it to a
combination of chemotherapy and trastuzumab, although, interestingly, some of these studies also had an arm
that looked at just the HER2 antibodies alone—that is, no chemotherapy; just treating with pertuzumab and
trastuzumab.
What those trials showed, and what impressed the FDA, was that the pathologic complete response rate, or the
complete eradication of the tumor from the breast and/or the lymph nodes at the time of surgery, was improved
with the addition of pertuzumab, and quite spectacularly so in some studies. Up to 50% to 60% of patients with
HER2-positive breast cancer treated with a combination of chemotherapy, pertuzumab, and trastuzumab had no
cancer left in their specimens when they underwent surgery.
That pathologic complete response will, hopefully, predict for long-term outcome, as I said, and the studies to
prove that are already underway. This approval from the FDA does require, and has the proviso that it will
require, confirmatory trials in the adjuvant setting.
The important thing about this approval is that it gets a potentially life-saving drug into the hands of doctors and
the patients who need it years before it will be established from these very long, large adjuvant trials that take
years and are very expensive to conduct.
There are a lot of issues with the use of pertuzumab in the neoadjuvant setting, because, if you stop and think
about it, we now have a drug that can be approved if the medical oncologist sees the patient before the surgeon
operates on her, because neoadjuvant treatment is before surgery. But, it is not approved now if the patient
undergoes the surgery and then goes to the medical oncologist.
We have some issues with regard to reimbursement and regulatory red tape that need to be worked out. Still,
that doesn’t diminish from this being a new paradigm for FDA approval of drugs, and many other
pharmaceutical companies will be trying this approach, which will, hopefully, get other life-saving drugs into
the hands of patients much sooner.

Roche to File T-DM1 Breast Cancer Drug on Good Data

ZURICH (Reuters) Mar 30 - Roche said patients with an aggressive type of breast cancer lived longer after
taking its experimental "armed antibody" drug without the disease worsening than those on a mix of
GlaxoSmithKline drug Tykerb and Roche's Xeloda.
The positive results from the first Phase III trial of the medicine - dubbed T-DM1 - clear the way for it to be
submitted to European and U.S. authorities for approval this year.
In a brief statement on Friday, Roche revealed only that patients on T-DM1 lived "significantly longer" without
their disease progressing.
Roche has been developing T-DM1 with ImmunoGen as a successor to its blockbuster Herceptin, which is
expected to generate sales of around $6 billion this year.
A key advantage of T-DM1 over Herceptin is the fact that it causes fewer adverse side effects like hair loss and
low white blood cell counts.
It combines trastuzumab, an antibody and the active ingredient in Herceptin, with the agent DM1 - a derivative
of an extremely powerful type of chemotherapy called maytansine - which is carried directly into cells.
As well as having fewer unpleasant side effects, Roche believes its new drug also offers greater convenience,
since it is one drug and eliminates the need to administer chemotherapy.
Experts believe the full set of results for progression-free survival are likely to be presented at the June 1-5
annual meeting of the American Society of Clinical Oncology, with overall survival results becoming available
by 2014.

Ten Years Later, Trastuzumab Survival Advantages March On

Neil OsterweilDec 07, 2012
SAN ANTONIO, Texas — A decade of data continue to demonstrate that adding trastuzumab ( Herceptin,
Genentech) to standard chemotherapy in women with HER2-positive breast cancer improves both overall and
disease-free survival.
Furthermore, the benefits conferred by trastuzumab are not waning over time.
At a median follow-up of 8.4 years, women randomly assigned to receive doxorubicin and cyclophosphamide
(AC) followed by paclitaxel plus trastuzumab had a 37% lower relative risk for death than women who received
AC alone, reported Edward H. Romond, MD, professor of medicine at the University of Kentucky Medical
Center in Lexington.
For women with high-risk HER2-positive disease, the trastuzumab-containing regimen also reduced the risk of
having a disease event by 40%.
These relative risk-reduction benefits were seen across nearly all subgroups, Dr. Romond said.
He presented data from the final planned joint analysis of overall survival from the NSABP B-31 and NCCTG
N9831 trials here at the 35th Annual San Antonio Breast Cancer Symposium (SABCS).
"For patients with hormone-receptor-positive disease, the absolute reduction in the rate of distant recurrence as
a first event continues to improve over time with the addition of trastuzumab, and reaches 9.6% at 10 years. For
patients with hormone-receptor-negative disease, the absolute risk of distant recurrence as a first event is
reduced by 9.6% at 7 years, after which distant recurrence from breast cancer is unlikely," Dr. Romond said.
A breast cancer specialist who was not involved in the study told Medscape Medical News that the long-term
data are welcome but not surprising.

...there was a real plateauing out in terms of the risk of recurrence... Dr. Claudine Isascs

"There continues to be a growing benefit [of trastuzumab ] over time, and in the ER [estrogen-receptor]-
negative subset of patients, it was nice to see that there was a real plateauing out in terms of the risk of
recurrence after about 7 years, which is reassuring, as we're following some of these patients beyond that," said
Claudine Isascs, MD, professor of medicine and codirector of the breast cancer program at the Georgetown
Lombardi Comprehensive Cancer Center in Washington, DC.
Dr. Romond presented data on 2018 women assigned to AC and paclitaxel, and to 2028 assigned to AC,
paclitaxel, and trastuzumab. In each arm, about 45% of women were both ER-positive and PR-positive, and the
remainder had tumors that were ER- or PR-positive, or both. About one half of all women in the studies had
tumors ranging from 2.1 to 5.0 cm in size, and about 40% had tumors measuring 2 cm or less. Roughly 10% in
each group had tumors larger than 5 cm.
In all, 102 women (5%) assigned to receive trastuzumab did not get the drugs because of cardiac symptoms or a
decrease over baseline in left ventricular ejection fraction following AC. These patients were included in the
intention-to-treat (ITT) analysis.
In the control arm, 413 women (20.4%) received trastuzumab after the first interim analysis of the trials in 2005
showed positive results; these patients are also included in the ITT analysis.
Ten-Year Data Similar to 6-Year Data
Six years after randomization, disease-free survival was 81.4% for patients assigned to trastuzumab vs 69.5%
among those assigned to AC. Similar results were seen at 8 years (76.8% vs 64.9%, respectively) and at 10
years (73.7% vs 62.2%), for an absolute difference at 10 years of 11.5%.
Trastuzumab was associated with a hazard ratio [HR] of 0.60 (95% confidence interval [CI], 0.53 - 0.68, P < .
0001).
Disease-free survival events included distant recurrences in 11.2% vs 19.4%, local regional recurrences in 4.1
vs 6.1%, contralateral breast disease in 2.3% vs 2.0%, and other second primary cancers in 3.3% vs 3.7%. In all,
1.9% of patients receiving trastuzumab died without recurrence, compared with 1.5% of patients receiving AC-
paclitaxel only.
Among ER- and/or PR-positive patients, distant recurrence as a first event occurred in 12.7% of those who had
taken trastuzumab, and in 22.3% of those who had not. Among ER- and PR-negative patients, the respective
rates were 11.9% and 21.5%, and as noted above by Dr. Isaascs, the events in both groups began to level out at
about 7 years but remained substantially better for trastuzumab-treated patients.
Dr. Romond noted that the absolute differences in overall survival between trastuzumab-treated patients and
control patients has increased gradually over the last decade, from 2.9% at 4 years after randomization to 5.5%
at 6 years, 7.8% at 8 years, and 8.8% at 10 years.
There were 286 deaths in the trastuzumab arm, and 418 in the standard chemotherapy arm. Deaths from the
primary breast cancer occurred in 10.3% and 16.8%, respectively, and from a second primary cancer in 1.2% vs
2.0%.
Survival rates were comparable between ER- and/or PR-positive patients (HR, 0.61; 95% CI, 0.49 - 0.76) and
ER- and PR-negative patients.(HR, 0.64; 95% CI, 0.52 - 0.79).
NSABP B-31 and NCCTG N9831 were supported by the National Cancer Institute. Dr. Romond has disclosed
no relevant financial relationships. Dr. Isaacs reported that she is on the speaker's bureau of AstraZeneca.
35th Annual San Antonio Breast Cancer Symposium (SABCS): Abstract S5-5. Presented December 7, 2012.

Existing Breast Cancer Drugs May Help More Women

Charlene LainoDec 07, 2012
San Antonio, Texas — Current screening tests may miss as many as 1 in 50 women with breast cancer who
would benefit from treatment with highly effective breast cancer drugs.
At issue is HER2-positive breast cancer, an aggressive form of the disease that was difficult to treat until the
FDA approved the drugHerceptin in 1998. Herceptin revolutionized the treatment of HER2-positive breast
cancer, reducing the risk of recurrence and prolonging lives.
Since then, two other drugs, Tykerb and Perjeta, have been approved for the treatment of HER2-positive breast
cancer. Others are in the pipeline.
The new study involved 1,500 women found to be HER2-negative on routine HER2 testing. Genetic analysis
showed 25 had HER2 mutations.
"These mutations would be missed by current HER2 testing," says researcher Ron Bose, MD, PhD, of the
Washington University School of Medicine in St. Louis.
"As a result, the women would not receive potentially lifesaving treatment with HER2 targeted drugs," he says.
The findings were presented at the San Antonio Breast Cancer Symposium (SABCS) here and published online
in the journal Cancer Discovery.
HER2 Mutations
A patient must have more than the normal two copies of the HER2 gene to be classified as HER2-positive.
About 20% to 25% of women with breast cancer fall into this category. The excess HER2 drives tumor growth.
The HER2 mutations stimulate tumor growth in a different way. "Many turn on HER2 activity in an
inappropriate manner, which probably results in abnormal, unregulated HER2 signaling. This is likely driving
the cancer cell," Bose says.
The genetic analyses revealed that 1.5% to 2% of all breast cancer patients have these genetic mutations. With
about 230,000 new cases of breast cancer in the United States each year, even this modest percentage translates
into more than 4,000 patients per year.
Will HER2 Targeted Drugs Help?
In laboratory tests, Herceptin and Tykerb killed many of the mutant cells. Two mutations that were resistant to
Tykerb responded well to neratinib, an experimental anti-HER2 drug.
Some mutations were found to be "silent," meaning they did not drive tumor growth and therefore would likely
not respond to anti-HER2 drugs, Bose says.
Now the researchers have launched a study in which women will be screened for HER2 mutations. Those who
have the mutations will be given neratinib. Doctors will follow the women to see if the drug is effective and
safe.
Asked if the high cost of genetic analysis would prohibit its routine use, Bose says that it is increasingly being
used in other forms of disease, such as lung cancer.
If trial results show that attacking the newfound mutations can prevent recurrences and save lives, then gene
tests -- and their cost -- will quickly be accepted as part of the standard of care.
"In the future, we will probably be talking about panels of relevant genes that will need to be sequenced in
breast cancer," he says.
SABCS co-director Kent Osborne, MD, a breast cancer specialist at Baylor College of Medicine in Houston,
says he believes even more mutations that drive breast cancer growth will be discovered in coming years.
And it's likely the newly discovered mutations may promote growth of other types of tumors as well, he says.
Osborne says he would also like to see studies testing whether the anti-HER2 drugs already on the market
benefit women with the mutations.
SOURCES:
San Antonio Breast Cancer Symposium, San Antonio, Texas, Dec. 4-8, 2012.
Bose, R. Cancer Discovery, published online Dec. 7, 2012.
Ron Bose, MD, PhD, Washington University School of Medicine, St. Louis.
Kent Osborne, MD, Baylor College of Medicine, Houston.

Biomarker Search in CLEOPATRA Comes Up Short

Neil OsterweilDec 10, 2012
SAN ANTONIO, Texas — The best way to determine whether patients with HER2-positive breast tumors will
respond to therapy is to look at, well, HER2.
In an analysis of biomarkers predictive of response to therapy and prognostic of outcomes in patients with
HER2-positive metastatic breast cancer, researchers could not identify any that would allow better tailoring of
treatment than HER2 itself, reported José Baselga, MD, chief of the division of hematology/oncology at
Massachusetts General Hospital in Boston, here at the 35th Annual San Antonio Breast Cancer Symposium.
"Our analysis confirms that HER2 is the only marker for selecting patients for HER2-targeted therapy. This was
despite comprehensive exploration of a broad panel of candidate biomarkers," he said.
In this phase 3 trial of patients who were HER2-treatment-naïve, known as CLEOPATRA, the absence of a
control group could have caused the lack of a signal for other biomarkers, Dr. Baselga explained.
The CLEOPATRA trial compared 2 regimens in patients with HER2-positive metastatic breast cancer:
pertuzumab ( Perjeta, Genentech) and trastuzumab ( Herceptin, Genentech) plus docetaxel; and trastuzumab,
docetaxel, plus placebo. Progression-free and overall survival were significantly better with pertuzumab.
The researchers did not find predictive or prognostic biomarkers. They did determine that mutations in the PI3
kinase were associated with worse prognosis, although they did not confer resistance to pertuzumab (patients
derived benefit regardless of their PI3K status). In patients with wild-type PIK3CA, median overall survival was
longer in the pertuzumab group than in the control group (21.8 vs 13.8 months). In patients with PIK3CA
mutations, the difference in median overall survival was not as dramatic (12.5 vs 8.6 month).
"Based on these data, clinical trials of HER2-targeted molecules in combination with PI3K -pathway-targeted
agents may be justified," Dr. Baselga said.
Scanning Tissues and Serum
Dr. Baselga and colleagues pored over tissue and serum samples collected from patients in CLEOPATRA; they
performed assays using various technologies (e.g., immunohistochemistry, polymerase chain reaction). The
markers included HER2, IGF1R, PTEN, EGFR, and TGF-α.
In a predictive analysis conducted to determine qualitative associations between biomarkers and benefit from
pertuzumab, each biomarker showed that all patients benefited from the addition of pertuzumab to the regimen,
regardless of the level of expression of any of the biomarker candidates.
In a prognostic analysis of all treated patients, several significant prognostic variables, including HER2 protein (
P = .05), HER2 and HER3 messenger RNA, and PI3KCA mutations, were found. That is, patients with levels of
these markers and wild-type rather than mutated PI3KCA had better prognoses in analyses adjusted for each of
the candidate biomarkers.
Dr. Baselga said that the findings are consistent with those from the TRYPHAENA and NeoSphere studies.
Ian Krop, MD, PhD, from the Dana-Farber Cancer Institute in Boston, who was not involved in the study, noted
that other studies have found that PI3K mutations are associated with better prognoses, contrary to what was
found in CLEOPATRA.
"One of the reasons [PI3K mutation] is associated with good prognosis in many cancers is that it's associated
with other good prognostic features, such as ER positivity," he said.
Dr. Baselga said they did not look at associations between candidate biomarkers and other prognostic factors.
"It would be very interesting to get a set of HER2-positive tumors untreated and see how they behave [in
relation] to PI3 kinase mutational status," he said.
Dr. Baselga reports being a scientific advisory board member for Genentech. Dr. Krop reports serving as an
adviser and consultant to the company.
35th Annual San Antonio Breast Cancer Symposium (SABCS): Abstract S5-1. Presented December 7, 2012.

Pertuzumab for Breast Cancer Cleared for EU Approval

Zosia ChusteckaDec 14, 2012
Pertuzumab ( Perjeta, Roche) for breast cancer has just been given a go-ahead in the first step of the European
approval process.
The drug was given a positive opinion from the Committee of Medicinal Products for Human Use (CHMP),
which is a recommendation for marketing authorization. The next step is actual approval from the European
Commission.
Pertuzumab was approved in the United States earlier this year, costing approximately $188,000.
The indication for its use is rather narrow. Pertuzumab, a humanized monoclonal antibody directed against
HER2, is indicated for use with the first available HER2-targeted agent trastuzumab ( Herceptin, Roche), as
well as docetaxel, in patients with metastatic or locally recurrent unresectable HER2-positive breast cancer who
have not received previous HER2 therapy or chemotherapy for their metastatic disease.
According to the CHMP, the benefits of pertuzumab are its ability to improve progression-free survival, overall
survival, and objective response rate, compared with placebo.
These benefits were demonstrated in the phase 3 CLEOPATRA (Clinical Evaluation of Pertuzumab and
Trastuzumab) trial, first reported at the San Antonio Breast Cancer Symposium in 2011, as reported at the time
by Medscape Medical News, and later published in the New England Journal of Medicine (2012;366:109-119).
The most common adverse effects with pertuzumab are diarrhea, alopecia, leucopenia, and febrile neutropenia,
the CHMP notes.
The drug is expected to be expensive, which could cause problems with reimbursement in European countries.
In the United States, double HER2 treatment with pertuzumab plus trastuzumab costs about $180,000 per
course of therapy.

Carboplatin Yes, Bevacizumab No for Triple-Negative Breast Cancer

Neil Osterweil
December 13, 2013
SAN ANTONIO — Adding carboplatin to paclitaxel in the neoadjuvant setting for triple-negative breast
cancer significantly improves pathologic complete response (pCR) rates. So, for that matter, does adding
bevacizumab (Avastin) — somewhat.
The catch is that bevacizumab adds only an incremental benefit, does not have synergistic activity with
carboplatin, and is associated with significantly increased toxicities that could outweigh the benefit, said
William M. Sikov, MD, from the Warren Alpert Medical School of Brown University in Providence, Rhode
Island.
"Should carboplatin be routinely added to stage II or III triple-negative breast cancer? With the caveat...that we
do not have long-term results — I think if you're looking in the neoadjuvant setting, my answer to that question
would be yes," Dr. Sikov said in a media briefing prior to his presentation.
He explained that carboplatin improved the pCR rate, but it is not known if that will result in significant
improvement in recurrence-free or overall survival.
Although bevacizumab also increased the pCR rate, it came "at the cost of significant toxicities, and I don't
think it should be routinely added to neoadjuvant chemotherapy," he said.
Jeffrey B. Smerage, MD, PhD, a breast cancer specialist from the University of Michigan Comprehensive
Cancer Center in Ann Arbor, who was not involved in the study, told Medscape Medical News that "Dr. Sikov's
comments make a lot of sense to me."
He noted that the addition of carboplatin to a standard neoadjuvant regimen "clearly" showed evidence of an
increase in pCR.
Even without long-term data, the results are helpful to clinicians, he suggested.
Dr. Smerage explained that in the neoadjuvant setting, patients tend to have larger tumors, often have clinically
positive lymph nodes, and generally have higher risks at baseline.
"It's also a setting in which your goal is response. Maybe the goal is to allow a more effective surgery, even if
the surgery is going to be a mastectomy.... Maybe your goal is to be able to attempt a lumpectomy, where the
goal of that therapy is response but not necessarily prolonged progression-free survival," he said.
Tough Nut to Crack
Triple-negative breast cancers — so called because they lack the drug targets of estrogen, progesterone, and
HER2 receptors — comprise approximately 20% of breast cancers, and are more common in blacks, Hispanics,
younger women, and those with BRCA1 mutations.
Although there have been advances in chemotherapy in the adjuvant setting, patients with triple-negative
disease still have worse prognoses than patients with either estrogen-receptor-positive or HER2-positive tumors.
Median overall survival for patients with advanced triple-negative cancers is less than 1 year, Dr. Sikov said.
In the neoadjuvant setting, evidence of a benefit in women with triple-negative disease comes from a meta-
analysis presented at last year's SABCS (abstract S1-11). That study showed that 34% of patients had a pCR
with neoadjuvant chemotherapy and a better clinical course than women with similar tumors who had residual
disease going to surgery.
Dr. Sikov's team chose to study carboplatin for 2 reasons: its activity in patients with BRCA mutation-related
cancers, which are similar to sporadic triple-negative cancers in several respects; and the high pCR rates in pilot
studies in which carboplatin was added to standard chemotherapy in patients with triple-negative tumors.
2 × 2 Design
The CALGB 40603 study was a randomized phase 2 trial with a 2 × 2 randomization scheme in which all
patients received paclitaxel 80 mg/m² weekly for 12 weeks, plus 1 of 3 treatments: bevacizumab 10 mg/kg
every 2 weeks for 9 cycles; carboplatin to the area under the curve (AUC) 6 every 3 weeks for 4 cycles; or
both carboplatin and bevacizumab.
All patients went on to dose-dense chemotherapy with doxorubicin and cyclophosphamide for 4 cycles.
The trial was designed to look at pCR rates in the breast and axilla, but was not powered to compare individual
treatment groups or to detect differences in recurrence-free or overall survival, Dr. Sikov noted.
A total of 443 patients were enrolled, and 427 went on to surgery and were included in the pCR analysis. (Dr.
Sikov explained that progression-free and overall survival will be reported at a later date.)
Rates of pCR in the breast were lower in patients who did not receive carboplatin than in those who did (46% vs
60%). The odds ratio (OR) for carboplatin was 1.76 (P = .001).
Rates of pCR in the breast were also lower in patients who did not receive bevacizumab than in those who did
(48% vs 59%). The OR for the angiogenesis inhibitor was 1.58 (P = .0089).
However, there was no evidence of a synergistic interaction between the carboplatin and bevacizumab, the
investigators found.
Looking at pCR in the breast and axillary lymph nodes, they again saw an effect on pCR in women treated with
carboplatin, compared with those who were not (41% vs 54%). The OR for carboplatin in the breast/axilla was
1.71 (P = .0029). The same pattern was seen with bevacizumab (44% vs 52%). The OR was 1.36, but it just
missed being statistically significant (P = .057)
Again, the investigators saw no evidence of synergy in the effect of the drugs on pCR in the breast and axilla
combined.
Bevacizumab in this study was also associated with increases in grade 3 toxicities, including hypertension,
febrile neutropenia (especially with carboplatin), serious infections despite a normal absolute neutrophil count,
bleeding, and thromboembolic and surgical complications.
"We await results of correlative studies, including subtype analysis, to see if we can identify markers of
response or resistance to standard neoadjuvant chemotherapy, as well as to the addition of carboplatin or
bevacizumab," Dr. Sikov said.
The study was funded by the National Cancer Institute, Genentech, and the Breast Cancer Research
Foundation. Dr. Sikov and Dr. Smerage have disclosed no relevant financial relationships.
36th Annual San Antonio Breast Cancer Symposium (SABCS): Abstract S5-01. Presented December 13, 2013.

New Presurgery Treatment Combination More Effective for Women With

Triple-negative Breast Cancer
San Antonio Breast Cancer Symposium, 2013 Dec 13 News December 16, 2013
SAN ANTONIO — Adding the chemotherapy drug carboplatin and/or the antibody therapy bevacizumab to
standard presurgery chemotherapy increased the number of women with triple-negative breast cancer who had
no residual cancer detected at surgery, according to results of a randomized, phase II clinical trial presented here
at the 2013 San Antonio Breast Cancer Symposium, held Dec. 10–14.
An increasing number of patients with triple-negative breast cancer are receiving chemotherapy before surgery,
a treatment approach called neoadjuvant chemotherapy. In about one-third of these patients, no identifiable
cancer cells are found in breast tissue and lymph nodes removed at surgery performed after the neoadjuvant
chemotherapy. These patients are said to have had a pathologic complete response and have a much lower risk
of cancer recurrence compared with patients whose cancers do not respond this well to the neoadjuvant
chemotherapy.
“Our study was designed to find out if adding either carboplatin or bevacizumab to standard preoperative
chemotherapy would increase the percentage of patients in whom cancer is eliminated before surgery,” said
William M. Sikov, M.D., F.A.C.P., associate professor of medicine at the Warren Alpert Medical School of
Brown University in Providence, R.I. “We are excited to report that adding either therapy significantly
increased the percentage of patients in whom cancer was eliminated from the breast, and that adding both was
even more effective.
“While our results show increases in pathologic complete response rates with both carboplatin and
bevacizumab, we do not yet know how large an impact, if any, these differences will have on cancer recurrences
or deaths. Although the study is not large enough to detect significant differences in these endpoints, we plan to
follow patients for 10 years after their surgery to see if patient outcomes suggest long-term benefits from the
investigational treatments.”
Sikov and colleagues treated 443 patients with operable, stage 2 or 3 triple-negative breast cancer in the
randomized, phase II clinical trial. The study was conducted by the Cancer and Leukemia Group B, which is
now part of the Alliance for Clinical Trials in Oncology, and is called CALGB/Alliance 40603. Patients were
randomly assigned to standard neoadjuvant chemotherapy, standard neoadjuvant chemotherapy plus
carboplatin, standard neoadjuvant chemotherapy plus bevacizumab, or standard neoadjuvant chemotherapy plus
carboplatin and bevacizumab. Surgery was performed from four to eight weeks after the completion of
neoadjuvant treatment.
The researchers found that among the 108 patients who were randomly assigned to standard neoadjuvant
chemotherapy alone, at surgery, cancer had been eliminated from the breast in 42 percent of these patients and
from both the breast and lymph nodes in 39 percent. These proportions increased to 50 percent and 43 percent,
respectively, for the 110 patients who were randomly assigned to standard neoadjuvant chemotherapy plus
bevacizumab; 53 percent and 49 percent, respectively, for the 113 patients who were randomly assigned to
standard neoadjuvant chemotherapy plus carboplatin; and 67 percent and 60 percent, respectively, for the 112
patients who were randomly assigned to standard neoadjuvant chemotherapy plus carboplatin and bevacizumab.
The increases in the pathologic complete response rates in the breast and in the breast and lymph nodes
observed among patients randomly assigned to standard neoadjuvant chemotherapy plus carboplatin were
statistically significant. Among patients randomly assigned to standard neoadjuvant chemotherapy plus
bevacizumab, only the increase in the pathologic complete response rate in the breast met the study’s criteria for
significance.
“Patients who were treated with carboplatin had more problems with low blood counts and were more likely to
miss doses of chemotherapy or to have their chemotherapy treatments delayed or the doses of the chemotherapy
drugs reduced compared with patients who did not receive carboplatin,” said Sikov. “In addition, about 10
percent of patients who were treated with bevacizumab developed high blood pressure and more of these
patients had problems with blood clots, bleeding, and infections.”
This study was funded by the National Institutes of Health, Genentech, and the Breast Cancer Research
Foundation. Sikov declares no conflicts of interest.
###
The mission of the 2013 San Antonio Breast Cancer Symposium is to produce a unique and comprehensive
scientific meeting that encompasses the full spectrum of breast cancer research, facilitating the rapid translation
of new knowledge into better care for patients with breast cancer. The Cancer Therapy & Research Center
(CTRC) at The University of Texas Health Science Center at San Antonio, the American Association for Cancer
Research (AACR), and Baylor College of Medicine are joint sponsors of the San Antonio Breast Cancer
Symposium. This collaboration utilizes the clinical strengths of the CTRC and Baylor and the AACR’s
scientific prestige in basic, translational, and clinical cancer research to expedite the delivery of the latest
scientific advances to the clinic. For more information about the symposium, please visit www.sabcs.org.
Publication Number: S5-01
Presenter: William M. Sikov, M.D., F.A.C.P., associate
Title: Impact of the addition of carboplatin (Cb) and/or bevacizumab (B) to neoadjuvant weekly paclitaxel (P)
followed by dose-dense AC on pathologic complete response (pCR) rates in triple-negative breast cancer
(TNBC): CALGB 40603 (Alliance)
Authors: William M Sikov1, Donald A Berry2, Charles M Perou3, Baljit Singh4, Constance Cirrincione5, Sara
Tolaney6, Charles S Kuzma7, Tim J Pluard8, George Somlo9, Elisa Port10, Mehra Golshan6, Jennifer R
Bellon6, Deborah Collyar11, Olwen M Hahn12, Lisa A Carey3, Clifford Hudis13 and Eric P Winer6. 1Miriam
Hospital and Alpert Medical School of Brown University, Providence, RI; 2University of Texas M.D. Anderson
Cancer Center, Houston, TX; 3UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC; 4New York
University Medical Center, New York, NY; 5Alliance Statistical Center, Durham, NC; 6Dana Farber Cancer
Institute, Boston, MA; 7Southeast Cancer Control Consortium, Winston-Salem, NC; 8Washington University-
St. Louis Medical Center, St. Louis, MO; 9City of Hope Comprehensive Cancer Center, Duarte, CA; 10Mount
Sinai Medical Center, New York, NY; 11Patient Advocates in Research, Danville, CA; 12University of Chicago
Medical Center, Chicago, IL and 13Memorial Sloan-Kettering Cancer Center, New York, NY.
Background: Anthracycline- and taxane-based neoadjuvant chemotherapy (NAC) results in a pCR in 30-35%
of TNBC patients (pts), which is associated with improved recurrence-free and overall survival (RFS/OS).
Thus, pCR rates may be useful in evaluating novel regimens in TNBC. In advanced TNBC, platinum analogues
like Cb are active and addition of B to chemotherapy increases response rates and time to progression. CALGB
40603 is a 2x2 randomized phase II study designed to determine if the addition of either Cb or B to standard
NAC significantly increases pCR rates in TNBC.
Methods: Pts had operable clinical stage II-III TNBC, defined as hormone receptors <10% and HER2 IHC 0-
1+ or FISH Results: 454 pts enrolled, median age 48, stage II 68%/stage III 32%. Of 354 pts with treatment
data, 59 did not complete NAC, 30 withdrew due to AEs, more often with B vs. not (11.5% vs. 3.5%). B was
discontinued in 23% of assigned pts vs. 6-13% for other agents. Grade 3-4 neutropenia (56% vs. 20%) and
thrombocytopenia (22% vs. 4%) were more common with Cb vs. not, while grade 3 hypertension was more
common with B vs. not (11% vs. <1%). Febrile neutropenia, usually during ddAC, was more common in pts
who received both Cb and B (19% vs. others 7%). Unaudited pCR results for the first 369 pts, with effects
reported as increments in pCR (95% CI), assuming no interaction, are as follows: pCR (breast) pCR
(breast/axilla) No Cb Cb B effect No Cb Cb B effect No B 30/89 33.7% 44/94 47.8% 14.9% (4.8-25.0%) 25/89
28.2% 39/92 42.4% 10.5% (0.5-20.5%) B 48/94 51.1% 57/94 60.6% p=0.004 40/94 42.6% 47/94 50.0%
p=0.031 Cb effect 11.7% (1.6-21.8%) p=0.022 10.3% (0.3-20.3%) p=0.034 There is no evidence of an
interaction between the effects of Cb and B (p=0.64 and 0.44, for breast and breast/axilla, respectively).
Conclusions: Preliminary results suggest that adding Cb or B to standard NAC significantly increases pCR
rates in stage II-III TNBC. These increases are additive, with pCR (breast) in 60.6% and pCR (breast/axilla) in
50% of pts who received both. Complete and confirmed results will be reported, including pCR rates for basal-
like tumors vs. not. Pts will be followed for RFS/OS to assess the impact of pCR on these endpoints. Conduct of
the trial was supported by grants from the NIH (ACTNOW and CA31946/CA33601), Genentech and the BCRF.
Clinical trial information: NCT00861705.

GSK Stops Tykerb-Only Arm of Late-Stage Breast Cancer Trial

LONDON (Reuters) Sep 09 - Breast cancer patients in a phase III trial will stop getting GlaxoSmithKline's
Tykerb (lapatinib) alone after an independent committee decided the drug was likely to produce worse results
that Roche's Herceptin (trastuzumab).
The British drugmaker said the other three arms of the trial -- which is designed to examine the performance of
Tykerb in combination with Herceptin -- would continue as planned.
"The (independent data monitoring) committee has indicated that the lapatinib alone arm is unlikely to meet the
pre-specified criteria to demonstrate non-inferiority to trastuzumab alone with respect to disease-free survival,"
GSK said in a statement on Friday.
Tykerb is marketed as Tyverb in Europe. Both it and Herceptin are designed for women with HER2-positive
breast cancer and are given alongside standard chemotherapy.
Patients in this trial, known as ALTTO, were originally randomized to receive either Tykerb alone, Herceptin
alone, Herceptin followed by Tykerb, or a combination of the two drugs together.
GSK said patients assigned to the lapatinib alone arm of the trial would discontinue the drug and discuss
treatment options with their doctors
Reuters Health Information © 2011

Standardized Assessment of the HER2 Status in Breast Cancer by

Immunohistochemistry
David G. Hicks, MD; Linda Schiffhauer, MDPosted: 08/09/2011; Laboratory Medicine. 2011;42(8):459-
467. © 2011 American Society for Clinical Pathology
Abstract
Immunohistochemistry (IHC) is widely used in surgical pathology, but it has been plagued by problems with
reproducibility and lack of standardization resulting in poor concordance between laboratories. In particular,
inaccuracy of routine human epidermal growth factor receptor 2 (HER2) testing in breast cancer patients has
been a major issue. In 2006 this led the American Society of Clinical Oncologists (ASCO) and College of
American Pathologists (CAP) to charge an expert panel with developing recommendations for HER2 testing.
After subsequent publication and adoption of these guideline recommendations through dissemination of best
practices, variation in clinical practice is expected to diminish and result in improved accuracy.In this article, we
review the role of genomic HER2 alterations in the development and treatment of breast cancer, highlight the
importance of accurate and reproducible HER2 testing, and discuss practical approaches to standardize HER2
testing by IHC. Pre-analytic and analytic variables are addressed, and a practical algorithm for test
interpretation is introduced.
Introduction
Published data from clinical trials suggest that only those breast cancer patients whose tumors demonstrate
HER2 protein over-expression and/or gene amplification are likely to benefit from targeted therapy with
trastuzumab.[1] Since breast cancer is a disease with significant clinical diversity, an individualized approach to
management and treatment decisions for each patient is necessary.[2] A major clinical challenge is correctly
identifying patients who would potentially benefit from adjuvant treatments, which would include
chemotherapy, endocrine therapy, and also targeted therapy for patients with human epidermal growth factor
receptor 2 (HER2)-positive disease. In current clinical practice, breast cancer biomarkers, including the estrogen
receptor (ER) and HER2, are routinely assessed to help select patients who are appropriate candidates for
treatment regimens that target these major molecular pathways of disease progression.[3] However, the
identification of patients who are likely to benefit from these targeted approaches remains challenging and
requires that the assays for these biomarkers be as accurate as possible, given their role in determining optimal
treatment.[4,5] This review will focus on standardizing the immunohistochemical evaluation of HER2 protein
expression in order to help ensure accurate and reproducible results.
Breast Cancer and the HER2 Genomic Alteration
Among new breast cancer patients, 15% to 20% will develop tumors that harbor a genomic alteration involving
the HER2 gene locus. This alteration results in amplification of the region on chromosome 17 containing this
proto-oncogene.[6] The protein product of the HER2 gene is a member of the HER-family of growth factor
receptors involved in the complex regulation of proliferation, cell growth, and survival. Gene amplification is an
early event in tumor development for this subset of breast cancers, drives HER2 gene and protein expression,
and results in a marked increase in the number of HER2 receptor molecules at the membrane of tumor cells.
The profuse over-expression of HER2 promotes dimerization of members of the HER-receptor family and
activation of intracellular signaling cascades that drive cellular proliferation, promote angiogenesis, and
enhance cell survival pathways, directly contributing to a more aggressive tumor biology and clinical behavior.
[7]

HER2 as a Target for Therapy in Breast Cancer

HER2 over-expression in breast cancer represents an ideal target for therapy, given the location of the receptor
on the surface of tumor cells and its role in driving the clinical course of the disease. Trastuzumab was
developed as a targeted biologic therapeutic against the HER2 receptor protein. Trastuzumab is a humanized
monoclonal antibody that combines the mouse recognition sequence of a monoclonal antibody (clone 4D5)
against an extracellular epitope of the receptor with a human IgG1. Trastuzumab demonstrates a high affinity
and specificity for the HER2 receptor and in preclinical studies was shown to be effective at inhibiting the
growth of HER2 over-expressing breast cancer cells.
In numerous clinical trials, HER2-targeted therapy has been shown to be remarkably effective against HER2-
positive breast cancer in both the metastatic and the adjuvant settings, particularly in combination with
cytotoxic chemotherapy. Recent clinical trials data have demonstrated that adjuvant trastuzumab in combination
with or following chemotherapy can reduce the relative risk of recurrence by up to 50% in early stage HER2
positive breast cancer.[8,1] The clinical efficacy of HER2 targeted therapy in selected patients with HER2-
positive breast cancer provides the rationale for testing all newly diagnosed breast cancer patients for the HER2
genomic alteration and/or over-expression of the receptor protein.
Clinical assays to assess the HER2 status include immunohistochemistry (IHC), which detects protein over-
expression, or fluorescence in situ hybridization (FISH), which detects gene amplification.[3] Both assays have
been clinically validated in prospective randomized clinical trials and have received Food & Drug
Administration (FDA) approval for predicting a clinical response and patient benefit from HER2-targeted
treatment. Since published data suggest that only those breast cancer patients whose tumors demonstrate protein
over-expression and/or gene amplification by the above assays are likely to benefit from therapy with
trastuzumab,1 the results of HER2 assays stand alone in determining which breast cancer patients will be the
most appropriate for HER2-targeted therapy. Therefore, accurate, reliable, and reproducible results are a high
priority for ensuring optimal patient treatment.
IHC vs Fish for HER2 Evaluation: Complementary Approaches
The IHC and FISH methodologies for evaluating the HER2 status in breast cancer should be considered
complementary in nature.[3] These tests examine different aspects of the biology underlying HER2-driven breast
tumors. Fluorescence in situ hybridization evaluates the status of the HER2 gene in the nucleus, while IHC
evaluates over-expression of the receptor protein at the surface of the cell. In the majority of HER2-positive
cancers, HER2 protein over-expression is the result of gene amplification, thus HER2 gene/protein status should
be highly correlated in most cases. Consequently, HER2 gene/protein discordant results are most commonly due
to technical issues. However, unusual HER2 genotypes, such as polysomy for chromosome 17 and genomic
heterogeneity, can lead to discrepant non-correlating cases that may be clinically important.[9,10] For such cases,
the assessment of both the gene and the protein may be necessary in order to sort out the most appropriate
HER2 status for the purpose of determining therapy.
The ASCO/CAP task force, in developing recommendations for HER2 testing, concluded that both tests were
equally efficient in identifying patients who are candidates for HER2-targeted therapy. In addition, the assays
must be properly validated, and all aspects of the test are performed in a highly standardized fashion with good
quality control.[11]
Standardizing HER2 IHC Testing: Pre-analytic Variables
Tissue Handling
The growing importance of molecular pathology and the use of biomarkers in clinical medicine have led to an
increasing emphasis on optimal tissue preparation for these assays.[12] An important variable in the analysis of
macromolecules, including proteins, RNA, and DNA, is the time interval between the surgical interruption of
blood flow by the surgeon to the initiation of tissue fixation. This interval has been termed the ischemic time.
Numerous studies have documented tissue ischemia, acidosis, and enzymatic degradation during this interval,
leading to the progressive loss of these macromolecules.[13] These deleterious effects terminate when the tissue
sample is placed into formalin and chemical fixation begins. Thus, an excessive time delay before tissue
fixation is begun has the potential to reduce the efficacy of analysis of clinically important protein and nucleic
acid target molecules in these tissue samples.[14] The emerging data for breast cancer specimens suggest that
delays as short as 1 to 2 hours can begin to compromise assay validity for ER, progesterone receptor (PR), and
HER2.[14] Every effort should be made to transport breast excision samples from a patient having a documented
or suspected cancer from the operating room to the pathology laboratory as soon as possible for an immediate
gross assessment. The success of such efforts will require better communication and cooperation between
surgeons, the operating room staff, and the pathology laboratory.[15]
Upon receipt in the pathology laboratory, the specimens must be oriented, carefully inked for surgical margin
assessment, sliced into sections at 2 to 5 mm intervals, and placed into formalin. If gross tumor is easily
identifiable, a small portion of tumor and fibrous normal breast tissue can be placed together in the same
cassette and put immediately into fixative at the time of the initial gross evaluation.[4] This helps to initiate good
tissue fixation and also ensures that normal breast elements are available as an internal positive control and have
been handled and fixed identically to the tumor tissue.
Tissue Fixation
The only fixative for breast tissue samples that has been clinically validated for ER and HER2 testing is 10%
phosphate buffered formalin. This is based on both the collective body of knowledge in the published literature
and the outcomes of numerous clinical trials that have correlated outcomes with the expected or characteristic
immunoreactivity of ER and HER2.[4,16] In addition, the FDA approval for assay kits analyzing ER, PR, and
HER2 explicitly state that 10% phosphate buffered formalin fixation should be used. The FDA approval for the
kits is invalid if an alternative fixative is used.
Fixation Time
Breast tissue samples must be fixed in 10% neutral buffered formalin for no less than 6–8 hours and for not
more than 72 hours before processing, according to published testing guidelines.[5] Formalin is aqueous,
completely dissolved formaldehyde. Because formalin penetrates tissue at an approximate rate of 1 mm/hour,
breast excision samples must be cut into slices in a timely fashion to initiate formalin infiltration and uniform
chemical fixation throughout the tissue. Tissue placed into formalin without cutting into sections will not be
exposed to formalin in a timely fashion and will remain ischemic until penetration by the fixative. The chemical
reaction of fixation involves protein cross-linking by formaldehyde, which is a time-dependent reaction. The
amount of time the tissue is exposed to formalin affects the degree of protein cross-linking, and this in turn will
affect the amount of antigen retrieval necessary for proper assay performance.[16] The use of standard IHC
assays and antigen retrieval protocols with under- or over-fixed tissue may lead to technical problems in
performing the assay and have the potential for yielding false-negative or even false-positive test results,[16,17]
which could alter adjuvant treatment decisions and adversely affect outcome.
Needle Core Biopsies vs Breast Excision Specimens
There is a misconception that smaller biopsy samples will fix more quickly than larger resection specimens and
therefore require less time in formalin. Formalin will penetrate more quickly into these smaller samples;
however, small biopsy samples require the same amount of fixation time as larger resection samples, because
chemical fixation requires adequate time for protein cross-linking to take place.[18] Similarly, larger resection
specimens need to be incised in a timely manner to ensure adequate penetration of formalin so the chemical
reaction of fixation can be completed.
A number of studies comparing ER/PR and HER2 IHC assays on needle core biopsies and resection specimens
from the same patient have suggested that the needle core may be a better tissue sample for testing by IHC
because these tissues are usually placed in formalin in a more timely fashion, will infiltrate more quickly
because of their size, and therefore may receive more consistent tissue fixation.[18] This conclusion assumes
these tissues have all received an adequate time in formalin fixative and the lesion has been adequately sampled
and is representative of the patient's tumor. Needle core biopsies can be problematic for HER2 evaluation as
they may be prone to certain artifacts that can make interpretation difficult. These include problems such as
edge effect (concentration of staining at the edge of the tissue profile) and crush artifacts. An awareness of these
artifacts is important so aberrant staining is not over-interpreted. Furthermore, patients with a negative HER2
assay result on a needle core biopsy should have the HER2 assessment of their tumor repeated on the excision
tissue sample if there is a clinical profile suspicious for HER2 positive disease.
Standardizing HER2 IHC Testing: Analytic Variables
HER2 Assay Selection
Many laboratories use a HER2 testing algorithm in which breast tumor samples are screened by IHC, and FISH
testing is reflexively performed only on cases scored as equivocal or 2+.[19] Other laboratories utilize primary
FISH testing for HER2. Either approach is acceptable, provided the tests are properly validated, performed, and
interpreted. The HER2 testing algorithm assumes that IHC assays are standardized, have rigorous quality
control, good concordance with FISH results, and good inter-laboratory agreement. The use of FDA-approved
test kits containing well-standardized, high-quality reagents of known specificity and sensitivity are
recommended to help ensure accurate and consistent results.
Technical Validation
The ASCO/CAP guidelines11 require a HER2 IHC test be validated before it can be offered clinically by a
laboratory. Validation is performed by testing 25–100 samples that have been fixed in formalin using the
standardized operating procedure for the laboratory, and then tested in parallel by an alterative method (FISH if
validating IHC) using a previously validated assay in either the same laboratory or in another laboratory. The
concordance between the 2 methods or laboratories must be at least 95% for both HER2 positive and HER2
negative test results.
Routine Use of Controls for IHC Testing
Positive and negative controls should be run with every assay to help ensure proper assay performance. Daily
evaluation of control material including known negative, equivocal and positive clinical samples, or cell line
controls can be used to monitor for assay drift and inadequate assay performance. Commercially available
HER2 IHC test kits contain formalin-fixed paraffin embedded breast cancer cell lines expressing different levels
of HER2 that can be used as a batch control (Image 1). These batch controls help to ensure proper assay
performance and to calibrate the appropriate assay sensitivity and dynamic range for each staining run. In
addition, the inclusion of a sample of tumor known to be HER2 positive on the same slide as the test sample
will help to ensure that all reagents were dispensed onto the slide and the assay is performing properly for the
test sample (Image 2).
Image 1. Formalin-fixed Paraffin Embedded Breast Cancer Cell Lines. The commercially available FDA-
approved HER2 IHC Hercep Test kit contains 3 FFPE breast cancer cell lines showing different levels of HER2
protein expression. (A): The cell line MDA-231 will express 21,600 ± 6700 copies of the HER2 receptor on the
surface of these tumor cells, which is below the level of sensitivity of this IHC assay; thus the cells should
appear negative for HER2 protein. (B): The cell line MDA-175 will express 92,400 ± 12,000 copies of the
HER2 receptor on the surface of these tumor cells and will show partial weak membrane staining (arrow) for
HER2. (C): The cell line SK-BR-3 will express 2,390,000 ± 1,000,000 copies of the HER2 receptor on the
surface of these tumor cells and will show thick, circumferential uniform membrane staining (arrow). The
intensity of the distribution of the staining with each of these cell lines correlates with the number of receptor
molecules on the surface of the cells.
Test Interpretation for HER2 IHC
The pathologist's critical evaluation of a HER2 assay plays an important role in determining the selection of the
most appropriate adjuvant treatment regimen for the breast cancer patient. This evaluation requires proper
training and experience in HER2 IHC analysis, strict criterion for interpreting the results of the test, and a broad
equivocal category for cases that are not clearly positive or negative. A diagnostic algorithm for the evaluation
of HER2 IHC assay results is shown in Figure 1. The critical evaluation of a HER2 IHC assay begins with a
review of the batch controls and the on-slide positive control to help ensure proper assay performance. The slide
of the patient sample of tissue should be scanned to help ensure an invasive tumor is easily identifiable and
there is no significant HER2 staining present within normal breast epithelial cells. Staining of adjacent normal
breast tissue elements (with the exception of apocrine metaplasia) suggests the assay is too sensitive and the
results for the invasive tumor should be considered inadequate for interpretation. The test should be repeated on
another block of the patient's tumor if possible.
When the controls are in order and the normal breast elements are negative, then the invasive portion of the
patient's breast tumor sample can be further evaluated for HER2 expression. The scoring of HER2 results
assessed by IHC must be semi-quantitatively evaluated to be clinically relevant. Human epidermal growth
factor receptor 2 IHC tests are all interpreted as positive (3+), negative (0-1+), equivocal (2+), or inadequate for
accurate interpretation.
Positive Result for HER2 IHC
Only cases with a diffuse intense circumferential membrane "chicken-wire" staining pattern in >30% of the
tumor (scored as 3+) should be considered HER2 positive by IHC. For the typical HER2-positive case, the
chicken-wire pattern of staining is readily identified at low power (×10) and is seen diffusely throughout the
areas of an invasive tumor (Image 3). Tumors with this staining pattern show a good concordance with gene
amplification by FISH in the vast majority of cases, and these patients will be the most likely to benefit from
HER2-targeted therapy. Higher grade poorly differentiated breast cancers, which tend to occur in younger
patients, are more likely to be HER2 positive.

Image 3. HER2-positive Breast Cancer by IHC (3+). (A): Poorly differentiated invasive carcinoma arising
in a 40-year-old female is suspicious for HER2-positive disease given the patient's age and histologic grade
(hematoxylin and eosin stained [H&E] section, ×200 original magnification). (B): The HER2 IHC assay shows
a diffuse intense circumferential membrane "chicken-wire" staining pattern throughout the tumor (scored as
3+), consistent with HER2-positive breast cancer by IHC (DAKO Hercep Test, ×200 original magnification).
Negative Result for HER2 IHC
Breast tumors with absent or weak membrane staining (scored as 0 or 1+, Image 4) typically demonstrate a
normal HER2 gene status and are regarded as negative. Tumors with this staining pattern show a good
concordance with an absence of amplification by FISH in the vast majority of cases, and these patients will be
unlikely to benefit from HER2-targeted therapy. Lower grade well differentiated breast cancers are more likely
to be HER2 negative. Less than 1% of grade 1 breast tumors will show evidence of HER2 gene amplification
and receptor over-expression.

Image 4. HER2-negative Breast Cancer by IHC (1+). (A): Classic invasive lobular carcinoma arising in a
77-year-old female has a characteristic "single-file" growth pattern and would unlikely be HER2 positive. (B):
The HER2 IHC assay shows faint, partial membrane staining (scored as 1+), consistent with HER2-negative
breast cancer by IHC (DAKO Hercep Test, ×200 original magnification). The pattern and intensity of the
staining is best appreciated at lower magnifications.
Equivocal Result for HER2 IHC
Breast tumors with circumferential membrane staining showing a thin pattern of staining and/or heterogeneity
in staining distribution (<30% of tumor cells) should be scored as equivocal (scored as 2+, Image 5). In
correlative studies, equivocal HER2 IHC staining has shown poor agreement with HER2 FISH and is
considered inconclusive. Breast tumors with an equivocal HER2 IHC result need to be reflexively tested by
FISH to assess for HER2 gene amplification, in an attempt to resolve the HER2 status of the tumor for clinical
decisions on adjuvant therapy. If the tumor shows isolated groups, clusters, or single cells with strong HER2
membrane staining, this may represent genomic heterogeneity for HER2 gene locus resulting in a composite of
HER2-positive and HER2-negative tumor cells. Use of the IHC stained slide to target the cells with protein
over-expression for HER2 FISH analysis is a good way to confirm HER2 genomic heterogeneity and ensure an
accurate assessment of the HER2 status. At present, the clinical significance of this finding in terms of the
potential benefit from trastuzumab therapy is unclear, but the report should contain a comment describing these
findings.

Image 5. HER2-equivocal Breast Cancer by IHC (2+). (A): Poorly differentiated invasive carcinoma arising
in a 49-year-old female is also suspicious for HER2-positive disease given the patient's age and histologic grade
(H&E stained section, ×200 original magnification). (B): The HER2 IHC assay shows areas of circumferential
membrane staining (arrow) with varying intensity that is not seen throughout the tumor (scored as 2+ or
equivocal) (DAKO Hercep Test, ×200 original magnification). A reflex FISH assay was ordered, and it showed
that the HER2 gene was amplified (HER2/CEP17=5.[2]).
Inadequate for Interpretation and Exclusion Criterion
Needle core biopsies with limited invasive tumor, edge artifact, or significant crush artifact should be
approached with caution and may not be able to be accurately interpreted. For instance, focal strong staining is
sometimes seen along tissue edges or in regions where tissue is disrupted due to an unequal distribution of assay
reagents. Also, crush artifact can be produced when thin gauge vacuum extracted needles are used for sampling.
These artifacts and regions should be ignored during assay interpretation to avoid false-positive results and
inappropriate therapy with trastuzumab. In addition, assays with strong membrane staining of normal ducts and
lobules should be excluded from interpretation, since this may represent either inadequate fixation or a technical
error, such as an inappropriate antibody dilution. Results should always be reported in the context of appropriate
positive, negative, equivocal, internal, and external controls run with each assay. A list of potential exclusion
criterion for the interpretation of a HER2 IHC result is shown in Table 1. For each of these situations, the results
 of the HER2 IHC test should be interpreted with caution, and consideration should be given to repeating the test
on a different sample or sending the block for HER2 FISH testing.
Table 1. Exclusion Criterion for the Interpretation of HER2 IHC
 Excessive time delays from tissue sample collection to the initiation of formalin fixation (time from
tissue collection to fixation ideally should be approximately 1 h or less; see reference 5. A tracking mechanism
may need to be put into place to ensure proper tissue handling).
 Tissue samples fixed for less than a minimum of 6–8 h in neutral buffered formalin.
 Tissue samples fixed for greater than 72 h in neutral buffered formalin.
 Tissue samples fixed in an alternative fixative other than formalin, unless that process has been
specifically validated by the laboratory.
 Tissue samples with only ductal carcinoma in situ and no invasive carcinoma.
 Tissue samples on unstained slides stored for >6 weeks prior to testing.
 Tissue samples, particularly needle biopsies, with significant crush artifact and/or edge artifact.
 Tissue samples with significant staining of normal breast elements within the tissue.
Critical Evaluation of HER2 Assay Results
Before a final HER2 determination is reported, the interpreting pathologist should critically review all aspects
of the test to ensure the information is as accurate as possible. Clinical breast tissue samples that do not meet the
pre-analytical requirements for the test should be interpreted with caution, and consideration should be given to
further testing on a different sample, a different block, or by an alternative methodology. In addition, the
patient's HER2 test result should fit or correlate with the clinical profile of the tumor. In a retrospective review
of more than 1000 consecutive HER2 assays, HER2-positive disease correlated with younger age at diagnosis,
ER negative results, axillary lymph node metastasis, lymphatic invasion, and high-grade histology.[20] In multi-
variant analysis, high histologic grade and younger patient age were found to be significant independent
predictors of HER2 positivity. Patients with a clinical profile of HER2-positive breast cancer may benefit from
FISH testing when their IHC results are negative.
Conclusions
The assessment of HER2 status in breast cancer is critical for the management of disease and therefore a
priority for pathological standardization. The selection of the most appropriate adjuvant treatment regimen,
including whether the patient is a candidate for HER2-targeted therapy, is heavily dependent on reliable and
accurate laboratory results assessing the HER2 status as part of their diagnostic evaluation.
The IHC and FISH methodologies are acceptable for determining the HER2 status of newly diagnosed breast
cancer as long as the assays have been properly validated through a multi-step process involving selection and
acquisition of equipment and reagents, training, and parallel testing of 25–100 cases to achieve at least 95%
concordance with another validated assay offered in the same lab or another lab. Quality controls must be in
place and continuously monitored. Immunohistochemistry and FISH both have technical and interpretive
challenges that require experience and training to help ensure accurate results. In addition, these tests are
complementary; examining different aspects of the biology underlying HER2-driven breast cancer, and in some
cases, both may be needed to help ensure the most accurate result for determining treatment.
Regardless of the methodology, the ancillary testing of newly diagnosed breast cancer for predictive biomarkers
such as ER and HER2 should reflect a consensus between the clinicians caring for these patients and the
pathology laboratory. Among the most important lessons learned from using HER2 testing is the need for
standardization of all parameters of testing, and this applies equally to IHC and FISH assays. This
standardization includes all aspects of pre-analytical tissue-sample handling, the type and duration of fixation,
tissue processing, assay performance, interpretation, and reporting. Rigorous standardization may be a challenge
for many institutions, but it will be necessary to ensure optimum patient care.
It follows that a commitment to reliable and reproducible test results is essential for any laboratory performing
HER2 determinations. Rigorous standardization will in all likelihood help improve the accuracy, reliability, and
reproducibility of these assays as well as concordance rates between IHC and FISH results. These steps will
help to provide the best possible information to treating clinicians and will ultimately result in selecting the
most appropriate treatment regimen for patients diagnosed with breast cancer.
Targeting Triple-Negative Breast Cancer Cells With the Histone Deacetylase Inhibitor
Panobinostat
Chandra R Tate; Lyndsay V Rhodes; H Chris Segar; Jennifer L Driver; F Nell Pounder, Matthew E Burow;
Bridgette M Collins-Burow
Posted: 07/27/2012; Breast Cancer Res. 2012;14(3):R79 © 2012 BioMed Central, Ltd.
Abstract and Introduction
Abstract
Introduction Of the more than one million global cases of breast cancer diagnosed each year, approximately
fifteen percent are characterized as triple-negative, lacking the estrogen, progesterone, and Her2/neu receptors.
Lack of effective therapies, younger age at onset, and early metastatic spread have contributed to the poor
prognoses and outcomes associated with these malignancies. Here, we investigate the ability of the histone
deacetylase inhibitor panobinostat (LBH589) to selectively target triple-negative breast cancer (TNBC) cell
proliferation and survival in vitro and tumorigenesis in vivo.
Methods TNBC cell lines MDA-MB-157, MDA-MB-231, MDA-MB-468, and BT-549 were treated with
nanomolar (nM) quantities of panobinostat. Relevant histone acetylation was verified by flow cytometry and
immunofluorescent imaging. Assays for trypan blue viability, 3-(4,5-dimethylthiazol-2-yl)-2,5-
diphenyltetrazolium bromide (MTT) proliferation, and DNA fragmentation were used to evaluate overall
cellular toxicity. Changes in cell cycle progression were assessed with propidium iodide flow cytometry.
Additionally, qPCR arrays were used to probe MDA-MB-231 cells for panobinostat-induced changes in cancer
biomarkers and signaling pathways. Orthotopic MDA-MB-231 and BT-549 mouse xenograft models were used
to assess the effects of panobinostat on tumorigenesis. Lastly, flow cytometry, ELISA, and
immunohistochemical staining were applied to detect changes in cadherin-1, E-cadherin (CDH1) protein
expression and the results paired with confocal microscopy in order to examine changes in cell morphology.
Results Panobinostat treatment increased histone acetylation, decreased cell proliferation and survival, and
blocked cell cycle progression at G2/M with a concurrent decrease in S phase in all TNBC cell lines. Treatment
also resulted in apoptosis induction at 24 hours in all lines except the MDA-MB-468 cell line. MDA-MB-231
and BT-549 tumor formation was significantly inhibited by panobinostat (10 mg/kg/day) in mice. Additionally,
panobinostat up-regulated CDH1 protein in vitro and in vivo and induced cell morphology changes in MDA-
MB-231 cells consistent with reversal of the mesenchymal phenotype.
Conclusions This study revealed that panobinostat is overtly toxic to TNBC cells in vitro and decreases
tumorigenesis in vivo. Additionally, treatment up-regulated anti-proliferative, tumor suppressor, and epithelial
marker genes in MDA-MB-231 cells and initiated a partial reversal of the epithelial-to-mesenchymal transition.
Our results demonstrate a potential therapeutic role of panobinostat in targeting aggressive triple-negative breast
cancer cell types.
Introduction
Over 200,000 new cases of invasive breast cancer are diagnosed in the United States each year and
approximately 40,000 of the patients diagnosed will die from the disease.[1] Breast cancers are routinely
classified by stage, pathology, grade and expression of estrogen receptor (ER), progesterone receptor (PR) or
human epidermal growth factor receptor (Her2/neu). Current successful therapies include hormone-based agents
that directly target these receptors.[2,3] Triple-negative breast cancer (TNBC) is a heterogeneous subset of
neoplasms that is defined by the absence of these targets.[4–6] Approximately 15% of globally diagnosed breast
cancers are designated as ER-, PR- and Her2/neu-negative.[1,7,8] Studies have shown that tumors of this
aggressive subtype are of higher histological grade, affect a disproportionate number of young women, and are
more likely to recur earlier at distant sites, resulting in poor overall prognoses.[4,5,9,10] To improve outcomes of
TNBC, we must unravel its biological pathways and modes of progression and use that knowledge to develop
novel targets and therapies.
Histone deacetylase inhibitors (HDACis) have emerged as a promising new class of multifunctional anticancer
agents.[11,12] That promise lies in the ability of HDACis to effect multiple epigenetic changes in aberrant cells. In
addition to regulating gene expression and transcription through chromatin remodeling, HDACis can also
modulate a variety of cellular functions including growth, differentiation, and survival[13,14] due, in part, to their
ability to enhance acetylation of a wide range of proteins, including transcription factors, molecular chaperones,
and structural components.[11,15,16] Specifically, HDACis have been linked to several downstream effects in tumor
cell lines which include: cell cycle arrest, induction of apoptosis, inhibition of angiogenesis, activation or
inactivation of tumor suppressor genes or oncogenes, and decreased invasion and metastases.[11,12,17]
Panobinostat (LBH589) is a potent pan-deacetylase inhibitor that can block multiple cancer related pathways
and reverse epigenetic events implicated in cancer progression.[18] HDACs can be subdivided into two groups:
zinc-dependent (Class I, II, and IV) and zinc-independent (Class III).[19] Panobinostat is a potent inhibitor with
activity against Class I, II, and IV HDAC enzymes, suggesting true pan-HDAC activity.[18] In preclinical studies,
panobinostat has shown potent inhibitory activity at low nanomolar concentrations across a wide range of
hematologic malignancies including lymphoma, multiple myeloma and acute myeloid leukemia.[20–22] It is also
being investigated as a treatment against non-responsive solid tumors as well as tumors of the lung, thyroid, and
prostate.[23–26] It has shown synergy with chemotherapeutics, radiation, demethylators, proteasome inhibitors and
other agents.[27–29] Based on these preclinical findings, panobinostat and other HDACis have undergone a rapid
phase of clinical development with many entering clinical trials, both as single agents or in combination with
other therapies.[12,23,30,31] To date, panobinostat has demonstrated favorable clinical responses, with limited
toxicity.[23,32,33] There is a critical need to develop pleiotropic therapies that specifically target the neoplasm as
well as the biological pathways and markers of TNBC progression. The purpose of this study was to determine
the ability of panobinostat to selectively target the TNBC subtype of breast cancer cells, assessed by its effects
on the growth, survival, and tumorigenesis of a representative panel of TNBC cells. We also sought to
characterize the effects panobinostat on the regulation of breast cancer genes, related signaling pathways and
morphology.
Discussion
In recent years, an increasing number of HDACis have been identified, developed and advanced to clinical
trials.[39,40] Panobinostat has shown potent activity at low nanomolar concentrations across a wide range of
hematologic malignancies and solid tumors in preclinical studies.[20–22,41] Others have demonstrated that HDACi
treatment can suppress oncogenes and induce re-expression of previously silenced tumor suppressors and
receptors such as the ER.[24,42–44] In addition to its single agent effects, recent studies have demonstrated a role
for panobinostat in resensitizing cancer cells to other agents including chemotherapy,[45] radiation,[46] autophagy
inhibitors[47] and endocrine therapies including tamoxifen[48] and letrozole.[49] In consideration of the promising
results reported by others, we endeavored to determine whether panobinostat would be effective against a panel
of breast cancer cell lines that display common characteristics of the triple-negative subtype.
In this study, we utilized MDA-MB-157, MDA-MB-231, MDA-MB-468, and BT549 cell lines as models of
TNBC growth and progression. In confirmation of other preclinical research,[20,24,42,44,50,51] we found that
panobinostat induced hyperacetylation of histones H3 and H4, decreased proliferation and survival, and induced
apoptosis and G2/M cell cycle arrest. The MDA-MB-231 and BT549 lines were chosen as models for our in
vivo xenograft studies using CB-17/SCID mice. Treatment with panobinostat decreased MDA-MB-231 and
BT549 tumor significantly with minimal animal toxicity, providing preclinical data on the effectiveness of
panobinostat on TNBC tumorigenesis at a low and well tolerated dose.
The panobinostat-induced effects on cell proliferation and survival appear to be TNBC cell specific as the ER-
positive cell lines tested were unaffected at all doses tested (up to 200 nM), contrary to previously published
work which reported panobinostat significantly inhibited cell survival and induced cell death in ER-positive and
ER-negative breast cancer cell lines though at a different time point.[44,47] We propose that the more aggressive,
highly proliferative nature and invasive phenotype of TNBC cells render them particularly susceptible to the
effects of panobinostat. Of the four TNBC cell lines tested, the MDA-MB-468 cells were the most resistant to
hyper-acetylation and DNA degradation by the drug. This is interesting as this cell line is the most
phenotypically different (spherical morphology) and least invasive of the four tested cell lines. The MDA-MB-
157, MDA-MB-231, and BT549 lines have been classified as basal-B,[52] with the MDA-MB-231 and BT-549
cell lines specifically classified as mesenchymal (stellate), claudin-low, and highly invasive.[53–56] The MDA-
MB-157 cells are classified as mesenchymal, claudin-low, and moderately invasive.[52] Clinically, the majority
of claudin-low tumors are of the triple-negative subtype and are associated with poor overall prognoses.[53]
However, MDA-MB-468 cells have been characterized under the basal-A subtype, as they possess both basal
(triple-negative) and luminal (spherical morphology) characteristics and are only minimally invasive.[52]
Additionally, super array data comparing panobinostat-induced gene expression changes between panobinostat-
sensitive (MDA-MB-231, basal-B) and panobinostat-insensitive (MDA-MB-468, basal-A; MCF-7, luminal)
cells revealed several changes specific to the basal-B subtype [See bolded genes in Additional file 1]. These ten
genes include known regulators of cell proliferation (FOSL1, STC2, TGFA, THBS2) and apoptosis (FAS,
FASLG), as well as angiogenesis (TNFAIP2). Additionally, many of the genes altered by panobinostat
specifically in MDA-MB-231 cells have documented roles in cell invasion and metastasis including CDH1,
CLDN7, FOSL1, PLAU, STC2, and TGFA. These data support the role of the selective effects of panobinostat
observed on the basal-B cell lines compared to the other subtypes tested.
Interestingly, superarray data identified CDH1 as being the most induced gene by panobinostat treatment
specifically in MDA-MB-231 cells, as these cells are characterized as mesenchymal, thus lacking significant
CDH1 expression. The TNBC subtype is exemplified by its highly aggressive and metastatic nature. A known
key step in the process of metastasis is the epithelial-to-mesenchymal transition (EMT). This oncogenic EMT is
typified by increased invasion and metastatic dissemination, therapeutic resistance and loss of expression of
tumor suppressors such as CDH1.[57,58] Studies have demonstrated that EMT and the resultant loss of CDH1
expression are crucial steps in tumor progression and correlate with poor clinical outcomes.[59–61] In confirmation
of our in vitro data on CDH1 up-regulation, we also noted an increase in CDH1 on the periphery of the primary
tumor from our MDA-MB-231 xenograft model. Decreased CDH1 expression at the tumor periphery has been
linked to increased metastasis-risk and decreased overall patient survival.[62] Induction of CDH1 expression by
LHB589 at the invasive edge may therefore be indicative of decreased metastatic potential. Panobinostat-
induced re-expression of CDH1, along with other morphological features, indicates the partial reversal of EMT,
a target of enormous potential, particularly in the TNBC subtype. This suggests panobinostat as a promising
therapeutic option for the more aggressive, TNBC/basal-like breast cancer subtypes.
Conclusions
Our results illustrate the ability of panobinostat to hyperacetylate histones, inhibit proliferation and survival, and
decrease in vivo tumorigenesis of TNBC cells. Our in vitro data suggest that this cytotoxicity is partially due to
cell cycle arrest and apoptosis. Also noted in treated cultures was an apparent partial reversal of the
mesenchymal phenotype evidenced by increased CDH1 protein expression and morphology changes in MDA-
MB-231 cells. This increased CDH1 was confirmed with measured upregulation of the CDH1 staining at the
primary tumor periphery in our xenograft model. Overall, our results affirm the efficacy and demonstrate a
potential therapeutic role of panobinostat in targeting aggressive triple-negative breast cancer cell types.

New Breast Cancer HER2 Diagnostic Tests Approved by FDA

Zosia ChusteckaPosted: 06/12/2012June 12, 2012 — Two diagnostic tests to identify HER2-positive breast
cancer have been approved by the US Food and Drug Administration (FDA) for use as companion diagnostics
for the new targeted therapy pertuzumab (Perjeta, Genentech/Roche).
The tests — HercepTest and HER2 FISH pharmDx Kit — are both manufactured by Dako in Glostrup,
Denmark.
The tests serve as diagnostic tools to identify patients with HER2-positivemetastatic breast cancer who might be
eligible for treatment with HER2-positivetargeted therapies. The latest of these — pertuzumab — was approved
just days ago for use in combination with trastuzumab (Herceptin) and chemotherapy in patients with HER2-
positivemetastatic breast cancer who have not been treated with either trastuzumab or chemotherapy.
"The role of HER2 in diagnosis and clinical decision making continues to evolve with the recent approval of
pertuzumab," said David Hicks, MD, director of surgical pathology at the University of Rochester Medical
Center in New York.
"It is clear that optimal patient care depends now more than ever on the accurate, reliable, and reproducible
assessment of HER2 status for the full benefit of pertuzumab to be derived by the appropriate patient
population," he noted in a Dako press release.
Dako reported that it had been collaborating with Genentech on a parallel FDA approval process for the 2 tests
and the new drug.
FDA Approves First Drug for Neoadjuvant Breast Cancer Use
Nick Mulcahy
October 02, 2013
The US Food and Drug Administration (FDA) today approved pertuzumab (Perjeta, Genentech) to be used in
combination with other agents before surgery in women with HER2-positive early-stage breast cancer.
Pertuzumab is the first medicine approved by the FDA for the neoadjuvant treatment of breast cancer. As such,
it is a "landmark" approval, said David Steensma, MD, from Harvard Medical School in Boston, Massachusetts,
last month, when he and other members of the FDA's Oncologic Drugs Advisory Committee reviewed and
recommended the drug.
The targeted therapy was previously approved for use in 2012 in patients with metastatic HER2-positive breast
cancer.
The FDA's endorsement of pertuzumab comes under the agency's accelerated approval program. Confirmatory
evidence from additional clinical trials will be needed eventually for the approval to be permanent.
Pertuzumab is now specifically indicated for the neoadjuvant treatment of breast cancer, in combination with
trastuzumab and docetaxel, for patients with HER2-positive, locally advanced, inflammatory, or early-stage
breast cancer (>2 cm in diameter) that is high risk, as part of a complete early breast cancer regimen also
containing fluorouracil, epirubicin, and cyclophosphamide or carboplatin. As part of this regimen, patients will
receive trastuzumab after surgery to complete 1 year of treatment.
"We are seeing a significant shift in the treatment paradigm for early stage breast cancer," said Richard Pazdur,
MD, director of the Office of Hematology and Oncology Products in the FDA's Center for Drug Evaluation and
Research, in a press statement. "By making effective therapies available to high-risk patients in the earliest
disease setting, we may delay or prevent cancer recurrences.''
Pertuzumab's accelerated approval for neoadjuvant treatment is based on a study designed to measure
pathologic complete response (pCR), defined as the absence of invasive cancer in the breast and lymph nodes.
In May 2012, the FDA issued a draft guidance on the use of the measure in this setting.
pCR is being used in lieu of the traditional measures of event-free or overall survival. The FDA has admitted
that pCR has not been proven to predict either event-free or overall survival. However, an FDA official recently
said that this high-risk early breast cancer population "justifies the risk" of considering pertuzumab on the basis
of its pCR.
The main study supporting the new application is the Neoadjuvant Study of Pertuzumab and Herceptin in an
Early Regimen Evaluation (NEOSPHERE), a randomized trial that compared a number of regimens with and
without pertuzumab in women with HER2-positive breast cancer. In that trial, 39.3% of patients treated with
pertuzumab, trastuzumab, and docetaxel (n = 107) had a pCR compared with 21.5% of patients treated with
trastuzumab and docetaxel (n = 107).
The most common severe (grade 3 or higher) adverse events for pertuzumab plus trastuzumab and docetaxel
were neutropenia (44.9%), febrile neutropenia (8.4%), leukopenia (4.7%), and diarrhea (5.6%).
Other significant adverse effects included decreased cardiac function, infusion-related reactions,
hypersensitivity reactions, and anaphylaxis.
The confirmatory trial is known as Adjuvant Pertuzumab and Herceptin in Initial Therapy of Breast Cancer
(APHINITY) and will provide further data on efficacy, safety, and long-term outcomes. Results are expected in
2016, according to the FDA.

Lapatinib as a Component of Neoadjuvant Therapy for HER2-Positive Operable

Breast Cancer (NSABP Protocol B-41): An Open-Label, Randomised Phase 3 Trial
Lancet Oncol. 2013 Oct 04;[EPub Ahead of Print], A Robidoux , G Tang, P Rastogi, CE Geyer, CA Azar, JN
Atkins, L Fehrenbacher, HD Bear, L Baez-Diaz, S Sarwar, RG Margolese, WB Farrar, AM Brufsky, HR
Shibata, H Bandos, S Paik, JP Costantino, SM Swain, EP Mamounas, N Wolmark
TAKE-HOME MESSAGE
In women receiving neoadjuvant AC-T for HER2-positive breast cancer, the substitution of lapatinib for
trastuzumab resulted in similar complete pathologic response rate. With the same neoadjuvant regimen, the
addition of lapatinib to standard trastuzumab resulted in an increased, but not statistically significant, complete
pathologic response rate.
Commentary by
Lee S. Schwartzberg, MD, FACP
Dual blockade with the anti-HER2 drugs trastuzumab and pertuzumab in combination with chemotherapy was
recently approved by the FDA in the neoadjuvant setting for HER2+ breast cancer based on a significant
improvement in pathologic complete response (pCR) rate. Other combinations of dual HER2 blockade have
also been investigated and reported. B-41, a study of chemotherapy with either lapatinib or trastuzumab alone or
in combination, was just published in The Lancet Oncology. Similar to that in other trials, the pCR rate was
numerically increased in the dual blockade group, although the benefit was more modest in B-41 and not
statistically significant. As in other studies, trastuzumab and lapatinib each led to similar pCR rates with
chemotherapy, and women with ER-negative tumors had a higher likelihood of pCR compared with ER-positive
patients. Unfortunately, the increase in pCR rate comes at a cost of substantial increase in severe toxicity
associated with this dual blockade approach, particularly diarrhea (27%; grade 3) and vomiting (5%; grade 3).
Cardiac dysfunction was not increased with the combination of trastuzumab and lapatinib. Given the less
impressive increase in pCR rate and the increased toxicity, dual HER2 blockade as neoadjuvant therapy should
be restricted for now to trastuzumab and pertuzumab.

ABSTRACT
Background: We studied the effect on tumour response to neoadjuvant therapy of the substitution of lapatinib
for trastuzumab in combination with weekly paclitaxel after doxorubicin plus cyclophosphamide treatment, and
of the addition of lapatinib and trastuzumab combined after doxorubicin plus cyclophosphamide treatment in
patients with HER2-positive operable breast cancer to determine whether there would be a benefit of dual
HER2 blockade in these patients.
Methods: For this open-label, randomised phase 3 trial we recruited women aged 18 years or older with an
ECOG performance status of 0 or 1 with operable HER2-positive breast cancer. Each received four cycles of
standard doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2 intravenously on day 1 every 3 weeks
followed by four cycles of weekly paclitaxel (80 mg/m2) intravenously on days 1, 8, and 15, every 4 weeks.
Concurrently with weekly paclitaxel, patients received either trastuzumab (4 mg/kg load, then 2 mg/kg
intravenously) weekly until surgery, lapatinib (1250 mg orally) daily until surgery, or weekly trastuzumab plus
lapatinib (750 mg orally) daily until surgery. After surgery, all patients received trastuzumab to complete 52
weeks of HER2-targeted therapy. Randomisation (ratio 1:1:1) was done centrally with stratification by clinical
tumour size, clinical nodal status, hormone-receptor status, and age. The primary endpoint was the pathological
complete response in the breast, and analysis was performed on an intention-to-treat population.
Findings: Patient accrual started on July 16, 2007, and was completed on June 30, 2011; 529 women were
enrolled in the trial. 519 patients had their pathological response determined. Breast pathological complete
response was noted in 93 (52·5%. 95% CI 44·9—59·5) of 177 patients in the trastuzumab group, 91 (53·2%,
45·4—60·3) of 171 patients in the lapatinib group (p=0·9852); and 106 (62·0%, 54·3—68·8) of 171 patients in
the combination group (p=0·095). The most common grade 3 and 4 toxic effects were neutropenia (29 [16%]
patients in the trastuzumab group [grade 4 in five patients (3%), 28 [16%] in the lapatinib group [grade 4 in
eight patients (5%)], and 29 [17%] in the combination group [grade 4 in nine patients (5%)]) and grade 3
diarrhoea (four [2%] patients in the trastuzumab group, 35 [20%] in the lapatinib group, and 46 [27%] in the
combination group; p<0·0001). Symptomatic congestive heart failure defined as New York Heart Association
Class III or IV events occurred in seven (4%) patients in the trastuzumab group, seven (4%) in the lapatinib
group, and one (<1%) in the combination group; p=0·185).
Interpretation: Substitution of lapatinib for trastuzumab in combination with chemotherapy resulted in similar
high percentages of pathological complete response. Combined HER2-targeted therapy produced a numerically
but insignificantly higher pathological complete response percentage than single-agent HER2-directed therapy;
these findings are consistent with results from other studies. Trials are being undertaken to further assess these
findings in the adjuvant setting.

T-DM1 Works Even in Heavily Pretreated Breast Cancer

Zosia ChusteckaSep 28, 2013
AMSTERDAM ― The novel twist on HER2-targeted therapy, which combines a monoclonal antibody with a
chemotherapy in 1 product, T-DM1 (ado-trastuzumab emtansine, Kadcyla, Roche/Genentech), has now been
shown to work even in heavily pretreated patients with advanced HER2-positive breast cancer.
New results from the phase 3 TH3RESA trial, presented for here at the European Cancer Congress 2013
(ECCO-ESMO-ESTRO), show that the new product nearly doubled progression-free survival (PFS) when
compared with physician's choice of treatment. The 602 participants had advanced metastatic disease and had
already been treated with a variety of chemotherapy and targeted agents that included trastuzumab (Herceptin,
Genentech) and lapatinib (Tykerb, SmithKline Beecham).
Median PFS was 6.2 months for women on T-DM1, compared with 3.3 months for those on physician's choice
of therapy, which was usually chemotherapy plus trastuzumab. This improvement in PFS is both statistically
and clinically meaningful, said lead investigator Hans Wildiers, MD, from the University Hospitals Leuven,
Belgium.
These new data extend the use of the new product to a larger population of patients from that included in the
pivotal registration trial for the drug, known as EMILIA. That study led to the approval in the United States for
use of T-DM1 in the treatment of patients with HER2-positive breast cancer who had previously been treated
with trastuzumab and a taxane chemotherapy. That same indication has recently been recommended for
approval in Europe, and European Union approval is expected before the end of the year.
The TH3RESA study extends use of T-DM1 into a salvage setting. "Two thirds of the participants had already
received 4 or more lines of therapy, and all had received at least 2 targeted agents," noted Dr Wildiers. "In
addition, 75% of participants had metastases to internal organs, in addition to skin and bone metastases."
"The main message is that once a woman has received treatment with trastuzumab and a taxane, no matter what
follows, T-DM1 should be given in second- or third- or fourth-line," he told Medscape Medical News.
Discussant for the paper, Clifford Hudis, MD, chief of breast cancer at Memorial Sloan-Kettering Cancer
Center, New York City, commented that there are not enough data to make the dogmatic statement that T-DM1
should be used in every patient with advanced HER2-positive breast cancer, but it should be considered. "If a
woman hasn't received it as second-line, then it should be considered as a third- or fourth-line treatment," he
told Medscape Medical News.
"Once HER2-positive breast cancer has recurred and metastasized, there are few treatment options available
that show any clear benefit for women who have probably undergone several previous treatments for the
disease," commented Cornelis van de Velde, MD, from the Leiden University Medical Center, the Netherlands,
and who is current president of the European CanCer Organization (ECCO). These results confirm and extend
the usefulness of T-DM1 for the treatment of women with advanced HER2-positive disease, he said in a
statement.
Reduced Toxicity
The novelty of T-DM1 is that it transports chemotherapy directly to the tumor, which reduces side effects when
compared with systemic chemotherapy. This was seen in the EMILIA study, and it was seen again in the
TH3RESA trial. Overall, there were fewer severe adverse reactions in the T-DM1 arm, reported by 32% vs 44%
in the control arm. Dr. Wildiers noted that patients receiving T-DM1 had a lower incidence of diarrhea,
neutropenia, and febrile neutropenia than those in the control arm, but there was a slight increase in severe
thrombocytopenia (4.4% vs 1.8%) and hemorrhage (2.2% vs 0.5%).
There were 2 cases of severe thrombocytopenia with hemorrhage, he noted, 1 a case of subarachnoid
hemorrhage and the other tumor-related hemorrhage. "This seems to be a rare side effect of T- DM1, but we did
not see a consistent pattern yet," he said in an interview. "The thrombocytopenia is known already, and now
there is hemorrhage," he said, although he added that he has not seen any instances among the 30 or so patients
he has treated in his own clinical practice.
The results from the TH3RESA trial confirm those from EMILIA and show that T-DM1 provides better disease
control and less toxicity than the standard treatment of trastuzumab and a taxane, Dr. Wildiers concluded.
In the EMIL1A study, there was a significant improvement in overall survival, and Dr. Wildiers says this is
likely to also be the case for TH3RESA once more time has elapsed. So far, there have been 105 deaths, and
there have been fewer deaths in the T-DM1 arm, but for the overall survival analysis to reach statistical
significance, 400 deaths must have occurred, he said. He speculated that this is likely to be seen in 2015.
Dr. Wildiers reports that he serves on the advisory board of Roche, and several coauthors are employees of
Genentech.
European Cancer Congress 2013 (ECCO-ESMO-ESTRO). Abstract LBA15. Presented September 28, 2013.

Neoadjuvant Therapy Tied to Loss of HER2 Positivity in Breast Cancer

Sep 24, 2013
NEW YORK (Reuters Health) Sep 24 - Loss of HER2 positivity is higher in breast cancer patients receiving
neoadjuvant chemotherapy without anti-HER2 agents, according to new research.
Loss of HER2 amplification following neoadjuvant trastuzumab-based (anti-HER2) therapy is associated with
reduced relapse-free survival, but the biological basis for this remains unclear.
Dr. Valentina Guarneri from University of Padova in Italy and colleagues used a prospective database to
evaluate the rate of HER2 loss and its prognostic significance in 107 HER2-positive breast cancer patients; 40
of the patients were treated with neoadjuvant chemotherapy and 67 received neoadjuvant chemotherapy plus
anti-HER2 agents.
Loss of HER2 expression was significantly more common among women with residual disease after
chemotherapy alone (14/35, 40%) than among women with residual disease after chemotherapy plus anti-HER2
agents (5/34, 14.7%), according to the report, online September 7 in Annals of Oncology.
"We would have expected a higher rate of HER2 conversion after anti-HER2 agents, as a consequence of the
selective pressure on resistant HER2-negative clones and the induction of HER2 loss as a mechanism of
resistance," the researchers write. "However, in our study, the addition of anti-HER2 to chemotherapy seems to
even lower the rate of HER2 loss."
Women who did not achieve pathologic complete response (pCR) were 9.55 times more likely to relapse than
were women who did achieve pCR (p=0.028), and there was a trend towards a higher risk of relapse among
women who had a loss of HER2 expression (p=0.063).
"These observations suggest the importance of retesting HER2 status after primary therapy, to better refine the
patient's prognosis," the researchers conclude.
"This population with particularly poor outcome may benefit from the inclusion in the clinical trial investigating
further adjuvant treatment approaches," they add. "Although in our series HER2 loss after primary systemic
treatment seems to occur more frequently when patients are treated with chemotherapy alone rather than
combined with anti-HER2 agents, there are no available data that could help to explain these observations."
Dr. Guarneri did not respond to a request for comments.
SOURCE: http://bit.ly/1bsGpQB
Ann Oncol 2013.

Breast Cancer Receptor Change May Predict Outcomes

IMNG Medical Media, 2013 Sep 23, S Boschert
Dr. Napa Parinyanitikul Dr. Lajos Pusztai
The subtyping of breast cancer by receptor status changed in 41% of 398 samples between the initial tumor and
residual disease after neoadjuvant chemotherapy.
In patients with any change in the status of estrogen receptor (ER), progesterone receptor (PR), or human
epidermal growth factor receptor 2 (HER2), after neoadjuvant chemotherapy, 63% were relapse free 5 years
later as compared with 48% of patients with no receptor change, a significant difference.
Overall survival at 5 years, however, did not differ significantly based on receptor status change, Dr. Napa
Parinyanitikul and her associates reported at a breast cancer symposium sponsored by the American Society of
Clinical Oncology. At 5 years, 73% of patients with a receptor status change and 63% with no change were
alive.
The study analyzed data on patients treated at her institution in 1992-2012 who had tumor biomarker results
from pretreatment biopsies and from samples of residual disease after neoadjuvant chemotherapy. Most patients
in the study were white, with clinical stage II or III disease.
Of the tumors, 49% were hormone receptor–positive and HER2 negative; 18% were HER2 positive, and 33%
were negative for all three receptors (triple-negative breast cancer). Neoadjuvant chemotherapy consisted of a
taxane-based regimen in 10%, an anthracycline-based regimen in 19%, an anthracycline/taxane-based regimen
in 71%, and trastuzumab-based chemotherapy in 49%. The 88% of patients with hormone receptor-positive
disease received adjuvant endocrine therapy with tamoxifen or an aromatase inhibitor.
After a median of 40 months of follow-up, 32% of women had died and 42% had a recurrence of breast cancer,
reported Dr. Parinyanitikul, a fellow at the University of Texas MD Anderson Cancer Center, Houston.
The likelihood of receptor status changes differed significantly by the subtype of breast cancer. Of hormone
receptor–positive cancers, 51% had a change in receptor status, compared with 27% of HER2-positive cancers
and 22% of triple-negative breast cancers.
Other factors did not significantly affect the likelihood of receptor status change, including patient age or race,
histology, tumor stage or grade, the presence of lymphovascular invasion, or the class of neoadjuvant
chemotherapeutic agents.
Of ER-positive tumors, 11% changed to ER negative after neoadjuvant chemotherapy; of ER-negative tumors,
21% changed to ER positive. Of the PR-positive tumors, 35% changed to PR-negative; of PR-negative tumors,
12% changed to PR positive. Of HER2-positive tumors, 40% changed to HER2 negative; of HER2-negative
tumors, 3% changed to HER2 positive. Among 35 patients treated with trastuzumab, the HER2 status changed
in 16 (46%).
Patients who had tumors with an ER-negative status that did not change had the worst 5-year rates for overall
survival (47%) and relapse-free survival (40%), compared with patients whose tumors had an ER-positive status
did not change (81% overall survival and 63% relapse-free survival), patients whose ER status changed from
positive to negative (67% and 66% survival rates, respectively), and patients whose ER status changed from
negative to positive (75% and 59%, respectively).
Similarly, patients who had PR-negative tumors whose status did not change had significantly lower rates of
overall survival (51%) and relapse-free survival (41%), compared with patients whose PR-positive tumor status
did not change (87% and 67%, respectively), those who changed from PR positive to PR negative (78% and
73%, respectively), and patients whose PR-negative status changed to PR positive (69% and 55%, respectively).
Changes or lack of change in HER2 subgroups were not significantly associated with varying outcomes.
The investigators also looked at the absolute percent changes in ER or PR status using cutoffs in 10%
increments from 10% to 50%. The 5-year overall survival rate was significantly greater in ER-positive patients
who had at least a 20% change in ER status, compared with those with less than a 20% change (87% vs. 73%,
respectively). The 5-year relapse-free survival rate also was significantly greater if the ER status changed by at
least 20% (71%), compared with smaller ER changes (59%).
Of cancers that were hormone receptor–positive and HER2 negative before neoadjuvant chemotherapy, 20%
changed to HER2-positive or triple-negative breast cancer after treatment, 12% of tumors that had been HER2
positive changed to triple negative tumors, and 2% of triple negative breast cancers changed to HER2-positive
after treatment. These changes produced only one significant effect on outcomes: 5-year overall survival rates
were significantly lower in patients who changed from HER2-positive to triple-negative breast cancer (23%),
compared with those whose HER2-positive cancer did not change to triple negative (71%).
Larger prospective studies are needed to confirm the findings and to determine any impact of biomarker
changes on long-term survival, she said.
Previous studies have reported discordance in hormone receptor status in up to 51% of breast cancers between
the primary tumor and residual disease and changes in HER2 status in up to 43% of cases. Conclusions about
associations between changes in receptor status and clinical outcomes have been inconsistent.
The symposium was cosponsored by the American Society of Breast Disease, the American Society of Breast
Surgeons, the National Consortium of Breast Centers, the Society of Surgical Oncology, and the American
Society for Radiation Oncology.
 Dr. Parinyanitikul reported having no financial disclosures.

Commentary – Technical imprecision affects status changes

Dr. Lajos Pusztai comments: Technical artifacts when testing receptor status in breast cancer complicate
assessments of their potential ramifications on outcomes.
ER and PR status can change if you repeat the testing on the same specimen without any change in the actual
marker status. In one “classic” study, the HER2 or ER status changed in 23% of samples after they were air-
mailed from one center to another. You can’t conclude that it was the airplane flight that changed receptor
status.
Similarly, in the current study, you can’t conclude that it was the chemotherapy that changed the receptor status,
because part of this discordance is from the technical imprecision of the test. If a test is 90% accurate, for
example, 10% of results on first testing will be “noise” and approximately 20% of results on repeat testing will
be discordant.
The study also did not report the proportion of cases in which initial receptor status tests were conducted in one
laboratory and the second test was conducted at a different center, as is often the case in the real world. That
also introduces a very large, obvious cause for receptor discordance independent of therapy.

Pattern of Rash, Diarrhea, and Hepatic Toxicities Secondary to Lapatinib and Their
Association With Age and Response to Neoadjuvant Therapy: Analysis From the
NeoALTTO Trial
J. Clin. Oncol 2013 Nov 18;[EPub Ahead of Print], HA Azim, D Agbor-Tarh, I Bradbury, P Dinh, J Baselga, S
Di Cosimo, JG Greger, I Smith, C Jackisch, SB Kim, B Aktas, CS Huang, P Vuylsteke, RK Hsieh, L Dreosti, H
Eidtmann, M Piccart, E de Azambuja
Research · December 03, 2013

TAKE-HOME MESSAGE
 Phase III trial results in women with HER-2 breast cancer receiving lapatinib showed that rash of any
grade was more common among those ≤ 50 years old (74% vs 48%).
 In women > 50 years old, the occurrence of rash within 6 weeks of starting lapatinib was associated with
increased likelihood of pCR (50% vs 27%); however, this association was not seen in younger women (41% vs
40%).
- Richard Bambury, MD

ABSTRACT
PURPOSE
We investigated the pattern of rash, diarrhea, and hepatic adverse events (AEs) secondary to lapatinib and their
association with age and pathologic complete response (pCR) in the Neoadjuvant Lapatinib and/or Trastuzumab
Treatment Optimisation (NeoALLTO) phase III trial.
PATIENTS AND METHODS
Patients with HER2-positive early breast cancer were randomly assigned to receive lapatinib (Arm A),
trastuzumab (Arm B), or their combination (Arm C) for 6 weeks followed by the addition of paclitaxel for 12
weeks before surgery. We investigated the frequency and time to developing each AE according to age (≤ 50 v >
50 years) and their association with pCR in a logistic regression model adjusted for age, hormone receptors,
tumor size, nodal status, planned breast surgery, completion of lapatinib administration, and treatment arm.
RESULTS
Only patients randomly assigned to arms A and C were eligible (n = 306). Younger patients (≤ 50 years)
experienced significantly more rash compared with older patients (74.4% v 47.9%; P < .0001). Diarrhea and
hepatic AEs were observed in 78.8% and 41.2% of patients, respectively, with no differences in rate or severity
or time of onset according to age. Early rash (ie, before starting paclitaxel) was independently associated with a
higher chance of pCR, mainly in patients older than 50 years (odds ratio [OR] = 3.76; 95% CI, 1.69 to 8.34) but
not in those ≤ 50 years (OR = 0.92; 95% CI, 0.45 to 1.88; P for interaction = .01). No significant association
was observed between pCR and diarrhea or hepatic AEs.
CONCLUSION
Our results indicate that the frequency and clinical relevance of lapatinib-related rash is largely dependent on
patient age.

Journal of Clinical Oncology

Pattern of Rash, Diarrhea, and Hepatic Toxicities Secondary to Lapatinib and Their Association
With Age and Response to Neoadjuvant Therapy: Analysis From the NeoALTTO Trial
J. Clin. Oncol 2013 Nov 18;[EPub Ahead of Print], HA Azim, D Agbor-Tarh, I Bradbury, P Dinh, J Baselga, S
Di Cosimo, JG Greger, I Smith, C Jackisch, SB Kim, B Aktas, CS Huang, P Vuylsteke, RK Hsieh, L Dreosti, H
Eidtmann, M Piccart, E de Azambuja

Shorter Trastuzumab Course No Help in Early Breast Cancer

Jul 03, 2013 By David Douglas
NEW YORK (Reuters Health) Jul 02 - In HER2-positive early-stage breast cancer, six months of adjuvant
trastuzumab is not equivalent to the standard 12 month course, according to French researchers.
"After 3.5 years follow-up, we failed to show that six months of treatment with trastuzumab was non-inferior to
12 months of trastuzumab," they said in a June 11th online paper in The Lancet Oncology. "Despite the higher
rates of cardiac events, 12 months of adjuvant trastuzumab should remain the standard of care."
The authors, led by Dr. Xavier Pivot of University Hospital J Minjoz, Besancon, note that a shorter course has
been advocated to alleviate cardiac concerns.
The new study was an open-label trial involving more than 3300 patients who received at least four cycles of
chemotherapy, breast-axillary surgery, and up to six months of trastuzumab. They were randomly assigned to
stop trastuzumab or continue it for another six months.
With follow-up lasting a median 42.5 months, intention-to-treat analysis showed two-year disease-free survival
rates of 93.8% in the 12-month group and 91.1% in the six-month group (p for noninferiority = 0.29).
The 626 patients with estrogen-receptor-negative tumors treated with sequential chemotherapy and trastuzumab
had the poorest disease-free survival: 89.8% in the 12-month group and 84.5% in the six-month group.
Overall, 159 patients (4.7%) died: 66 (3.9%) in the 12-month group and 93 (5.5%) in the six-month group.
About this, the authors write, "The estimated hazard ratio was 1.46 (95% CI 1.06-2.01), however the test of
proportional hazards was significant (p=0.03), indicating that proportional hazards cannot reasonably be
accepted as plausible for overall survival."
"Longer follow-up with more events is required to provide mature data for overall survival," the researchers say.
There were 128 cardiac events (either clinical or based on assessment of left ventricular ejection fraction) while
patients were receiving trastuzumab. These were significantly more common in the 12-month group than in 6-
month patients (5.7% vs 1.9%).
The researchers note that a number of other trials are investigating shorter trastuzumab duration but "on the
basis of the results presented here, 12 months of adjuvant trastuzumab should remain the standard of care for
women with HER2-positive early breast cancer."
Commenting on the findings by email, Dr. Filippo Montemurro, co-author of an editorial published with the
report, told Reuters Health, "Although the results of (this study) must not alter current clinical practice, they
support the notion that the treatment of patients with HER2-positive operable breast cancer requires more
individualized approaches."
In this respect, Dr. Montemurro of the Institute for Cancer Research and Treatment, Candiolo, Italy concluded
that "trastuzumab treatment duration remains a potential component of tailored strategies."
Dr. Pivot did not respond to requests for comments.
SOURCES: http://bit.ly/13paI77 and http://bit.ly/13paI77
Lancet Oncol 2013.
EU Says Yes to Subcutaneous Herceptin and Other Extensions
Zosia Chustecka
Jul 01, 2013
In Europe, the Committee for Medicinal Products for Human Use (CHMP) has issued positive opinions on a
new formulation of trastuzumab (Herceptin, Roche), and for product label extensions for lapatinib (Tyverb,
Glaxo) and bortezomib (Velcade, Janssen). This is the last step in the process before official European Union
approval.
The new formulation of trastuzumab allows subcutaneous administration of the drug, with an injection under
the skin delivered in 2 to 5 minutes. In contrast, a typical intravenous infusion of trastuzumab lasts 30 to 90
minutes.
The subcutaneous formulation uses recombinant human hyaluronidase (rHuPH20), developed by Halozyme
Therapeutics, and was tested in a pivotal phase 3 study known as HannaH, conducted by Roche in 102 sites
outside the United States. The results of that study showed that the safety and efficacy of the subcutaneous
formulation is comparable to that seen with the intravenous formulation, the companies report.
Trastuzumab is indicated for HER2-postive breast cancer, which accounts for about 15% to 20% of breast
cancer and is particularly aggressive, the companies add.
Extended Indications
Also recommended for approval in Europe are expansions to the indications for 2 already-marketed drugs.
Lapatinib is indicated for HER2-positive breast cancer, and the wording to date on the labeling has specified it
to be used in combination with capecitabine (Xeloda, Roche) in patients with advanced disease that has
progressed on prior therapy, which must have included anthracyclines, taxanes, and trastuzumab. It has also
been indicated for use with an aromatase inhibitor in postmenopausal women with hormone-receptor–positive
disease, not currently intended for chemotherapy.
The new additional indication allows use of lapatinib in combination with trastuzumab for patients with
hormone-receptor–negative metastatic disease that has progressed on prior trastuzumab therapies in
combination with chemotherapy.
Bortezomib is indicated for multiple myeloma, and the wording to date has stipulated its use as monotherapy in
adult patients who have had at least 1 prior therapy and already undergone or are unsuitable for hematopoietic
stem-cell transplantation and as a combination therapy with melphalan and prednisone in adult patients with
previously untreated disease who are not eligible for high-dose chemotherapy with hematopoietic stem-cell
transplantation.
The new indication allows use of bortezomib in combination with dexamethasone or with dexamethasone and
thalidomide in adult patients for induction therapy with previously untreated multiple myeloma who are eligible
for high-dose chemotherapy with hematopoietic stem-cell transplantation.

Review
Nature Reviews Clinical Oncology 9, 16-32 (January 2012) | doi:10.1038/nrclinonc.2011.177
Treatment of HER2-positive breast cancer: current status and future perspectives
Carlos L. Arteaga, Mark X. Sliwkowski, C. Kent Osborne, Edith A. Perez, Fabio Puglisi & Luca Gianni
Abstract
The advent of HER2-directed therapies has significantly improved the outlook for patients with HER2-positive
early stage breast cancer. However, a significant proportion of these patients still relapse and die of breast
cancer. Trials to define, refine and optimize the use of the two approved HER2-targeted agents (trastuzumab and
lapatinib) in patients with HER2-positive early stage breast cancer are ongoing. In addition, promising new
approaches are being developed including monoclonal antibodies and small-molecule tyrosine kinase inhibitors
targeting HER2 or other HER family members, antibodies linked to cytotoxic moieties or modified to improve
their immunological function, immunostimulatory peptides, and targeting the PI3K and IGF-1R pathways.
Improved understanding of the HER2 signaling pathway, its relationship with other signaling pathways and
mechanisms of resistance has also led to the development of rational combination therapies and to a greater
insight into treatment response in patients with HER2-positive breast cancer. Based on promising results with
 new agents in HER2-positive advanced-stage disease, a series of large trials in the adjuvant and neoadjuvant
settings are planned or ongoing. This Review focuses on current treatment for patients with HER2-positive
breast cancer and aims to update practicing clinicians on likely future developments in the treatment for this
disease according to ongoing clinical trials and translational research.
Key points
 HER2 gene amplification and/or overexpression occurs in about 20% of breast cancers and is associated
with more-aggressive disease and, until the advent of HER2-targeted agents, a worse outcome
 The monoclonal antibody, trastuzumab (which targets HER2), and the small-molecule tyrosine kinase
inhibitor, lapatinib (which targets HER1 and HER2), have considerable efficacy in HER2-positive breast cancer
 New agents in development include vaccines, modified antibodies and derivatives, tyrosine kinase
inhibitors and other agents directed against HER2, other HER family members, and downstream and/or
resistance pathways
 Targets in downstream and/or resistance pathways of particular interest in HER2-positive breast cancer
include mTOR, PI3K, IGF-1R, Akt, HSP90 and VEGF
 In advanced-stage disease, randomized trials suggest that the antibody–drug conjugate, trastuzumab-
DM1, and the dimerization inhibitor, pertuzumab, may have superior efficacy or add to the efficacy of
trastuzumab-based therapy
 Lapatinib, bevacizumab (which targets VEGF), neratinib (a dual HER1–HER2 inhibitor), and the
peptide vaccines, GP2 and AE37, are all in adjuvant trials for HER2-positive early stage breast cancer
Introduction
HER2 is a transmembrane receptor with tyrosine kinase activity but without a known ligand that was initially
identified in a rat glioblastoma model.1 It belongs to a family of four receptors (EGFR/HER1, HER2, HER3,
HER4) that are involved in regulating cell growth, survival and differentiation through interlinked signal
transduction involving activation of the PI3K/Akt and the Ras/Raf/MEK/MAPK pathways (Figure 1).2 When
highly expressed, an excess of HER2 at the cell membrane results in constitutive signaling of downstream
pathways.2 Structural studies revealed that HER2 is always in an active conformation and ready to interact with
the ligand-activated HER receptors,3 and a dominant role has been proposed for HER3 in HER2 signaling.4
Amplification of the HER2 gene and/or overexpression at the messenger RNA or protein level occurs in about
20% of patients with early stage breast cancer.5 Before the advent of HER2-directed therapies, this increased
level of HER2 was associated with high recurrence rates and increased mortality in patients with node-positive
and node-negative disease.5, 6
Figure 1 | Heterodimer formation of members of the HER family and downstream signaling.

Signaling downstream of HER family activation is dependent on heterodimerization of

the HER family member triggered by ligand binding to the extracellular ligand-binding domain (with the
exception of HER2, which has no identified ligand and is always in an open conformation that allows
dimerization). Phosphorylation of the HER kinase domains (with the exception of HER3, which does not have a
kinase domain) initiates a downstream cascade resulting in VEGF transcription and other physiological
responses required for carcinogenesis. Abbreviations: AR, amphiregulin; BTC, betacellulin; EPG, epigen; EPR,
epiregulin; HB-EFG, heparin-binding EGF-like ligand; NRG, neuregulin.
HER2-positive breast cancer therapy
Trastuzumab
The monoclonal antibody trastuzumab is currently the only approved adjuvant treatment specifically for
patients with HER2-positive early stage breast cancer. Its antitumor action is not completely understood but is
thought to be mediated by several mechanisms following binding of the antibody to the extracellular domain
(ECD) of the HER2 receptor; these mechanisms include antibody-dependent cell-mediated cytotoxicity
(ADCC), inhibition of cleavage of the ECD of the HER2 receptor (preventing formation of a residual truncated
but constitutively active form),7 inhibition of ligand-independent HER2 receptor dimerization, inhibition of
downstream signal transduction pathways, induction of cell-cycle arrest, induction of apoptosis, inhibition of
angiogenesis, and interference with DNA repair.8, 9 Other potential mechanisms of action have been proposed,
but data from preclinical and translational studies are conflicting. These mechanisms include downregulation of
HER2 through endocytosis and trastuzumab-induced internalization of HER2, with consequent increased
intracellular degradation, and potential immunological mechanisms such as elimination of tumor-specific CD4+
CD25bright regulatory T cells resulting in an improved immune response against HER2-positive tumors.10 In
patients, trastuzumab seems to induce tumor cell apoptosis, whereas in culture, antiproliferative effects
predominate.11
In the adjuvant setting, trastuzumab is recommended by both US (National Comprehensive Cancer Network
[NCCN]) and European (St. Gallen) guidelines for use as monotherapy after completion of chemotherapy, and
in combination with paclitaxel or docetaxel after completion of doxorubicin plus cyclophosphamide, or given
concurrently with carboplatin and docetaxel.12, 13 These recommendations are based on results of four large
ongoing trials, in addition to several smaller trials (Table 1). Results of individual studies are supported by a
recent meta-analysis that included six randomized clinical trials and showed that the combination of
trastuzumab with adjuvant chemotherapy produced a significant benefit in disease-free survival (DFS; odds
ratio [OR] = 0.69), overall survival (OR = 0.78), locoregional recurrence (OR = 0.53), and distant recurrence
(OR = 0.62), as compared to chemotherapy alone.14 Of note, the statistically significant advantage in overall
survival initially observed with the addition of trastuzumab to chemotherapy in the HERA trial15, 16 was not
evident at the most recent analysis.16 However, this finding is probably because 65% of patients in the
observation arm crossed over to trastuzumab after the release of positive trial results in 2005.16
Table 1 | Phase III data for adjuvant trastuzumab in patients with HER2-postive early stage breast
cancer
Although small tumors (<1 cm) were not included in the majority of randomized trials that assessed
trastuzumab, women with node-negative HER2-positive tumors that are 0.6–1.0 cm in size are thought to
benefit from adjuvant trastuzumab therapy, on the basis of the demonstration of higher risk than previously
appreciated in this population. In addition, subgroup analyses from several of the randomized trials have shown
consistent benefit of trastuzumab irrespective of tumor size.17
Despite the wealth of clinical data available on adjuvant trastuzumab therapy, a number of important questions
are still unanswered, including the optimal duration of treatment and how best to combine trastuzumab with
cytotoxic and other agents so as to maximize efficacy, but minimize toxicity. Several trials are addressing the
question of the optimal duration of trastuzumab therapy (Table 2). Data from the 2-year arm of the ongoing
HERA study—expected in 2012—should indicate whether longer trastuzumab therapy is better than the current
standard duration of 1 year, and several other trials are comparing short durations (9 weeks or 6 months) with
the standard treatment. The FinHER study has already provided evidence that 9 weeks of adjuvant trastuzumab
(given concurrently with chemotherapy) has improved efficacy in terms of distant relapse-free survival
compared with chemotherapy alone, but this was not compared with the standard 1-year duration of
trastuzumab treatment.18, 19 Data from the NCCTG N9831 trial (Table 1) suggest that trastuzumab can be more
effective if started concurrently with the taxane component of adjuvant chemotherapy than if started after
chemotherapy has finished.20 This approach also reduces the duration of intravenous therapy by approximately 3
months, which might improve convenience.21
Table 2 | Ongoing phase III trials of adjuvant trastuzumab in patients with HER2+ early stage
breast cancer
According to the results of large clinical trials, trastuzumab is generally well tolerated when added to, or
administered following, a chemotherapy regimen.22 Although potential cardiotoxicity is a concern, the majority
of trastuzumab-related cardiac events are asymptomatic decreases in left ventricular ejection fraction (LVEF).
On the basis of available data on the use of trastuzumab in the adjuvant setting, both asymptomatic and
symptomatic (including congestive heart failure [CHF]) side effects seem to be treatable and mostly
reversible.22 The risk of severe CHF or cardiac events in patients who received anthracyclines as treatment for
breast cancer before receiving trastuzumab ranges from 0.6% to 3.9%, on the basis of the data from the main
adjuvant trials.22 In addition, a meta-analysis including 10,955 patients from adjuvant trials showed that the risk
of clinically significant cardiac events (grade 3 or 4) related to chemotherapy and 1 year of trastuzumab therapy
was 1.9% versus 0.3% in patients who did not receive the antibody.23
The BCIRG 006 trial compared the efficacy and safety of a non-anthracycline regimen (docetaxel, carboplatin
and trastuzumab) with doxorubicin and cyclophosphamide; both arms were followed by docetaxel treatment.24
In addition, another arm evaluated doxorubicin and cyclophosphamide followed by docetaxel and trastuzumab.
A higher incidence of symptomatic CHF was observed when trastuzumab was added to the anthracycline-based
regimen than when added to the non-anthracycline regimen (2% versus 0.4%; P <0.001).24
Clinical evaluation before treatment with trastuzumab should include careful screening for cardiac risk factors
(that is, baseline LVEF 50–55% in patients >65 years with hypertension, diabetes, or smoking habit, and with
BMI >25) and consequent close cardiac monitoring according to specific circumstances. Trastuzumab must be
avoided if baseline LVEF is <50%.
Data from two major randomized trials in the neoadjuvant setting,25, 26 as well as many nonrandomized trials,27
indicate that the addition of trastuzumab to neoadjuvant chemotherapy also significantly improves pathological
complete response (pCR) rates and event-free survival in patients with locally advanced-stage or early stage
breast cancer suitable for preoperative (primary systemic) therapy. In the two randomized neoadjuvant trials,25, 26
trastuzumab was administered concomitantly with anthracyclines and, although a decrease in LVEF was
observed in 27% of patients,25 symptomatic cardiac events occurred in only 2% of patients given trastuzumab
concurrently with doxorubicin.25
Trastuzumab is also approved and widely used for patients with metastatic HER2-positive disease in
combination with paclitaxel28 or docetaxel,29 or as monotherapy.30 On the basis of the preclinical data on the
chemotherapy-sensitizing effect of trastuzumab, the benefit of continuing anti-HER2 treatment beyond
progression was examined in several retrospective trials and these studies supported this strategy.31 In addition,
although prematurely closed, a randomized phase III trial demonstrated that the combination of trastuzumab
plus capecitabine resulted in a significant improvement in overall response and time to progression compared
with capecitabine alone in patients with HER-2-positive breast cancer who experienced progression during
trastuzumab treatment.32
Trastuzumab can be combined with a range of other cytotoxic agents,33, 34, 35, 36 including anthracyclines,
although concurrent administration with anthracyclines is associated with an increased risk of cardiotoxicity. 28
This risk can be manageable if the cumulative dose of anthracycline is kept low and/or less-cardiotoxic
anthracyclines are used.25, 37, 38 Importantly, the cardiac dysfunction associated with trastuzumab use, which is
thought to be mediated via inhibition of HER2 signaling in cardiac myocytes, seems to be largely reversible.39,
40, 41

Lapatinib
Lapatinib is the only treatment, other than trastuzumab, approved specifically for patients with HER2-positive
advanced-stage breast cancer. Lapatinib reversibly inhibits the intracellular tyrosine kinase activity of both
HER2 and EGFR (also known as HER1), suppressing tyrosine autophosphorylation and thereby downstream
pathways, such as the MAPK/Erk1/2 and PI3K/Akt pathways.42, 43, 44 Importantly, preclinical studies showed that
lapatinib could inhibit the growth of HER2-positive breast cancer cells that were resistant to trastuzumab
(including those with truncated HER2 receptors),45 and that lapatinib could enhance the apoptotic effect of anti-
HER2 antibodies.44, 46, 47 These findings suggested that lapatinib might have additive or even synergistic activity
if combined with trastuzumab, and that it might have activity in patients with disease resistant to trastuzumab.
Better central nervous system (CNS) penetration was also predicted (since lapatinib is a small molecule),
potentially leading to improved control of CNS disease by lapatinib compared with trastuzumab.
Early clinical trials indicated modest clinical activity (response rates <10%) for single-agent lapatinib in patients
whose disease had progressed when receiving trastuzumab,48 but the combination of lapatinib and capecitabine
showed significantly superior efficacy compared to capecitabine alone in such patients.49, 50 A subsequent
randomized trial also showed that the combination of lapatinib and trastuzumab had better efficacy than
lapatinib alone in patients whose disease had progressed on trastuzumab.51, 52 The combination of trastuzumab
and lapatinib was well tolerated in this study, with a low incidence of symptomatic (2%) and asymptomatic
cardiac events (3.4%). Overall, despite targeting the same pathway, the incidence of cardiac toxicity seems to be
lower with lapatinib than with trastuzumab,53 possibly owing to different effects on cardiomyocyte
mitochondrial ATP stores,54 other differences in the mechanism of action, or to less-sustained inhibition of
HER2 by lapatinib compared with trastuzumab. Randomized trials (Table 3) have shown that CNS involvement
might be reduced by lapatinib co-administration with chemotherapy,49 but results of definitive head-to-head
comparisons with trastuzumab are awaited (Table 4). The efficacy of lapatinib seems to be confined to patients
with strong HER2 overexpression, as with trastuzumab, although some trials are still ongoing in patients with
HER2-negative disease (Tables 3 and 4).55
Table 3 | Selected phase III data for lapatinib in patients with breast cancer
Table 4 | Ongoing randomized trials with lapatinib in patients with HER2-positive breast cancer
Two major adjuvant trials of lapatinib are now ongoing (TEACH and ALTTO), in addition to several trials in
the neoadjuvant setting and in patients with advanced-stage disease. These trials should establish in the next few
years whether lapatinib and trastuzumab should be used together or sequentially, and which settings are optimal
for the two agents.
Initial results of the NEO-ALTTO trial have been presented.56 The study randomized 455 patients with >2 cm
HER2-positive breast cancer tumors suitable for neoadjuvant therapy to receive lapatinib, trastuzumab or the
combination of both. Anti-HER2 agents were given without chemotherapy for 6 weeks, and then weekly
paclitaxel was added for 12 weeks before surgery. Adjuvant therapy consisted of three cycles of 5-fluorouracil–
epirubicin–cyclophosphamide, and the same anti-HER2 therapy administered in the preoperative phase was
continued up to a year. The rate of pCR was significantly higher with the combination of lapatinib and
trastuzumab compared with trastuzumab alone (51.3% versus 29.5%; P = 0.0001); the pCR rate was 24.7% with
lapatinib alone. In terms of toxic effects, patients in the lapatinib arm experienced more grade ≥3 diarrhea
(23%), hepatotoxicity (13%), neutropenia (16%) and skin disorders (7%) than patients in other arms.56
Another phase III neoadjuvant trial (GeparQuinto) enrolled 620 patients with HER2-positive disease to receive
trastuzumab and chemotherapy or lapatinib and chemotherapy.57 A higher rate of pCR was observed in patients
treated with trastuzumab (31.7%) than in patients treated with lapatinib (21.7%). Of note, in the lapatinib-
treated arm 3.4% of patients discontinued treatment because of toxic effects.
In the randomized phase II CHERLOB trial, the activity of preoperative taxane–anthracycline chemotherapy in
combination with trastuzumab, lapatinib, or combined treatment of trastuzumab and lapatinib was evaluated in
patients with HER2-positive, stage II–IIIA breast cancer.58 For all arms, chemotherapy consisted of weekly
paclitaxel followed by 5-fluorouracil–epirubicin–cyclophosphamide. The pCR rate was 28% in the trastuzumab
arm, 32% in the lapatinib arm, and 48% in the combination (trastuzumab–lapatinib) arm. No patient had
symptomatic cardiac events, including CHF. Diarrhea, rash, and hepatic disorders occurred more frequently in
lapatinib-containing arms than in the trastuzumab arm.
Overall, these data suggest that the combined use of trastuzumab and lapatinib might provide superior efficacy
to either agent used alone, with manageable toxic effects. The recent premature closure of the lapatinib-alone
arm of the ALTTO study supports this view.
Mechanisms of resistance
Although trial results anticipated in the next few years will help to optimize the adjuvant trastuzumab therapy
and establish the role of lapatinib, it is likely that inherent and acquired resistance to trastuzumab and lapatinib
will still result in relapse and progression of HER2-positive disease. At the moment, approximately 5,000
patients with HER2-positive breast cancer die from this disease each year in the USA, despite the availability of
trastuzumab and lapatinib (M. Sliwkowski, personal communication). Furthermore, the risk of cardiotoxicity
currently precludes certain patients from trastuzumab treatment, limits the choice of agents that can be used
concurrently with trastuzumab, and necessitates careful cardiac monitoring during HER2-directed therapy. As a
result, there is still a real need for new therapies for patients with HER2-positive breast cancer.
Potential mechanisms of resistance to trastuzumab include factors related to HER2 interactions with other
members of the HER family or trastuzumab, including the loss of,59 or increased, HER2 expression;60 increased
HER1 or HER3 expression;61 increased TGF-α expression (a ligand for EGFR/HER1); steric hindrance of
HER2-antibody interaction by membrane-associated glycoproteins;62 and inhibition of trastuzumab binding by
HER2 ECD fragments cleaved from the HER2 receptor.61 Incomplete HER family blockade might be an
important resistance mechanism, since it could allow another HER receptor to compensate when one receptor is
blocked.63 Resistance to trastuzumab might also arise through alternative signaling pathways or through
constitutive activation of the PI3K/Akt signaling pathway, which is activated by HER2 signaling (and therefore
suppressed by HER2 inhibitors such as trastuzumab). Constitutive activation might occur, for example, due to
mutations in the PIK3CA gene and/or loss of PTEN. Similar to HER2, the IGF-1R, which can form
heterodimers or heterotrimers with HER2,64 activates the PI3K/Akt pathway and this mechanism is thought to
be an important source of trastuzumab resistance.61, 62, 65 Conversely, PTEN suppresses the activation of the
PI3K/Akt pathway and loss of PTEN activity results in increased Akt activity and resistance to trastuzumab.61, 62,
65
In addition, downregulation of the cyclin-dependent kinase p27kip1,62 increased activity of the GTPase p21-
rac1,66 and increased Met receptor tyrosine kinase activity,67 have all been implicated in trastuzumab resistance,
at least in in vitro studies. It is thought that multiple mechanisms of resistance may coexist in trastuzumab-
resistant cells.59
Many of the mechanisms of resistance to trastuzumab would not be expected to interfere with the activity of
lapatinib, notably those involving interactions with the ECD of the HER2 receptor, ligand binding or
dimerization. Resistance due to PI3KCA mutations and a low PTEN expression would be expected to affect the
sensitivity of tumor cells to both trastuzumab and lapatinib.59 However, despite some recent conflicting results,
data suggest that PI3K amino acid substitutions and PTEN loss may be less important in resistance to lapatinib
compared with trastuzumab.61, 68, 69 Indeed, resistance to lapatinib has been attributed to redundant survival
pathways that could be induced as a consequence of a marked inhibition of HER2 kinase activity. For example,
prolonged inhibition of the PI3K/Akt pathway in lapatinib-exposed cells might result in upregulation of the
transcription factor FOXO3A, which in turn leads to increased estrogen receptor signaling.70
Similar to the derepression of estrogen receptor, increased phosphorylation of RelA, the pro-survival subunit of
NFκB, has been proposed as a potential estrogen receptor-independent mechanism of acquired autoresistance to
lapatinib.71 Preclinical data suggest that activation of RelA by persistent exposure to lapatinib might promote
cell survival and, in turn, cause resistance by competing with the drug-induced proapoptotic effects.
A number of therapeutic strategies have been devised to overcome or avoid resistance to trastuzumab and
lapatinib (Table 5). Strategies that are not likely to specifically benefit patients with HER2-positive disease or
do not clearly involve the HER2 pathway (for example, new cytotoxic agents) will not be considered further
here, although such agents can logically be ideal candidates for combination with HER2-targeted therapies
owing to non-cross resistance and non-overlapping toxicity.
Table 5 | New approaches in the therapy of patients with HER2-positive breast cancer *
Antibody modification
ADCC involves an interaction between the constant region (Fc) of an antibody and leukocyte (Fcγ) receptors
(FcγRs). The genotype of the FcγRIIIa-158 correlates with response and progression-free survival (PFS) in
patients receiving trastuzumab-based therapy for metastatic breast cancer, suggesting that ADCC is important in
the antitumor activity of trastuzumab.72 Attempts to improve the immune effector function of therapeutic
antibodies include synthesis of an IgE homolog of trastuzumab,73 and modification of the Fc region by amino
acid substitution or depletion of fucose from the oligosaccharide moiety.74 Recombinant antibodies lacking
fucose show enhanced FcγR binding and ADCC,75 and in mice, nonfucosylated trastuzumab was more effective
against tumor xenografts than unmodified trastuzumab.76 Interestingly, ADCC of a fucose-negative version of
trastuzumab and ADCC of commercial trastuzumab (fucosylated) were analyzed using peripheral blood
mononuclear cells (PBMC) from 30 volunteers including 20 patients with breast cancer.77 PBMC were used as
effector cells and HER2-positive breast cancer cell lines as target cells. The study showed a significantly
enhanced ADCC with the fucose-negative version of trastuzumab, suggesting that removal of a fucose from the
antibody structure could result in improved efficacy (and, possibly, a low dose of the drug required).
Other ways of enhancing the immunological function of trastuzumab include construction of bispecific or
trispecific antibodies, antibody fragments, or single-chain derivatives that bind to specific FcγRs or CD3 on the
surface of immune effector cells, as well as to HER2. Single-chain antibodies can also be manipulated to reduce
unwanted immunological effects, such as cytokine release.78 Most single-chain antibodies have not progressed
beyond preclinical evaluation, although ertumaxomab reached phase II clinical assessment. Ertumaxomab is a
trifunctional, hybrid monoclonal antibody that binds to HER2, CD3, and the FcγR type I/III. Thus, it linked T
lymphocytes and macrophages to HER2-expressing cancer cells, leading to their destruction by phagocytosis.79
In vitro studies indicated that ertumaxomab could destroy cells with low levels of HER2 expression, as well as
those with high HER2 overexpression.80 A phase I study in patients with HER2-positive breast cancer showed
antitumor responses in five of 15 patients, in addition to strong immunological responses in almost all patients.81
Toxicity was mainly related to cytokine release, and systemic inflammatory response syndrome was the dose-
limiting toxicity. Unfortunately, the development of ertumaxomab in breast cancer seems to have been
terminated, although apparently not owing to safety concerns (NCT00522457, NCT00351858 and
NCT00452140).
Arming HER2 targeting agents
Trastuzumab, or derivatives of trastuzumab, have also been used as a means of delivering a range of toxins or
drugs to HER2-expressing cells. However, toxicity (for example hepatotoxicity with pseudomomas exotoxin
conjugates82) can be problematic. The most advanced compound in development is trastuzumab-DM1, a
conjugate of trastuzumab (one molecule) with an average of 3.5 molecules of the microtubule polymerization
inhibitor DM1 (a derivate of maytansine), which retains the known mechanisms of action of trastuzumab,
despite conjugation.83 Thrombocytopenia was a dose-limiting toxicity in a phase I study.84 In two phase II
studies in patients with heavily pretreated HER2-positive cancers who had progressed on trastuzumab and
lapatinib in the metastatic setting, trastuzumab-DM1 produced response rates between 33.8% and 41%.85, 86
Higher response rates were seen in patients with centrally-confirmed HER2-positive disease, reinforcing the
importance of accurate HER2 assessment in patients receiving HER2-targeted therapies.85, 86 Trastuzumab-DM1
also produced higher response rates and had a favorable toxicity profile compared with trastuzumab plus
docetaxel, in a randomized study in previously untreated patients with HER2-positive breast cancer.88 In
particular, the incidence of grade ≥3 adverse events in the trastuzumab-DM1 arm was half that in the
trastuzumab plus docetaxel arm (37% versus 75%), no grade 3 neutropenia was observed with trastuzumab-
DM1, and only 1.5% of patients experienced alopecia. Importantly, trastuzumab-DM1 was not associated with
an increased risk of cardiotoxicity compared with trastuzumab plus docetaxel.88 Currently, randomized studies
are ongoing comparing trastuzumab-DM1 with capecitabine plus lapatinib, and combining trastuzumab-DM1
with pertuzumab, in patients with HER2-positive advanced-stage disease (Table 6).
Table 6 | Key randomized trials of new agents for patients with HER2-positive breast cancer
Inhibition of HER2 dimerization
Although active against HER2 homodimers, trastuzumab is not effective against ligand-induced HER2
heterodimers. HER2–EGFR interactions and, particularly, HER2–HER3 interactions are important in driving
HER2-positive breast cancer cells, and also in bypassing trastuzumab-mediated inhibition of cell growth and
proliferation.3, 4 The monoclonal antibody, pertuzumab, binds to the HER2 ECD but at a different site to
trastuzumab, and is able to inhibit ligand-induced dimerization of HER2 with its receptor partners.89, 90
Preclinical experiments showed that pertuzumab and trastuzumab produced a more-complete blockade of the
HER signaling network when combined, and were more effective in HER2-positive tumor xenografts, than
either antibody alone.91 However, cetuximab, a monoclonal antibody targeting EGFR, did not increase the
antiproliferative effects of either trastuzumab or pertuzumab when administered concurrently.92 In a phase II
clinical trial, treatment with pertuzumab and trastuzumab together resulted in a 24% overall response rate and a
50% clinical benefit rate, in patients with HER2-positive metastatic breast cancer that had previously
progressed on trastuzumab.93 However, efficacy in patients with HER2-negative breast cancer was
disappointingly low (response rates <5%).94
Currently, the efficacy and tolerability of pertuzumab in combination with trastuzumab are being evaluated in
several randomized trials in patients with HER2-positive breast cancer. In the NEOSPHERE neoadjuvant trial,
patients with operable, locally advanced or inflammatory HER2-positive breast cancer were randomized to
receive one of four combination treatments: docetaxel plus trastuzumab and pertuzumab, docetaxel plus
trastuzumab, docetaxel plus pertuzumab, or pertuzumab plus trastuzumab (without chemotherapy).95 A
statistically significant increase in pCR rate was seen when pertuzumab was combined with docetaxel and
trastuzumab as compared with the docetaxel and trastuzumab combination (45.8% versus 29%; P = 0.014; Table
6). Interestingly, a pCR rate of 16.8% was observed in patients who did not receive chemotherapy. Although
promising, these results are not considered to be practice changing because the study was not designed to test
long-term outcomes and pCR is not unanimously accepted as a surrogate for disease-free survival and overall
survival. However, a preliminary announcement of positive data from the CLEOPATRA study (in which
patients with metastatic breast cancer were randomized to received pertuzumab plus trastuzumab and docetaxel,
or placebo plus trastuzumab and docetaxel) suggest that the findings of the NEOSPHERE study may be
validated in this larger and more-definitive trial.
Since trastuzumab and pertuzumab both target the HER2 receptor and are structurally very similar, additive
toxicity might be anticipated when the two drugs are administered concurrently. However, as seen with
concurrent administration of trastuzumab and lapatinib, cardiac toxicity does not seem to be increased when
pertuzumab is given with trastuzumab. A pooled analysis of cardiac safety in 598 patients participating in
pertuzumab clinical trials showed no apparent increase in cardiac dysfunction when pertuzumab was given
concurrently with trastuzumab.96 Of the patients treated with pertuzumab alone, pertuzumab in combination
with a non-anthracycline-containing cytotoxic, or pertuzumab with trastuzumab, 6.9%, 3.4%, and 6.5%,
respectively, developed asymptomatic reduction in LVEF. In addition, 0.3%, 1.1%, and 1.1%, respectively,
developed symptomatic CHF. However, the data on cardiac safety with novel anti-HER2 agents need to be
interpreted with caution because the trials are conducted in carefully selected populations of patients who
tolerated prior trastuzumab treatment.
Selective HER1 or HER3 inhibition
Preclinical data indicate that overexpression of HER2 in breast cancer is frequently associated with
overexpression of HER1, and that inhibition of HER1 enhances the response to trastuzumab in HER1–HER2
co-expressing cells.47, 97 The potential utility of simultaneous HER1 and HER2 inhibition is supported by the
positive findings of lapatinib and pertuzumab trials. However, despite these observations, clinical activity of
selective HER1 inhibitors in patients with breast cancer has been disappointing, either as single agents,98, 99 or in
combination with chemotherapy (in patients unselected for HER2 status),100, 101 or in combination with
trastuzumab in patients with HER2-positive breast cancer.102, 103 As a result, attention has shifted to other
members of the HER family, particularly HER3. Although HER3 has only weak intrinsic tyrosine kinase
activity,104 HER2–HER3 heterodimers form the most potent mitogenic signaling pair in the HER family,105 and
HER3 is now recognized as having a critical role as a co-receptor for amplified HER2.106 Accordingly, HER3
targeting agents are now in development, including several antibodies (Table 5).
Novel tyrosine kinase inhibitors
New tyrosine kinase inhibitors (TKIs) in development for patients with HER2-positive breast cancer include
irreversible TKIs, and TKIs with a broader spectrum of activity than lapatinib (Table 5). Irreversible inhibitors
have been shown to be more potent and to prolong target inhibition compared with lapatinib,107 as well as
potentially bypassing pathways involved in resistance to HER2-targeting agents. Neratinib is the most advanced
irreversible EGFR–HER2 TKI in development for breast cancer. A phase II study of neratinib in 136 patients
with HER2-positive metastatic breast cancer showed a 24% response rate in women previously treated with
trastuzumab, and a 56% response rate in trastuzumab-naive patients. PFS at 16 weeks was 59% and 78%,
respectively—results that compare favorably with other single-agent anti-HER2 therapies.108 No grade 3 or 4
cardiotoxicity related to neratinib was reported, but grade 3 and 4 diarrhea was the most frequently occurring
adverse effect. Neratinib is now being studied in various combinations and in head-to-head comparisons with
trastuzumab, lapatinib and new targeted agents. A phase III trial of adjuvant neratinib has also started (Table 6).
Top of page
Inhibition of the PI3K pathway
The PI3K family is complex, consisting of multiple members, divided into three main classes.109 Class IA PI3Ks
are activated by growth factors via tyrosine kinase receptors (including HER family members) and are most
clearly involved in malignant diseases. Deregulation of this pathway is thought to be a cause of resistance to
HER2-targeted therapies, as well as resistance to cytotoxics and hormonal therapies.109, 110, 111, 112 PI3K pathway
inhibition would be expected to restore sensitivity to trastuzumab and/or lapatinib in patients with HER2-
positive breast cancer, as well as being inherently antiproliferative and proapoptotic. However, multiple PI3K
isoforms are expressed in the heart, where they are involved in hypertrophy and cardiac failure,113 so PI3K
inhibitors have the potential to exacerbate the cardiac toxicity of HER2-targeted agents. PI3K also has an
important role in cellular responses to insulin, and inhibition of PI3K (particularly the p110α catalytic isoform)
can potentially cause insulin resistance. Although this mechanism has not been a major problem in clinical
studies so far, hyperglycemia has been observed in phase I studies.114, 115, 116, 117, 118, 119
Activation of PI3K results in stimulation of Akt and mTOR kinases, leading to the promotion of tumor cell
proliferation and survival. Inhibitors of the PI3K pathway can be categorized into four main groups: PI3K
inhibitors (isoform-specific or pan-class I PI3K inhibitors), dual PI3K–mTOR inhibitors, Akt inhibitors, and
mTOR inhibitors. All seem to have only modest antitumor activity when used alone in patients with breast
cancer and are likely to need co-administration of other agents for optimal activity.120
GDC-0941121 is one of several pan-class I PI3K inhibitors currently in phase I–II clinical development (Table 5).
In preclinical experiments, GDC-0941 was efficacious in trastuzumab-resistant cells,111 was able to suppress the
growth of >70% of breast cancer cell lines when used in combination with trastuzumab, pertuzumab or
lapatinib,110 and was able to render HER2-amplified cells and tumor xenografts more sensitive to docetaxel.110 In
phase I, there was evidence of antitumor activity in three of 19 patients with no grade >3 treatment-related
toxicity or hyperglycemia.114 Ongoing phase I trials are evaluating GDC-0941 in combination with trastuzumab-
DM1 in patients with trastuzumab-resistant HER2-positive breast cancer, and in combination with paclitaxel,
carboplatin and bevacizumab in HER2-unselected metastatic breast cancer.
Several dual PI3K–mTOR inhibitors are in clinical development (Table 5 and Supplementary Table 1 online), of
note, SF1126—a pan PI3K inhibitor. In a phase I trial, SF1126 produced disease stabilization with transient
dose-limiting diarrhea in one patient.117
Three mTOR inhibitors have been evaluated in patients with breast cancer (Table 5). Temsirolimus
monotherapy produced a response rate of <10% in heavily pretreated patients with advanced-stage disease,122
and did not significantly improve the efficacy of letrozole in postmenopausal women with advanced-stage
breast cancer.123 The mTOR inhibitor ridaforolimus has also been evaluated in phase I–II trials and found to
produce generally low response rates.124, 125, 126, 127 The dose-limiting toxicity was mucositis but metabolic effects
including hyperglycemia, hypertriglyceridemia, and hypercholesterolemia were also observed.124, 125, 126, 127
Preliminary data from a phase II trial of ridaforolimus in combination with trastuzumab in trastuzumab-
refractory patients produced two partial responses in the first 14 patients.128 However, there seem to be no
ongoing trials of ridaforolimus in patients with breast cancer.
Trials of everolimus have been more encouraging. Everolimus produced a response rate of 12% as
monotherapy,129 and it was also combined with trastuzumab and chemotherapy with manageable toxicity.130, 131
Many clinical trials of everolimus have now started in patients with breast cancer, including randomized trials in
patients with HER2-positive disease and a trial of trastuzumab plus everolimus in patients with low to moderate
HER2 expression (Table 6).
HSP90 inhibitors
Heat shock protein 90 (HSP90) is a molecular chaperone that stabilizes and prevents the proteasomal
degradation of a range of cellular proteins, including HER2 and other proteins involved in signal transduction
pathways. Inhibition of HSP90 increases the degradation of HER2 and enhances trastuzumab-induced growth
arrest and apoptosis in HER2-expressing breast cancer cells.132 Several HSP90 inhibitors have been evaluated in
patients with breast cancer. Although tanespimycin alone did not show significant antitumor activity in phase I
trials,133 responses were seen in phase II trials when given in combination with trastuzumab to patients with
HER2-positive breast cancer after progression on trastuzumab-containing therapy.134 Five of 21 patients
achieved a partial response to tanespimycin plus trastuzumab and additional minor responses were seen.135
However, despite these promising results and a change in formulation to avoid the necessity of Cremophor to
improve solubility, no further trials of tanespimycin in HER2-positive breast cancer seem to be planned.
Another HSP90 inhibitor, alvespimycin, also seems to have stalled in development for patients with HER2-
positive breast cancer. Although no responses were seen with alvespimycin monotherapy in unselected patients
in phase I,136 there was evidence of antitumor activity when alvespimycin was given in combination with
trastuzumab after failure of trastuzumab-containing therapy.137 However, a subsequent phase II trial in HER2-
positive breast cancer was terminated and there seem to be no new trials of this agent. A phase II trial of
retaspimycin138 in combination with trastuzumab is ongoing in patients with HER2-positive breast cancer
previously treated with trastuzumab, although a similar trial (NCT00627627) was stopped before enrollment,
and development of retaspimycin seems to have ended following termination of a phase III trial in patients with
gastrointestinal stromal tumors owing to high mortality in the experimental arm.139
Other HSP90 inhibitors in development include BIIB021,140 which is orally active and currently being evaluated
in combination with trastuzumab in patients with trastuzumab-resistant HER2-positive breast cancer. AUY922
is also being evaluated as monotherapy in a similar patient population trial (NCT00526045) and several other
compounds are in early clinical development (Table 5).
Multikinase and angiogenesis inhibitors
HER2 signaling induces VEGF transcription (Figure 1), and inhibition of HER2 with trastuzumab has been
shown to result in an antivascular effect.141 These preclinical data provide a basis for the evaluation of
angiogenesis inhibitors in patients with HER2-positive and other forms of breast cancer. To date, clinical trials
of angiogenesis inhibitors in breast cancer have tended to be restricted to patients with HER2-negative disease.
However, this restriction is more due to a low incidence of HER2-positive disease compared to HER2-negative
disease and the practicalities of integrating angiogenesis inhibitors into regimens that already include a HER2-
targeted agent than for scientific reasons. Indeed, since overexpression of HER2 is associated with increased
expression of VEGF and angiogenesis,142 patients with HER2-positive disease might particularly benefit from
treatment with an angiogenesis inhibitor.
The monoclonal antibody, bevacizumab, blocks angiogenesis by binding to circulating VEGF-A, preventing its
binding to the VEGF receptor 2 (VEGFR2). In the USA, bevacizumab was originally granted 'accelerated
approval' by the FDA for use in combination with paclitaxel in patients with metastatic breast cancer, on the
basis of an improvement in PFS in the E2100 trial in patients with predominantly HER2-negative disease.143
The license for bevacizumab in metastatic breast cancer is currently being revoked in the USA following new
studies that failed to confirm a clinically significant improvement in PFS or overall survival, and showed a poor
safety profile for bevacizumab. However, the debate about the therapeutic benefits of bevacizumab in metastatic
breast cancer continues and it is still recommended as a therapeutic option by the Breast Cancer Guideline
Committee of the NCCN and by the European Medicines Agency (EMA).
Bevacizumab has been successfully combined with trastuzumab in a phase II trial,144 and is currently being
evaluated in combination with trastuzumab and chemotherapy in several randomized trials in patients with
HER2-positive disease, including one trial in the adjuvant setting (Table 6). These trials all incorporate careful
cardiac monitoring, because bevacizumab has been associated with adverse cardiac events, most frequently
hypertension, which could potentially exacerbate the cardiac toxicity of co-administered trastuzumab.145
Several multi-targeted kinase inhibitors have been evaluated in patients with breast cancer (Table 5). These are
thought to act as angiogenesis inhibitors by targeting VEGFR, but also to have inhibitory effects on other signal
transduction pathways. However, only modest results have been reported in patients with breast cancer so far,
and only pazopanib seems to be in active development for patients with HER2-positive disease (Table 6).
IGF-1R, cancer vaccines, immunotherapy
Inhibitors of the IGF-1R pathway, cancer vaccines and immunotherapy for HER2-positive breast cancer are
summarized in Table 5. There is a growing interest in HER2 as a target for immunotherapy. Several adjuvant
clinical trials using immunogenic peptides from the HER2 protein (AE37 or E75 or GP2) plus GM-CSF given
intradermally have been performed. Different trials were conducted with a similar dose-escalation design with
increasing doses of peptide (AE37 or E75 or GP2) and varying amounts of GM-CSF. Preliminary data
suggested that all three peptide vaccines were safe and well tolerated. In addition, a synergistic effect between
peptide vaccination and trastuzumab was observed, suggesting that integration of immune vaccination with
standard therapy is a promising strategy.
Conclusions
Currently, treatment with trastuzumab for 1 year in addition to chemotherapy is the only approved HER2-
specific adjuvant treatment for patients with HER2-positive early stage breast cancer. However, many new
agents are in clinical development, including those directed at the HER2 receptor itself, and those targeting
downstream effectors and interacting compensatory signaling pathways. Five new agents are currently in
adjuvant trials in patients with HER2-positive disease: lapatinib and bevacizumab, which are both already
approved for use in patients with advanced-stage breast cancer; the dual EGFR–HER2 inhibitor neratinib; and
the peptide vaccines, GP2 and AE37. Several more agents are in phase III trials in patients with advanced-stage
HER2-positive disease, notably the dimerization inhibitor pertuzumab, the antibody–drug conjugate
trastuzumab-DM1, and the mTOR inhibitor everolimus. Assuming positive results, these new treatments are
likely to enter the adjuvant setting in the near future.
Review criteria
This Review was inspired by a seminar organized by the Fondazione Michelangelo to update clinicians on
current and future treatment options for HER2-positive early stage breast cancer. PubMed was searched for
articles in English published before March 2011 using the terms “breast cancer”, “HER2”, “trastuzumab”,
“lapatinib”, “pertuzumab”, “lapatinib”, “TDM-1”, and “resistance”. Additional relevant references published
 after this date were included. Reference lists from key articles were searched for additional material. Abstracts
from the ASCO and ESMO annual meetings, and San Antonio Breast Cancer Symposium were considered.
Articles were identified on the basis of the authors' knowledge of the clinical development of anti-HER2
therapy for breast cancer. ClinicalTrials.gov was searched for relevant trials.

Taking a Break After 100 Cycles of Bevacizumab

Kathy D. Miller, MD
Feb 04, 2013
Hi. This is Dr. Kathy Miller at Indiana University with a quick Medscape blog to let you know about a
landmark occasion, at least for me personally. My ECOG-2100 (Eastern Cooperative Oncology Group) trial[1]
has been the source of much discussion and much controversy. Many in the community do not know that this
trial has remained open all of these years. It has remained open because 1 patient continued therapy, and if we
had closed the trial, that patient, who was randomly assigned to receive combination treatment, would not have
been able to continue the therapy that had worked so well for her all this time. Late last week, that patient
elected to stop therapy on the trial. Her disease is not progressing and she is not having more toxicity, but she
has now completed 100 cycles of therapy and at that landmark has elected to stop therapy and enter a period of
observation. Because of that, the trial was officially closed early this week.
You may wonder why I am bringing this to your attention. It is not noteworthy except that it reminds us of
something that I learned long ago from Victor McKusick: that we need to treasure those exceptions because we
can learn from them.
We all have those rare patients with metastatic disease who, whether because of the biology of their tumors,
patient factors that we do not understand, or an exquisite sensitivity to therapies, do exceedingly well for a very
long period of time. Perhaps if we focus on those successes, those exceptions -- if we interrogate their tumors
with some of the deep sequencing techniques that we have been discussing in this and other forums, if we talk
to those patients about what else they have been doing and what other things they have added to the equation,
perhaps we can uncover why those patients are such long-term survivors. That may lead us to new interventions
that may help a broader group of patients. So please join me in congratulating this remarkable woman and
wishing her well. This probably marks the end of an era for bevacizumab in breast cancer.
Think about this the next time you see those exceptions in your practice. What can you learn from them that
may be of value?
I will be back with you again soon with another topic.
References
1. Miller K, Wang M, Gralow J, et al. Paclitaxel plus bevacizumab versus paclitaxel alone for metastatic
breast cancer. N Engl J Med. 2007;357:2666-2676. Abstract

Timing of Trastuzumab Administration Does Not Affect Benefit in Breast Cancer

November 28, 2013
NEW YORK (Reuters Health) Nov 28 - In the neoadjuvant treatment of HER2-positive breast cancer,
administering trastuzumab concurrently with anthracyclines offers no advantage over sequential administration,
according to the results of a new multicenter trial.
The researchers compared the two approaches to neoadjuvant therapy in 282 women with operable HER2-
positive invasive breast cancer. The participants underwent surgery within six weeks after completing treatment.
Those randomly assigned to sequential neoadjuvant treatment received fluorouracil, epirubicin, and
cyclophosphamide (FEC) for four cycles, followed by paclitaxel and trastuzumab weekly for 12 weeks. The
concurrent treatment group received paclitaxel and trastuzumab for 12 weeks followed by four FEC cycle plus
weekly trastuzumab.
The pathological complete response rate was 56.5% in the sequential treatment group compared to 54.2% in the
concurrent treatment group, Dr. Kelly K. Hunt, at the University of Texas MD Anderson Cancer Center in
Houston, and colleagues found.
Rates of neutropenia were 25.3% and 31.7% in the two groups, respectively, according to the report in The
Lancet Oncology, online November 13.
While cardiotoxic effects of delivering trastuzumab along with anthracyclines is an ongoing concern, rates of
depressed left ventricular ejection fraction after 24 weeks of treatment were 7.1% in the sequential treatment
arm and 4.6% in the concurrent treatment group.
"However," Dr. Hunt and colleagues point out, "because of the small sample size, differences between
treatments in terms of cardiac tolerability during neoadjuvant treatment might not have been evident."
Overall, they conclude, "Concurrent administration of trastuzumab with anthracyclines offers no additional
benefit and is not warranted."
The authors of an accompanying editorial agree with that assessment, "although not because of lack of safety
nor lack of efficacy."
Drs. Shannon Puhalla and Adam Brufsky at the University of Pittsburgh Cancer Institute, Pennsylvania, explain
that dual HER2 blockade has now entered neoadjuvant treatment for early breast cancer. "The substantial
benefit of combined HER2-targeted neoadjuvant treatment probably renders the question of anthracycline with
concurrent trastuzumab versus sequential trastuzumab irrelevant."
SOURCE: http://bit.ly/1b4M89z and http://bit.ly/1b4M89z
Lancet Oncol 2013.

EU Approves Trastuzumab Emtansine for HER2 Breast Cancer

Zosia Chustecka
November 20, 2013
Trastuzumab emtansine (Kadcyla, Roche/ImmunoGen) has now been approved in Europe for use in the
treatment of HER2-positive metastatic breast cancer, following a positive opinion issued in September.
The product was approved in the United States in February, and was approved in Japan in September.
The novel product is comprised of the HER2-targeting monoclonal antibody trastuzumab linked to the cytotoxic
agent DM1 (the product is also known as T-DM1). It is approved for use in patients with HER2-positive
metastatic breast cancer who were previously treated with trastuzumab (Herceptin, Genentech/Roche) and a
taxane chemotherapy, separately or in combination.
This indication is based on results from the pivotal phase 3 EMILIA study, which involved 991 patients and
showed a significantly improved overall survival for those on the novel drug. Patients on trastuzumab emtansine
survived nearly 6 months longer than patients receiving the standard therapy of lapatinib (Tykerb) plus
capecitabine (Xeloda) (median overall survival, 30.9 vs 25.1 months), and also experienced fewer severe
adverse (reported by 43.1% vs 59.2% with standard therapy).
In the press release announcing the European Union approval, Roche gave further details about the adverse
events reported as follows. The most common grade 3 or higher adverse events reported in patients receiving
trastuzumab emtansine were thrombocytopenia (12.9%), elevated AST (4.3%), elevated ALT (2.9%), anemia
(2.7%), fatigue (2.4%), hypokalemia (2.2%), and neutropenia (2%). For patients receiving lapatinib and
capecitabine, they were diarrhea (20.7%), hand and foot syndrome (16.4%), vomiting (4.5%), neutropenia
(4.1%), fatigue (3.5%), nausea (2.5%), and mucosal inflammation (2.3%).
When the EMILIA trial results were first reported, breast cancer experts were enthusiastic about both the
survival advantage and the reduced adverse events. Kathy Miller, MD, associate professor of medicine at
Indiana University School of Medicine in Indianapolis, said in her Medscape videoblog: "This is the classic
light-beer scenario: It's less filling and tastes great. T-DM1 was more effective by every measure: improvement
in overall response rate, disease-free survival, progression-free survival, overall survival, and less toxicity. It
was a clear winner if ever there was one."
However, after the product was launched, there was frustration about its high price tag. This product is the third
HER2-targeted therapy from the Roche/Genentech stable. The original targeted drug trastuzumab (Herceptin)
was launched 1988, and in the United States costs around $4500 per month, then in 2012 came pertuzumab
(Perjeta), which costs around $6000 per month, and now there is trastuzumab emtansine, which costs around
$9800 per month.
British Journal of Cancer (2011) 104, 1675–1679. doi:10.1038/bjc.2011.138 www.bjcancer.com
Trastuzumab beyond progression in HER2-positive advanced breast cancer: The Royal
Marsden experience
T Waddell1,3, A Kotsori1,3, A Constantinidou1, N Yousaf1, S Ashley2, M Parton1, M Allen1, N Starling1,
P Papadopoulos1, M O'Brien1, I Smith1 and S Johnston1
Background:
Recent UK clinical guidance advises against continuing trastuzumab (T) beyond disease progression (PD) in the
absence of brain metastases in patients with HER-2 positive (+ve) advanced breast cancer .We have
retrospectively evaluated the outcome of patients with HER-2+ve locally advanced (LA) or metastatic breast
cancer (MBC) who continued T beyond PD, treated in our unit.
Methods:
All HER-2+ve patients on our prospectively maintained database with LA or MBC who received T beyond PD
after adjuvant or one line of T for advanced disease were assessed for response and outcome. From the
timepoint of T continuation beyond PD, we calculated the overall disease control rate, time to progression
(TTP), and overall survival (OS).
Results:
One hundred and fourteen patients with HER-2+ve LA or MBC treated with T beyond PD were identified. The
main site of disease was visceral_in 84 (74%) patients. Seventy-six (66%) had one line of chemotherapy before
continuation of T beyond PD and 21 (19%) had two or more. Post-progression, 66 (58%) received T combined
with chemotherapy. Of the 93 (82%) patients with documented clinical or radiological response evaluation, 67
(59%) were considered as having stable disease or better. The median TTP was 24 weeks (95% CI: 21–28) and
the median OS was 19 months (95% CI: 12–24).
Conclusion:
Our results from an unselected group of patients provide additional evidence that continuation of T beyond PD
is of clinical benefit.

Quantification and Clinical Relevance of Gene Amplification at Chromosome

17q12-q21 in Human Epidermal Growth Factor Receptor 2-amplified
Breast Cancers
Pierre-Jean Lamy; Frédéric Fina; Caroline Bascoul-Mollevi; Anne-Claire Laberenne; Pierre-Marie Martin;
L'Houcine Ouafik; William Jacot
Posted: 05/03/2011; Breast Cancer Research. 2011;13(1):R15 © 2011 BioMed Central, Ltd.
Abstract and Introduction
Abstract
Introduction: Human epidermal growth factor receptor 2 (HER2)-amplified breast cancers represent a tumor
subtype with chromosome 17q rearrangements that lead to frequent gene amplifications. The aim of this study
was to quantify the amplification of genes located on chromosome 17q and to analyze the relations between the
pattern of gene amplifications and the patients' characteristics and survival.
Methods: Patients with HER2-positive breast tumors (HER2 score of 3+ by immunohistochemistry or positive
for HER2 amplification by fluorescence in situ hybridization (FISH)) (n = 86) and with HER2-negative breast
tumors (n = 40) (negative controls) were included in this study. Using a quantitative polymerase chain reaction
method and DNA extracted from frozen tumor specimens, 11 genes (MED1, STARD3, HER2, GRB7, THRA,
RARA, TOP2A, IGFBP4, CCR7, KRT20, KRT19 and GAS), which are localized within Chr17q12-q21 and
have a putative role in breast cancer development, were quantified. Relapse-free and overall survival rates were
estimated from the date of surgery to the date of the event of interest (recurrence or death) using the Kaplan-
Meier method.
Results: Gene amplification was observed only in HER2-positive tumors, and the frequency of amplification
decreased with the distance of the gene from HER2. HER2 presented the highest level of amplification. TOP2A
was not included in the smallest region of amplification involving HER2. Amplification of RARA, KRT20 and
KRT19 was significantly associated with node-positive breast cancer (P = 0.030, P = 0.002 and P = 0.033,
respectively). During a median follow-up period of 55 months (range, 6 to 81 months), the subgroup of patients
with hormone receptor-negative cancer and without TOP2A amplification showed the worst survival (relapse-
free survival: hazard ratio (HR) = 0.29, 95% confidence interval (95% CI), 0.13 to 0.65, P = 0.001; and overall
survival: HR = 0.28, 95% CI, 0.10 to 0.76, P = 0.008).
Conclusions: HER2 amplification seems to drive genomic instability along chromosome 17q, leading to
different patterns of gene amplification. This study confirms the clinical importance of identifying, among
patients with HER2-positive breast tumors, the subgroup of patients with hormone receptor-negative and
nonamplified TOP2A cancers as they have the worst prognosis.
Introduction
Gene amplification at chromosome 17q (Chr17q) involves the human epidermal growth factor receptor 2
(HER2) gene and is observed in about 15% to 20% of breast cancers. HER2 amplification is associated with
aggressive tumor behavior (increased metastatic potential and reduced survival), and it also predicts a patient's
response to trastuzumab therapy.[1,2] Although HER2-positive breast cancers are classified as a tumor subgroup,
they are quite heterogeneous. Indeed, they can be divided more or less equally into hormone receptor-negative
(estrogen receptor/progesterone receptor-negative, or ER/PR-negative) and hormone receptor-positive (ER/PR-
positive) tumors. In the ER/PR-positive subgroup, development of resistance to antihormonal therapy could be
explained by the cross-talk between the HER2 and ER pathways.[3] Furthermore, first-line treatment of HER2-
positive breast cancers with trastuzumab presents response rates that vary between 25% and 35%, and the
benefit of trastuzumab therapy has been shown only in patients with high levels of HER2 amplification.[4]
Comparative genomic hybridization arrays and fluorescence in situ hybridization (FISH) studies have shown
that HER2-amplified breast cancers present a variety of alterations on Chr17 and gene amplifications at
Chr17q12-q21 are particularly frequent and complex.[5] Among the genes that are located in this region and have
been reported to be amplified in breast cancers, topoisomerase IIα (TOP2A), a gene coding for the enzyme
targeted by anthracyclines, is located 2 Mb from HER2. TOP2A amplification might be linked to the sensitivity
to anthracyclines observed in HER2-positive breast tumors.[6–18] Most of the published data indicate that TOP2A
amplification occurs only in HER2-amplified tumors. However, some authors have reported cases in which
TOP2A was amplified also in the absence of HER2 amplification.[19,20] Interestingly, the same studies do not
support the role of TOP2A amplification as a predictive marker for response to anthracyclines. These works
also report a different frequency of TOP2A amplifications and deletions. The presence of TOP2A deletions,
often analyzed together with TOP2A amplification, has complicated the question of the relations among TOP2A
alteration, prognosis and response to anthracyclines. Technical issues, the cutoff levels used to classify a gene as
amplified or deleted and different quality assurance guidelines could also explain these discrepancies.[21,22]
Nevertheless, the molecular variations within the Chr17q amplicon and their clinical implications remain
largely unknown. Indeed, besides TOP2A, other genes which are located not only in the HER2 smallest region
of amplification (SRA)[23,24] but also all along the long arm of the Chr17[5,24–27] might also be amplified, and they
could play functional roles in breast cancer development and progression. To explore this hypothesis, we carried
out a quantitative analysis of a set of 11 genes that were chosen for their localization along Chr17q12-q21 and
for their putative role in breast cancer development. Two genes were located on the centromeric side (MED1
and STARD3), and nine were located on the distal side (GRB7, THRA, RARA, TOP2A, IGFBP4, CCR7,
KRT20, KRT19 and GAS) of Ch17q12-21 relative to HER2 localization. The relation between gene
amplification and patients' characteristics and survival was then analyzed. We show that amplification of
TOP2A and of other genes distal to HER2 does not occur in tumors in which HER2 is not amplified. We
confirm that TOP2A is not included in the SRA involving HER2 and describe different copy number alterations
along the distal side of Chr17q. We also show that TOP2A nonamplification is related to worse survival in the
subpopulation patients with of ER/PR-negative tumors.
Discussion
In this work, we quantified gene amplification in the 17q12 to 17q21 region around HER2 in HER2-amplified
breast tumors. Among the patients with primary breast cancer, fewer than 12% had HER2-positive tumors. This
result is in accordance with recent studies reporting 12% to 15% of HER2 amplification compared to the 20% to
25% found in historical studies,[29,30] in which Chr17 polysomy may have led to discordant interpretations
between higher signals due to polysomy and those due to an absolute increase of HER2 gene copy number in a
significant proportion of cases.[31] Gene amplification on the centromeric side (MED1 and STARD3) and the
distal side (GRB7, THRA, RARA, TOP2A, IGFBP4, CCR7, KRT20, KRT19 and GAS) relative to HER2
localization on Chr17q was determined by qPCR, an efficient method for performing copy number analysis,[32]
and with reference genes located on Chr17 (SSTR2) and Chr4 and Chr2 (GAPDH and ACBT, respectively) to
differentiate polysomy from true amplification. In fact, tumors presenting only Chr17 polysomy should not be
considered as HER2-amplified, and patients with this presentation might not benefit from anti-HER2 therapy,
although these tumors present moderate HER2 overexpression,[28,33] but only as a result of treatment with
anthracyclines.[34]
We have confirmed that gene amplification, including that of TOP2A, occurs only in patients with HER2-
amplified breast tumors. We then showed that HER2 presents the highest amplification value and that the
frequency of amplification of a gene decreases with its distance from HER2. These results suggest that
instability within Chr17q is driven by HER2 amplification. Indeed, HER2-positive tumors have higher levels of
overall genomic instability than HER2-negative tumors, supporting the idea that HER2 amplification is the key
amplicon driver on Chr17q.[35,36] Moreover, we found a correlation between the amplification levels of HER2
and that of MED1, STARD3 and GRB7, but not of TOP2A and the other genes localized on the distal side of
Chr17q. Therefore, the SRA of HER2 seems to be limited to a small number of genes, among which are
STARD3 and GRB7 as described by Katoh et al. [37] and as recently reported by Beroukhim et al. [38] in different
cancer types. Kuwahara et al. [39] identified a region between HER2 and GRB7 (a gene located 47 kb from
HER2) that contains a recombinant hot spot for amplification, deletion and translocation. This site might be
located between GRB7 and THRA, a gene located 315 kb from GRB7, given that 84 (97.7%) of the cancer
specimens we assessed presented GRB7 amplification, whereas only 47 (54.7%) showed THRA amplification.
The presence of this hot spot might explain why the frequency of recombination for a gene is higher when it is
located closer to HER2 and gradually decreases for genes located far away from HER2. In general, the gene
amplification architectures derived from our results illustrate the complexity of the rearrangement mechanisms
(sister chromatid breakage-fusion-bridge cycles, formation and reinsertion of double minutes and repeated units
at a single locus) and highlight the diversity of HER2-amplified cancers.[40,41]
Finally, we found a low overall number of deletions (<5.8%), regardless of the gene analyzed. For TOP2A, the
deletion rate was 4.7%, which is low compared with values found in other studies (between 8.1% and 35%).[22]
This might be explained by the fact that in heterogenic tumors, which simultaneously present amplifications and
deletions, qPCR cannot detect deletions that are present in a very small number of cells. It is also possible that
in certain studies the percentage of tumors with deletions was overestimated as a result of poor standardization
of the FISH technique. Indeed, Di Leo et al. [42,43] recently showed high interlaboratory variations for TOP2A
quantification, whereas Press et al. [44] found a deletion rate comparable to ours in a prospective study using
standardized FISH.
We then investigated the clinical impact of Chr17 anomalies. Amplification of RARA, KRT20 and KRT19
correlated with node invasion, suggesting that tumors with amplification of genes on the distal side of Chr17q
are more aggressive than tumors with amplifications restricted to the SRA of HER2. MED1 amplification
showed a tendency to be associated with ER-positive tumors. MED1 encodes the mediator complex subunit 1
(MED1)[45] that anchors mediator to ERβ[46] while also interacting with ERα.[47] Although our study did not show
any significant impact of MED1 amplification on survival, the prognostic value of MED1 should nevertheless
be evaluated in a larger ER/PR-positive population. Similarly, TOP2A amplification was not a statistically
significant prognostic factor, but patients with tumors in which TOP2A was amplified tended to have better
RFS and OS rates (see Figure 2b). This result is in accord with a recent study in which patients with HER2-
positive, TOP2A-amplified cancers presented a trend of better survival than patients with HER2-positive breast
cancers with deleted or normal TOP2A.[48] Conversely, the subgroup of patients with ER/PR-negative breast
cancers and nonamplified (normal or deleted) TOP2A showed the least favorable RFS and OS rates in our
population. We could not determine whether the prognosis was even less favorable in the case of ER/PR-
negative tumors with TOP2A-deleted status than of tumors with normal TOP2A. Nevertheless, TOP2A
deletions, which are often heterozygous,[49] do not result in total loss of expression of the protein.[50] Their
unfavorable prognosis might be explained by the fact that ER/PR-negative, TOP2A nonamplified tumors may
not be responsive to hormone therapy and/or to anthracycline-based therapy because of the absence or
insufficient number of targets. Adjuvant therapy would thus not be beneficial for these patients. Indeed, recent
findings suggest that the presence of TOP2A deletions is not associated with better chemosensitivity or response
to anthracyclines, while the occurrence of TOP2A amplifications may identify a subgroup of patients with
increased response to anthracyclines.[18,44] Many studies have been conducted on the impact of the presence of
HER2 and TOP2A amplifications on survival and response to chemotherapy. Only a few studies found that
there was no benefit to treating patients with HER2-positive cancer with anthracyclines or that TOP2A
amplification had no predictive value. The subject remains controversial,[51] but nevertheless two large trials (the
National Surgical Adjuvant Breast and Bowel Project B-11 and the National Cancer Institute of Canada MA.5
studies) have retrospectively shown a correlation between HER2 amplification and benefit from adjuvant
anthracycline-based chemotherapy.[52,53] Moreover, a pooled analysis that included 8 studies and 1,536 HER2-
positive patients indicated that anthracyclines were superior to non-anthracycline-based regimens in terms of
disease-free and overall survival.[54]
Conclusions
Few studies have used qPCR to assess gene copy number alterations in HER2-amplified breast cancer. The
assay we have developed can be used to assess the amplification status of multiple genes. We have shown that
MED1, STARD3, TOP2A, GRB7, THRA, RARA, IGFBP4, CCR7, KRT19, KRT20 and GAS amplification
occurred only in HER2-amplified breast cancers with variable frequencies. We have confirmed that HER2
seems to drive genomic instability along Chr17q and that TOP2A was not included in the SRA of HER2. The
different patterns of amplification we observed suggest complex amplification mechanisms leading to a variety
of subtypes. RARA, KRT19 and KRT20 amplification could be related to a more invasive breast cancer profile.
Moreover, we confirm the clinical importance of identifying the subgroup of patients with ER/PR-negative,
TOP2A nonamplified cancer, as they have the worst prognosis. A prospective study including a larger number
of patients treated with trastuzumab and anthracycline-based adjuvant therapy would be useful to determine the
predictive value of TOP2A amplification and the prognostic value of gene copy number variations along
Chr17q.

HER-3 Overexpression is Prognostic of Reduced Breast Cancer Survival: A

Study of 4046 Patients
Connie G. Chiu, MD; Hamid Masoudi, MD; Samuel Leung, MSc; David K. Voduc, MD, FRCPC; Blake Gilks,
MD, FRCPC; David G. Huntsman, MD, FRCPC; Sam M. Wiseman, MD, FRCSC
Posted: 07/05/2010; Annals of Surgery. 2010;251(6):1107-1116. © 2010 Lippincott Williams & Wilkins
Abstract and Introduction
Abstract
Introduction: Advances in molecular biology have led to the identification of potential markers of prognostic
and therapeutic importance in human cancers. HER-2 testing and targeted therapy now represents a critical
cornerstone in the management of breast cancer. The objectives of the current study were to determine the
frequency and prognostic significance of HER-3 over-expression and HER-4 over-expression by invasive breast
cancer.
Methods: Tissue microarrays were constructed using clinically annotated formalin-fixed and paraffin-
embedded tumor samples from 4046 patients diagnosed with invasive breast carcinoma with a median 12.5
years of follow-up. Type 1 growth factor receptor family members HER-1, HER-2, HER-3, and HER-4
expression levels were determined by immunohistochemistry, and HER-2 status was further resolved by
fluorescent in-situ hybridization. The study cohort was randomly divided and analyzed as a core data set and a
validation data set.
Results: HER-3 over-expression was identified in 10.0% of tumors and was a significant marker of reduced
patient breast cancer-specific survival on univariate analysis (P = 1.32 × 10−5). Furthermore, in tumors with
normal expression levels of HER-1 and HER-2, the overexpression of HER-3 had a significant negative
prognostic effect on disease-specific survival (HR: 1.541, 95% CI: 1.166–2.036, P = 2.37 × 10−3) independent
of patient age at diagnosis, Estrogen receptor status, tumor grade, tumor size, nodal status, and the presence of
lymphatic or vascular invasion by cancer. HER-4 overexpression was identified in 78.2% of breast cancers and
was not a significant marker of patient survival (P = 0.214). Results of all statistical tests were positively
confirmed in the validation data set analysis.
Conclusions: HER-3 status is an important prognostic marker of disease-specific survival in patients with
invasive breast cancer. Accordingly, evaluation of the HER-3 expression level may identify a subset of patients
with a poor disease prognosis, and who could undergo further evaluation for the efficacy of HER-3 targeted
anticancer agents.
Introduction
The utilization of clinicopathologic and tumor molecular characteristics to determine patient prognosis and
response to treatment represents a critical cornerstone in the current management of breast cancer. Recognized
breast cancer disease prognosticators include: patient age, tumor grade, tumor size, lymph node status, and
lymphatic or vascular invasion by cancer.[1–4] The recent development and widespread clinical application of
HER-2 testing and HER-2 targeted anticancer drugs, such as trastuzumab (Herceptin, Genetech Inc., South San
Francisco, CA) to breast cancer, underscores the importance of cancer biomarker discovery.[5,6]
HER-2 is a transmembrane receptor that functions in conjunction with other members of the type 1 growth
factor receptor (T1GFR) family.[7] The T1GFR family consists of 4 known members: HER-1 (also known as
epidermal growth factor receptor, EGFR, and c-erb B-1), HER-2 (c-erb B-2), HER-3 (c-erb B-3), and HER-4
(c-erb B-4). The T1GFRs are transmembrane receptors with an extracellular ligand-binding domain, and an
intracellular tyrosine kinase domain, that exist as monomers in their inactivate form. Upon ligand binding the
T1GFRs form dimers (with themselves or other family members) and initiate a signaling cascade through
activation of its tyrosine kinase, leading to cellular proliferation and transformation.[8–10] For breast cancer,
HER-2 is the preferred dimerization partner for other T1GFRs,[11] and it exerts increased signaling potency
through a reduced rate of ligand dissociation and receptor internalization.[12–14]
Despite the well-recognized role of HER-2 in tumorigenesis and cancer progression,[10] this receptor is only
active upon dimerization with other T1GFR members.[15,16] Despite there being greater than 30 ligands that have
been identified that bind the T1GFRs, there are no reported ligands that bind HER-2.[16,17] Similarly, HER-3
must also form heterodimers for cellular signaling because it lacks intrinsic tyrosine kinase activity, although it
has the ability to bind ligand.[18,19] This reciprocal relationship between HER-2 and HER-3 illustrates the unique
evolution of the T1GFR family.[20] In particular, HER-3 has been found to be the preferred dimerization partner
for HER-2,[11] and together they form the most mitogenic couplet among all the T1GFR family members.[21]
The cooperative signaling of HER-2 and HER-3 in breast cancer oncogenesis has been demonstrated in multiple
transgenic animal models. In an analysis of lysates derived from mammary tumors of HER-2 transgenic mice,
protein levels of HER-3 were identified to be elevated when compared with adjacent normal tissue, while HER-
1 and HER-4 protein levels remained largely unchanged.[22] Furthermore, in breast cancer cell lines
overexpressing HER-2, the blockade of HER-3 gene expression led to the loss of the proliferative state that was
similar to the levels observed when HER-2 gene expression was blocked. Interestingly, blockade of HER-1
gene expression blockade did not influence breast cancer cell growth.[23] Additionally, HER-3 has been found to
be coupled with potent mitogenic pathways involved in T1GFR signaling.[24]
The current study was carried out to validate the observations made in a prior study carried out by our group in
which archival tumors from 242 patients with invasive breast cancer were characterized for T1GFR family
expression by immunohistochemistry (IHC) utilizing tissue microarrays (TMAs).[25] HER-3 over-expression
was identified in 12.0% of tumors and was significantly associated with decreased breast-cancer-specific
survival by both univariate and multivariate analyses. HER-4 overexpression was not significantly associated
with patient survival. The current study evaluated a much larger breast cancer patient cohort with an extensive
patient follow-up period.
Currently, HER-2 cellular signaling has been reported to be critically dependent on the expression of other
TIGFR family members, and in particular, HER-2/HER-3 heterodimers represent the most mitogenic couplet
among all T1GFR dimers or heterodimers. Furthermore, HER-2 expression status of the primary breast tumor
has also been reported to be of prognostic and therapeutic utility for breast cancer patients, and has been widely
incorporated into recent clinical practice. The objectives of the current study were to determine the frequency
and prognostic significance of HER-3 overexpression and HER-4 overexpression by invasive breast cancer.
Trastuzumab-DM1 is Effective and Less Toxic for First-line Therapy of HER2-positive Metastatic Breast
Cancer
Posted: 02/08/2011; Ther Adv Med Oncol. 2011;3(1):3-9. © 2011 Sage Publications, Inc.
Edith Perez (Mayo Clinic, Jacksonville, FL, USA) presented the results of the first randomized trial of T-DM1
as a first-line treatment for metastatic breast cancer. T-DM1 is an antibody–drug conjugate consisting of
trastuzumab, which targets cells that overproduce human epidermal growth factor receptor 2 (HER2) protein,
and DM1, a cell-killing agent that targets microtubules.
There were 137 women with HER2-positive metastatic breast cancer (with no prior chemotherapy for their
metastatic disease) who received trastuzumab plus docetaxel or T-DM1. Median follow up at approximately 6
months revealed an overall response rate of 48% in patients administered T-DM1 compared with 41% in the
trastuzumab plus docetaxel group. Notably, clinically relevant adverse events were significantly lower with T-
DM1 (37%) compared with traztuzumab plus docetaxel (75%).
Professor Perez explained that the trial is ongoing; however, the early results have prompted a phase II trial to
begin, MARIANNE, which will evaluate taxane plus trastuzumab versus T-DM1 versus T-DM1 plus
pertuzumab.
These initial results are heartening because they suggest that future therapies may be as effective but less toxic.
Linking of a monoclonal antibody to a cytotoxic drug may thus become a therapeutic possibility not only for
HER2 targeting but also for other specific cancers.

Semiquantitative Hormone Receptor Level Influences Response to

Trastuzumab-containing Neoadjuvant Chemotherapy in HER2-positive
Breast Cancer
Rohit Bhargava; David J Dabbs; Sushil Beriwal; Isil A Yildiz; Preeti Badve; Atilla Soran; Ronald R Johnson;
Adam M Brufsky; Barry C Lembersky; Kandace P McGuire; Gretchen M Ahrendt
Posted: 03/14/2011; Modern Pathology. 2011;24(3):367-374.
Abstract
Pathologic complete response to neoadjuvant chemotherapy without trastuzumab in hormone receptor-
negative/HER2+ tumors is seen in 27–45% of cases. In contrast, estrogen receptor (ER)+/HER2+ tumors
demonstrate pathologic complete response in ~8% of cases and is generally limited to weak-to-moderate
ER+/HER2+ tumors. It is speculated that addition of trastuzumab to neoadjuvant chemotherapy regimen will
increase the pathologic complete response rates in all HER2+ tumors. A list of HER2+ patients who received
neoadjuvant chemotherapy (with trastuzumab) in the years 2007–2010 was obtained from our hospital database.
The 104 HER2+ tumors were classified into three groups based on semiquantitative hormone receptor and
HER2 results as follows: ERBB2 (ER–/PR–[H-score ≤10]/HER2+), Luminal B-HER2 Hybrid (LBHH; weak to
moderate ER+ [H-score 11–199]/HER2+), and Luminal A-HER2 Hybrid (LAHH; strong ER+[H-score
≥200]/HER2+). Pathologic complete response was defined as absence of invasive carcinoma in the resection
specimen and in the lymph nodes. Percentage tumor volume reduction was also calculated based on pretherapy
size and detailed evaluation of the resection specimen. In all, 52% (25 of 48 cases) of ERBB2 tumors showed
pathologic complete response, which was significantly higher than the pathologic complete response rate in
LBHH (33%; 10 of 30) and LAHH (8%; 2 of 26) tumors. Average percentage tumor volume reduction was also
highest in ERBB2 tumors (86%), followed by LBHH (74%) and LAHH (64%) tumors. We conclude that
addition of trastuzumab to neoadjuvant chemotherapy regimen significantly increases the pathologic complete
response rates in all HER2+ tumors. However, the benefit of trastuzumab is highest in ER-negative tumors and
progressively decreases with increase in tumor ER expression. This information can be utilized to counsel
patients considered for neoadjuvant chemotherapy and the same principle could be applied in the adjuvant
setting.
Introduction
Preoperative or neoadjuvant chemotherapy is increasingly used in breast carcinoma since studies have shown no
difference in survival benefits with respect to timing of chemotherapy (before or after surgery).[1–4] Moreover,
the benefits of neoadjuvant chemotherapy from surgical and investigational standpoint are manifold. A few
years ago, neoadjuvant chemotherapy was used only in locally advanced breast cancers that were deemed
inoperable.[5] More recently, it has been increasingly used for tumors that are resectable, but the intent is to
reduce the tumor size by neoadjuvant chemotherapy and subsequently remove a smaller portion of breast tissue
than would otherwise be removed at primary surgery.[6–8] Breast cancer is a heterogeneous disease at
morphological, immunohistochemical and even at molecular level. Therefore, some breast carcinomas respond
completely to neoadjuvant chemotherapy and others show minimal or no response. From a surgeon's
perspective, it is important to know in advance if they will be able to convert a mastectomy to breast-conserving
surgery at the time of initial evaluation.
Recent studies have shown that pathologic complete response is seen in significant proportion of estrogen
receptor (ER)-negative tumors and is only rarely observed in ER-positive disease.[9–12] In our previous study of
359 cases, pathologic complete response was observed in 33% of ER−/PR−/HER2+ cases, 30% of triple-
negative cases and in <10% of ER+ cases. Among the ER+ tumors, pathologic complete response was
predominantly seen in tumors that co-expressed HER2 with low-to-moderate ER expression.[9] Although
pathologic complete response was seen mainly in ER-negative tumors, tumor volume reduction was seen in
most carcinomas and appeared to be inversely related to tumor ER expression (especially in HER2+ tumors). In
these previous studies, including our previous study, most patients were treated with chemotherapy regimens
that did not include trastuzumab.[9,11,13] This is because trastuzumab has been only rarely used in neoadjuvant
chemotherapy regimens before 2006, where its use was limited to clinical trials (MD Anderson trial, NOAH
trial and GeparQuattro trial).[14–16] Recently, trastuzumab is increasingly used preoperatively in HER2+ breast
carcinoma, often as TCH regimen (Taxotere®, carboplatinum, Herceptin®) or as AC followed by TH (ie,
adriamycin, cyclophosphamide followed by taxane and herceptin) or in some other combination.[17, 18]
Pathologic complete response to neoadjuvant chemotherapy without trastuzumab in hormone receptor-
negative/HER2+ tumors is seen in 27–45% of cases.[9,10,12] In contrast, ER+/HER2+ tumors demonstrate
pathologic complete response in ~8% of cases and is generally limited to weak-to-moderate ER+/HER2+
tumors.[9] It is speculated and also shown in recently concluded clinical trials that addition of trastuzumab to
neoadjuvant chemotherapy regimen will increase the pathologic complete response rates in all HER2+ tumors.
[14–16,19]
However, even in these clinical trials the effect of trastuzumab on different subsets of HER2+ tumors has
not been addressed. The primary aim of this study was to analyze the rate of pathologic complete response in
different types of HER2+ tumors. We also objectively calculated residual tumor volume and studied percentage
tumor volume reduction to trastuzumab-containing chemotherapy in different categories of HER2+ tumors.
Discussion
Neoadjuvant or preoperative chemotherapy in operable breast cancer is increasingly used despite some
disadvantages. The specific disadvantages are loss of prognostic information in node-negative tumors treated
with preoperative chemotherapy, lack of reliability of negative margins in tumors that show assymetric
reductions, potential for overtreating patients with clinically sizable tumors that are composed predominantly of
noninvasive disease, the patient anxiety associated with leaving a resistant tumor in the patient while they are on
neoadjuvant chemotherapy and loss of untreated primary tumors for other research purposes. Although the
above arguments seem significant, there are several equally significant arguments in favor of neoadjuvant
chemotherapy. Neoadjuvant chemotherapy provides an opportunity to examine the in vivo tumor responsiveness
to particular chemotherapy regimen. Recent data in breast cancer also show that patient survival is not affected
by timing of chemotherapy. Moreover, at least some degree of tumor volume reduction is achieved in a majority
of breast cancer cases. Therefore, many patients for whom a mastectomy is initially proposed can be later
changed to breast-conserving surgery after neoadjuvant chemotherapy. Last, but not the least, chemotherapy
could be started for patients who are waiting for surgery because of pending gene testing results or other
reasons. Because of these reasons, neoadjuvant chemotherapy is increasingly used in breast cancer. However,
the therapeutic regimens used are quite variable but most patients receive adriamycin- and/or taxane-based
chemotherapy. In the last 5 years, trastuzumab is increasingly used in the neoadjuvant regimens for HER2+
tumors. Although the effectiveness of trastuzumab in HER2+ tumors is well established in the adjuvant setting,
there is still paucity of studies analyzing response in the neoadjuvant setting.
The molecular studies using gene expression analysis have classified breast cancers into at least four distinct
categories: Luminal A, Luminal B, ERBB2 (or HER2 enriched) and basal like.[22–24] Further gene expression
studies showed that these tumor classes respond differently to neoadjuvant chemotherapy.[12]
Immunohistochemical studies using surrogate markers for molecular classes showed similar results. Our
previous study of 359 cases treated with neoadjuvant chemotherapy with only a handful of HER2+ patients
receiving trastuzumab suggested that the extent of ER reactivity by immunohistochemistry could influence
tumor response to trastuzumab.[9] In order to test our preliminary findings, we expanded our analysis in this
study to >100 HER2+ tumors treated with trastuzumab and also divided the tumors into three categories based
on the extent of ER expression. Based on data from metastatic breast cancer studies, most HER2+ tumors are
treated in a standard fashion at our institution with TCH chemotherapy since 2006 in the neoadjuvant setting.[25]
Therefore, there was negligible variability in chemotherapy regimen in the cases used in this study.
Our study clearly demonstrates that addition of trastuzumab to neoadjuvant chemotherapy regimen increases the
rate of pathologic complete response by ~10–20% in all varieties of HER2+ tumors. In our previous study,
where most HER2+ tumors were treated with chemotherapy regimen that excluded trastuzumab, the pathologic
complete response rates in ERBB2, LBHH and LAHH tumors were 33, 8 and 0%, respectively. In contrast, in
this study, where all tumors were treated with trastuzumab-containing chemotherapy, the pathologic complete
response rates in ERBB2, LBHH and LAHH tumors were 52, 33 and 11%, respectively. In comparison with one
somewhat similar study of HER2+ tumors treated without trastuzumab,[13] the pathologic complete response rate
in ERBB2 tumors in this study appears to be slightly lower. However, it should be noted that most cases in our
study underwent a very thorough gross and microscopic examination, and presence of even a single viable
invasive tumor cell in the breast or the lymph node was considered as incomplete response. Although the
pathologic complete response in ERBB2 tumors was 52%, the mean and median percentage primary tumor
volume reduction in ERBB2 tumor group was 86 and 100%, respectively.
In addition to pathologic complete response, we also analyzed tumor volume reduction in all tumors, where we
utilized a very standard and practical approach in estimating tumor volume reduction. We believe the method
reported in this study is at least as objective, if not more, compared with other methods,[26–28] and yet quite
simple compared with MD Anderson method[29] of estimating tumor volume reduction. This method made it
possible to compare the differences between different tumor categories with confidence. Similar to pathologic
complete response, maximum percentage tumor volume reduction was identified in ERBB2 tumors, followed
by LBHH tumors and least in LAHH tumors. In addition to estimating absolute percentage tumor volume
reduction for each case, we also analyzed the percentage of tumors in each group showing ≥50% tumor volume
reduction. This information is very important from a surgeon's viewpoint in order to counsel patients about the
likelihood of a breast-conserving surgery after chemotherapy. Our results suggest that ≥50% tumor volume
reduction can be expected in a majority of the HER2+ cases, with highest in ERBB2 and lowest in LAHH
tumors. These findings clearly demonstrate that response to trastuzumab-containing chemotherapy in HER2+
tumors is inversely related to amount of ER expression.
It is well known that hormonal therapy in HER2+ tumors is not very effective, but the relative resistance to
trastuzumab therapy in ER+/HER2+ tumors is under-recognized. Several studies have suggested that ER and
HER2 cross-talk is responsible for this resistance when these tumors are treated with hormonal therapy alone.[30,
31]
Recently, it has been shown that a combination of trastuzumab and hormonal therapy is superior than
hormonal therapy alone.[32–34] However, the question of relative resistance to trastuzumab therapy in
ER+/HER2+ tumors still remains. Whether this is because of ER and HER2 cross-talk only or other growth
factor receptors are also involved is a subject of active investigation. The involvement of other growth factors
and their receptors may provide another target for these unique tumors. Some recent studies have shown
significant synergy between ER and insulin growth factor (IGF) system that is demonstrable in both normal and
malignant breast tissues.[35–37] The activated ER complexes bind to estrogen-responsive elements in the promoter
regions of the target genes that include IGF-1R. In the presence of unaltered ER pathway, ER ligands can
promote cell growth via IGF-1R. In a similar manner, growth factors (EGF and IGF) have been shown to
activate ER by phosphorylating the receptor. It is known that IGF-1R primarily activates the MAPK and
PI3/Akt pathways and both of these signal transduction pathways phosphorylate the serine residue in the AF1
domain of the ER.[38, 39] This synergy obviously is possible if both ER and IGF-1R are expressed by tumor cells.
Interestingly, we have recently shown that IGF receptor 1 (IGF-1R) is expressed at a significantly higher level
in all ER+ tumors (including ER+/HER2+) compared with ER−/HER2+ tumors (Appl Immunohistochem Mol
Morphol; in press).[40] Similar findings were reported by Harris et al. [41] If these findings are also supported by
additional studies, IGF-1R may be another molecule that could be targeted with available antibodies [42–45] in
these difficult-to-treat ER+/HER2+ tumors, despite the presence of two well-known targets.
In summary, we have clearly shown that addition of trastuzumab to neoadjuvant chemotherapy regimen
significantly increases the pathologic complete response rates in all HER2+ tumors. However, the benefit of
trastuzumab is highest in ER-negative tumors and progressively decreases with increase in tumor ER
expression. This information can be utilized to counsel patients considered for neoadjuvant chemotherapy and
the same principle could be applied in the adjuvant setting. Generally, patients who achieve pathologic complete
response have excellent prognosis compared with the ones that fail to achieve pathologic complete response.
Whether addition of trastuzumab in neoadjuvant chemotherapy regimen would have the same effect will be
analyzed in the years to come.

Targeted Breast Cancer Drug Shrinks Tumors

December 17, 2009 (San Antonio) — A new targeted cancer drug has been shown to shrink tumors in women
with metastatic breast cancer after an average of seven other drugs, including Herceptin, failed.
The new drug, called T-DM1, combines Herceptin with a potent chemotherapy drug. It's a Trojan horse
approach, where Herceptin homes in on cancer cells and delivers the cancer-killing agent directly to its target.
Tumors shrank in one-third of women with metastatic breast cancer given T-DM1, says Ian Krop, MD, of the
Dana-Farber Cancer Institute in Boston. In another 12%, tumors stopped growing for at least six months.
The women remained cancer-free for an average of seven months -- results unheard of in patients this sick, he
says.
All the women, who had breast tumors for an average of three years, had cancer that had metastasized, or spread
to other parts of the body. They had been treated with an average of seven different therapies, including
Herceptin, Tykerb, and Xeloda, and each had failed.
"This is the first study looking at women who have failed so many other treatments," Krop tells WebMD. "But
we think these results are as good as we've ever seen is such a refractory [sick] population," he says.
The findings were presented at the San Antonio Breast Cancer Symposium.
How T-DM1 Works
About 20% of breast cancer patients have HER2-positive cancers -- tumors that have too much of a type of
protein called HER2. Herceptin, a man-made antibody, binds to and blocks the HER2 receptor that appears on
the surface of some breast cancer cells.
But metastatic breast cancer eventually becomes resistant to Herceptin. So researchers have searched for new
drugs that target HER2.
T-DM1 is such a drug. The "T" stands for trastuzumab, the scientific name for Herceptin. The "DM1" is derived
from an old chemotherapy drug called maytansine that was abandoned several decades ago when it was found
to be too toxic for patients, Krop says.
Because Herceptin only zeroes in on cancer cells that express HER2, DM1 is delivered only to those cells, he
says.
"The cytotoxic drug goes right to the cancer cells, so it’s not floating around and causing other problems. And
Herceptin still does all the things that Herceptin does" to fight cancer, Krop says.
All the women experienced some side effects, typically the fatigue and nausea often seen with chemotherapy, he
says.
Edith Perez, MD, a breast cancer specialist at the Mayo Clinic in Jacksonville, Fla., tells WebMD that the drug's
benefits far outweigh the risks.
"The response rate they saw in the study is exceptional in a group of patients this ill," she says.
One patient with pre-existing fatty liver disease and multiple other medical conditions died from liver failure.
Perez says that the death due to liver failure is not overly concerning given the women's overall poor
health."These patients are very sick and right now we have no choices to offer them."
In other ongoing studies, T-DM1 is being pitted against other cancer drugs in patients with both metastatic and
earlier-stage breast cancer, Krop says. Researchers expect T-DM1 will perform even better in women with
earlier-stage cancer, he adds.
The study was funded by Genentech and Hoffmann-La Roche, which are developing the new drug.
SOURCES:
32nd Annual San Antonio Breast Cancer Symposium, San Antonio, Dec. 9-13, 2009.

A "Direct Assault" on Anthracycline-Based Therapy for Breast Cancer?

December 15, 2009 (San Antonio, Texas) — Most women with HER2-positive early breast cancers should not receive an
anthracycline-based adjuvant chemotherapy, suggested a presenter here at the 32nd Annual San Antonio Breast Cancer
Symposium.
This treatment guidance was offered by Dennis Slamon, MD, PhD, from the Jonsson Comprehensive Cancer Center at the
University of California, Los Angeles, and is partly rooted in new 5-year data from the ongoing phase 3 trial known as
Breast Cancer International Research Group (BCIRG) 006.
However, another breast cancer expert approached by Medscape Oncology disagreed with this conclusion.
"That's going beyond the data," said Gary Lyman, MD, from the Duke Comprehensive Cancer Center in Durham, North
Carolina. He also disagreed with several other comments made by Dr. Slamon, who is well known for his advocacy
against anthracyclines.
The results that Dr. Slamon presented are the third analysis of the BCIRG 006 trial, which is being conducted in more than
3000 women and compares chemotherapy alone with 2 experimental regimens of chemotherapy plus trastuzumab
(Herceptin, Genentech-Roche): 1 with anthracycline-based chemotherapy and 1 with taxane-based chemotherapy.
Dr. Slamon highlighted the findings that came from the 2 trastuzumab groups.
He noted that, at 5 years, there were 29 fewer events in the anthracycline-based group (185 events among 1074 women)
than in the taxane-based group (214 events among 1074 women).
However, this "numerical advantage came at the cost of 21 cases of congestive heart failure and 8 acute leukemias," he
pointed out, referring to the anthracycline-based therapy.
The efficacy differences are outweighed by the toxicity differences.
"The efficacy differences are outweighed by the toxicity differences," Dr. Slamon said at a press briefing.
Furthermore, the study data show that the "incremental benefit" conferred by the anthracycline-based therapy is based on
the effect seen in a subgroup of HER2-positive women — those with tumors containing alterations in the topoisomerase II
alpha (TOP2A) gene. This group, which comprises about one third of HER2-positive breast cancers, is the only one in
which anthracyclines "make sense," said Dr. Slamon.
Consideration for a nonanthracycline-based regimen should be high.
"Consideration for a nonanthracycline-based regimen should be high" for most HER2-positive early breast cancers, Dr.
Slamon explained.
Provocatively, Dr. Slamon called evidence of the limitations of anthracyclines, including data from the new study, a
"direct assault on anthracycline-based regimens."
However, Dr. Lyman had a different perception of the efficacy and safety findings of the anthracycline-based regimen in
the study.
"Many oncologists will differ with his opinion," said Dr. Lyman. So will many patients, he suggested.
"When I show the data to my patients, they will be more concerned about what is most effective in treating their breast
cancer than about the hypothesized long-term risk of cardiac effects and second malignancies," he told Medscape
Oncology.
Dr. Lyman emphasized the fact that, in the BCIRG 006 trial, the anthracycline-based regimen has an evolving superiority
compared with the taxane-based therapy. ''If you look at the disease-free survival and overall survival curves, they have
widened since the last analysis, favoring the anthracycline regimen," he observed.
Furthermore, Dr. Slamon's recommendation to not use anthracyclines is not appropriate, Dr. Lyman said, because although
the study "may justify leaving out anthracyclines in patients with HER2-positive breast cancer and significant cardiac risk,
it was clearly not powered to answer the question of whether anthracyclines are unnecessary in all HER2-positive
disease."
 Dr. Lyman explained that the study showed a statistically significant superiority for both chemotherapy-plus-trastuzumab
regimens over chemotherapy alone in disease-free survival and overall survival.
Also, these are only 5-year data, said Dr. Lyman, adding: "We'd like to see more mature data." Dr. Slamon, in his press
conference, agreed with the need for longer-term data.
As previously reported by Medscape Oncology, Dr. Slamon is an advocate for using nonanthracycline-containing
regimens in most HER2-positive patients. He has also argued that TOP2A is a proven biomarker for predicting response to
adjuvant anthracycline-based treatment. However, both of these ideas are contended by other experts and reportedly
conflicting data.
Overall Results From the Study
BCIRG 006 was conducted in 3222 women with Her2/neu-positive early breast cancer who were randomized to 1 of 3
treatment group:
 The control group — chemotherapy with doxorubicin (Adriamycin, Bedford Laboratories) and cyclophosphamide
followed by docetaxel (Taxotere, Sanofi-Aventis) (n = 1072)
 The anthracycline-based experimental group (AC→TH) — doxorubicin and cyclophosphamide followed by
docetaxel and trastuzumab (n = 1074)
 The taxane-based experimental group (TCH) — docetaxel, carboplatin, and trastuzumab (n = 1074).
Patients were prospectively stratified by the number of positive nodes (0, 1 to 3, and 4+) and hormone-receptor status.
Patients with estrogen-receptor- and/or progesterone-positive tumors received hormonal therapy for 5 years after
chemotherapy (about 50% of all patients in each group). About 60% of all patients in each group underwent mastectomy
and about 68% of each group received radiotherapy.
One of the distinguishing features of the trial is that, when trastuzumab efficacy results were announced in 2005, only 23
patients (2.1%) crossed over to an experimental group to receive the drug, noted Dr. Slamon. Thus, the statistical power of
the study was not affected.
These new data are from a third protocol-specified analysis, which was conducted after 650 events, said Dr. Slamon.
At 5 years, there were 656 events among the patients: 257 in the control group, 185 in the AC→TH group, and 214 in the
TCH group.
For the primary end point of disease-free survival, both of the trastuzumab-containing groups were statistically superior to
the control group. Compared with the control group, the AC→TH group had a hazard ratio of 0.64 (95% confidence
interval [CI], 0.53 – 0.78; P < .001), and the TCH group had a hazard ratio of 0.75 (95% CI, 0.63 - 0.90; P = .04).
The same held true for the secondary end point of overall survival.
There were 348 deaths among the patients: 141 in the control group; 94 in the AC→TH group; and 113 in the TCH group.
Compared with the control group, the AC→TH group had a hazard ratio of 0.63 (95% CI, 0.48 - 0.81; P < .001) and the
TCH group had a hazard ratio of 0.77 (95% CI, 0.60 - 0.99; P = .038). Both were statistically significant improvements.
The advantages in the 2 experimental groups were also seen in low- and high-risk patients, said Dr. Slamon.
Differences in Interpretation
In terms of safety, the TCH group was generally better tolerated and, when compared with both the control and AC→TH
groups, had statistically significantly lower rates of grade 3/4 nonhematological toxicities for arthralgia, myalgia, hand-
foot syndrome, stomatitis, and vomiting, and of grade 3/4 hematological toxicities for neutropenia and leucopenia.
However, Dr. Slamon focused on the differences in grade 3/4 cardiac left ventricular function (LVEF) and congestive
heart failure. The AC→TH group had 21 such events, whereas the TCH group had only 4 events.
However, as Dr. Lyman pointed out, a graph presented by Dr. Slamon showing mean LVEF in the different groups over 5
years revealed "trends that indicated a recovery of cardiac function among patients treated with anthracyclines."
But Dr. Slamon suggested that the damage is not reversible. "The damage we are doing to the heart is ongoing," he told
reporters.
Dr. Slamon also emphasized that there were 8 total treatment-related leukemias, and 7 were among the patients treated
with anthracyclines (both the AC→TH and control groups), whereas there was only 1 such event among patients in the
TCH group (this patient also received an anthracycline for treatment of B-cell lymphoma). "These treatment-related
leukemias are well known in the literature," he noted.
There can be, among intelligent people, very different conclusions about the same data.
However, Dr. Lyman pointed out that most of the cases of leukemia (6 of the 8 cases) were in the control group. There
was no difference in the number of cases of leukemia among the patients in the AC→TH group and the TCH group (both
had 1 case apiece), observed Dr. Lyman. "That's the real comparator here," he said.
"Bottom line, there can be, among intelligent people, very different conclusions about the same data," said Dr. Lyman
about the ways his perspective differs from Dr. Slamon's.
The study was sponsored by Sanofi-Aventis with support from Genentech. Dr. Slamon reports receiving a research grant
from Amgen, is a member of the speakers' bureaus for Genentech and Sanofi-Aventis, and is a consultant to Pfizer. Dr.
Lyman has disclosed no relevant financial relationships.
32nd Annual San Antonio Breast Cancer Symposium (SABCS): Abstract 62. Presented December 12, 2009.

Concurrent Trastuzumab Is Best in HER2 Breast Cancer

December 15, 2009 (San Antonio, Texas) — Giving trastuzumab (Herceptin, Genentech-Roche) concurrently — as opposed to sequentially
— with adjuvant chemotherapy should be the standard of care, suggested the lead investigator of the only trial designed to compare the 2
approaches.
The recommendation comes from a portion of the trial that involved 1903 women with HER2-positive early breast cancer.
Updated results, now with a median follow-up of 5.3 years, show a rate of disease-free survival of 84.2% for concurrent therapy and 79.8%
for the sequential therapy, said Edith Perez, MD, here at the 32nd Annual San Antonio Breast Cancer Symposium. She is chair of the North
Central Cancer Treatment Group Breast Committee, which ran the study (N9831), and is from the Mayo Clinic in Jacksonville, Florida.
The difference is not statistically significant, but the 25% reduction in the risk for recurrence or death with concurrent therapy, compared with
sequential therapy, shows a "strong trend," said Dr. Perez.
She explained that the result was not statistically significant because there were not as many patient events as the investigators initially
projected. "We did not think the drug would be this effective at study design," she added.
The "implication for practice" from the study is that "adjuvant trastuzumab be incorporated in a concurrent fashion with taxane
chemotherapy," said Dr. Perez.
"The results of this trial have been awaited all over the world," said Claudine Isaacs, MD, who moderated a meeting press conference
highlighting the study. Dr. Isaacs is from the Georgetown Lombardi Comprehensive Cancer Center in Washington, DC.
We did not think the drug would be this effective at study design.
Trastuzumab is approved for both concurrent and sequential therapy by the US Food and Drug Administration, but concurrent is used by
most clinicians in the United States, said Dr. Isaacs. However, in other parts of the world, only sequential therapy is practiced, she continued.
"This could mean that up to 10,000 women around the world each year may have a better outcome if [trastuzumab] is used along with
chemotherapy. Given that, I believe this study will lead to a global re-evaluation of the way [trastuzumab] is used," Dr. Perez said in a press
statement.
Dr. Perez credited a "positive interaction between chemotherapy and [trastuzumab]" for the additional benefit seen with the concurrent
administration.
The chemotherapy in the trial was anthracycline-based, which was a feature of another phase 3 clinical trastuzumab trial presented here —
the Breast Cancer International Research Group 006 trial.
Unlike that trial, however, there seemed to be no controversy surrounding Dr. Perez's results.
Dr. Perez highlighted one of the concerns with anthracyclines — cardiac safety — in her presentation, telling reporters during a press
conference that it "generates a tremendous amount of interest." The 3-year cumulative incidence of grade 3/4 congestive heart failure or
sudden cardiac death was 3.3% for concurrent therapy and 2.8% for sequential therapy. No one in the audience commented on the data,
which were previously published (J Clin Oncol. 2004;22:322-329).
I feel very confident that anthracycline-based therapy is appropriate.
"I feel very confident that anthracycline-based therapy is appropriate," said Dr. Perez.
Other experts were also positive about the trial. "It's a very important finding," said Dr. Isaacs.
"An exciting report," is how the director of the meeting, C. Kent Osborne, MD, described the results.
Sequential Therapy Is Effective Too
It clarifies a previously muddy picture.
"Scientifically, this is an important result because it clarifies a previously muddy picture," Eric Winer, MD, from the Dana-Farber Cancer
Institute in Boston, Massachusetts, told Medscape Oncology.
Dr. Winer was referring to an early result from the trial that suggested there was no benefit from sequential therapy with trastuzumab,
compared with the chemotherapy alone.
The trial consisted of 2 comparisons, one of which was the abovementioned sequential versus concurrent therapy. The other comparison
involved 2448 patients randomly assigned to chemotherapy alone or chemotherapy sequentially followed by trastuzumab.
The chemotherapy in both comparisons was doxorubicin (Adriamycin, Bedford Laboratories) and cyclophosphamide, then paclitaxel
(Abraxane, Abraxis Bioscience).
You get benefit if you give trastuzumab after chemotherapy and you get even more if you give it at the same time.
After a median follow-up of 5.5 years, the investigators found that the rate of disease-free survival was 80.1% for chemotherapy with
sequential trastuzumab and 71.9% for chemotherapy alone. This difference is statistically significant (P = .0005).
The outcome was adjusted for possible confounding variables such as tumor size, number of positive nodes, and estrogen-receptor status,
report the investigators.
"Now it's been shown that sequential therapy is beneficial too," said Dr. Winer.
"You get benefit if you give trastuzumab after chemotherapy and you get even more if you give it at the same time," summarized Dr. Winer.
32nd Annual San Antonio Breast Cancer Symposium (SABCS): Abstract 80. Presented December 12, 2009.
Dual HER2 Approach Improves Survival in Metastatic Breast Cancer
December 14, 2009 (San Antonio, Texas) — For the first time, an improvement in overall survival has been seen in women with metastatic
breast cancer who responded to but then progressed on trastuzumab (Herceptin, Genentech/Roche). Continuing with trastuzumab and adding
on lapatinib (Tykerb, GlaxoSmithKline) produced a significant survival advantage of 4.5 months, compared with treatment with lapatinib
alone, and resulted in a median overall survival of 14 months, which is "astonishing," according to one breast cancer expert.
These results come from the EGF104900 phase 3 clinical trial of dual HER2 blockade, and were presented here at the 32nd Annual San
Antonio Breast Cancer Symposium (SABCS) by Kimberly Blackwell, MD, from Duke University Medical Centre in Durham, North
Carolina.
"This is a very impressive improvement in overall survival," Dr. Blackwell said. It compares with what has been seen in first-line therapy in
metastatic breast cancer when trastuzumab is added to chemotherapy, but the patients in this trial were heavily pretreated, so this is second-,
third-, even fourth-line use, and this result was achieved without using chemotherapy, she pointed out.
Trastuzumab and lapatinib might be "acting together to form a sort of 'dual blockade' to obstruct the HER2 pathways necessary for the tumor
to thrive," Dr. Blackwell suggested. Both agents are specific for HER2, but lapatinib works inside the cell and trastuzumab works on the
outside of the cell, and this combination might "provide a more complete antitumor attack," she said in a statement.
"This is a refreshing study for all of us," Dr. Blackwell told Medscape Oncology. "The last time there was such an impact [was] the original
trastuzumab study."
The improvement in overall survival in this patient population "is astonishing," said Claudine Isaacs, MD, director of the Clinical Breast
Cancer Program at the Lombardi Comprehensive Cancer Center in Washington, DC, in an interview with Medscape Oncology.
Edith Perez, MD, director of the Breast Cancer Program at the Mayo Clinic in Jacksonville, Florida, who moderated the press briefing at
which these results were discussed, said the breast cancer community has been "eagerly awaiting these results."
In an interview with Medscape Oncology, Dr. Perez said she agrees that this is an "impressive" improvement in overall survival, and pointed
out that this is the first time a survival advantage has been demonstrated in metastatic breast cancer that has progressed after trastuzumab. The
trial that resulted in the approval of lapatinib for this indication, in combination with capcitebine, showed an effect on progression-free
survival but not on overall survival, she pointed out.
Dr. Perez said that she would now recommend use of the combination of lapatinib and continuing with trastuzumab in women who have
already progressed on trastuzumab, noting that this combination was less toxic than lapatinib and capcitebine.
Dr. Blackwell also said that, in her clinical practice, she would now consider using this combination in women who had "previously done
well on HER2-based therapy."
Benefit From Continuation of Trastuzumab?
There was some discussion over how much of the benefit seen in this trial came from continuing trastuzumab after progression, and how
much from the addition of lapatinib.
Dr. Perez told reporters that this study validates the idea of continuing on trastuzumab therapy, even after progression on the drug. "This is
important, because there are many physicians who stop trastuzumab once the patient progresses," she said.
Eric Winer, MD, chief of the Division of Women's Cancers at the Dana-Farber Cancer Institute in Boston, Massachusetts, who was
approached for comment, said he was surprised by the overall survival result. He agreed that this is the first improvement in survival that has
been seen in this patient population, but pointed out that "it hasn't been looked for that often."
Trastuzumab is a remarkable drug.
His take was that this study shows that continuing trastuzumab after a patient has progressed is beneficial; this has also been shown in several
other studies. "This is another study that shows that trastuzumab is a remarkable drug, and is a better drug than we ever thought when it was
first approved," he said. The product has changed the natural history of the disease, he added.
However, Dr. Winer added, there does appear to be an interaction between trastuzumab and lapatinib, and said the combination should be
studied further.
This combination is being studied further. The ALLTO trial is looking at lapatinib and trastuzumab in combination and in sequential use, and
comparing both with chemotherapy, but is in a different patient population — women with early breast cancer. Another trial, the Neo-ALLTO
study, will look at the same treatments but they will be administered prior to surgery, Dr. Blackwell told Medscape Oncology.
Unethical Not to Offer Lapatinib
The point about trastuzumab continuation was also raised after Dr. Blackwell's presentation. During the question period that followed, Kathy
Pritchard, MD, from the Toronto-Sunnybrook Regional Cancer Center, in Ontario, said: "What you have shown is that continuing
trastuzumab in this setting is useful." She suggested that the trial should have had a group in which the treatment was continuation of
trastuzumab without the addition of lapatinib.
Dr. Blackwell countered that when the trial was being designed, such a treatment group had been considered but was discounted because it
was thought to be unethical to offer women who had already progressed on trastuzumab only continuation of treatment with trastuzumab
when there was another HER2-specific drug that was available. Hence, the trial offered these women treatment with lapatinib or lapatinib
plus a continuation of trastuzumab, she explained.
The trial involved 296 women with HER2-positive metastatic breast cancer who had progressed on trastuzumab-containing regimens (the
median number of previous regimens was 3). All women were treated with lapatinib, either alone (at a dose of 1500 mg once daily) or
together with trastuzumab (in this group the dose of lapatinib was 1000 mg once daily, and trastuzumab was given at 2 mg/kg after a loading
dose of 4 mg/kg).
Women in the lapatinib group who progressed were allowed to cross over to the combination group, and about half did so (77 of 148 patients;
52%).
The results that Dr. Blackwell presented come from an updated survival analysis conducted after 218 deaths (77%) had occurred.
They show a significant survival advantage for the combination group, in which the median overall survival was 14 months, compared with
9.5 months in the lapatinib group (hazard ratio [HR], 0.74; 95% confidence interval 0.57 - 0.97; P = .026).
There were 15 more women out of 100 who were still alive.
This represents a 26% reduction in the risk of dying, Dr. Kimberley said. "After 1 year, there were 15 more women out of 100 who were still
alive in the combination arm, compared with the lapatinib alone arm," she said.
"The actual survival benefit of the combination may be underestimated because of the high frequency of the crossover," Dr. Blackwell
explained. If you take away the patients who crossed over, the reduction in the risk of dying on the combination rises to 36% (HR, 0.64), she
told Medscape Oncology.
The combination had an acceptable tolerability profile and there was no increase in the cardiac signal. "As a practicing clinician, I found it
remarkable that there was no safety issue," Dr. Blackwell said.
Dr. Blackwell reports receiving honoraria from GlaxoSmithKline and Genentech to conduct the study. Dr. Perez receives no direct funding
from pharmaceutical companies, but has served on independent monitoring committees for Genentech and Novartis.
32nd Annual San Antonio Breast Cancer Symposium (SABCS): Abstract 61. Presented December 12, 2009.

Highlights in HER-2-Positive Breast Cancer

Posted: 01/20/2009
Introduction
Nothing is more valuable for the development of targeted cancer therapy than knowing what the target is, particularly when it is critical to the
growth of the cancer cell. That truism was borne out again at the 31st Annual San Antonio Breast Cancer Symposium (SABCS 2008) in 3
reports that centered on new anti-HER-2 therapies. This field continues to experience rapid drug development.
Trastuzumab-DM1 Conjugate
The idea of "smart bombs" has long appealed in oncology. According to this concept, a mechanism would be employed to deliver
chemotherapy directly to a tumor, thereby minimizing collateral damage to other tissues. This concept has led to many attempts to develop
antibodies linked to chemotherapy or other toxins. For the most part, the historical experience in this effort has met with mixed success.
However, that story may be changing.
Trastuzumab-DM1 (TDM1) is a novel conjugate of the chemotherapy agent, DM1, and the trastuzumab antibody. DM1 belongs to a
maytansine class of chemotherapy that targets microtubules. It is chemically linked to trastuzumab to form TDM1; on average, 3-4 molecules
of DM1 bind to every trastuzumab molecule. Phase 1 studies have explored TDM1 with use of either an every-3-week or a weekly schedule.
Toxicities identified in phase 1 studies included fatigue, thrombocytopenia, and liver enzyme abnormalities. Encouraging results in phase 1
trials included substantial numbers of overt treatment responses in women with HER-2-positive metastatic breast cancer.
The first report of phase 2 activity with TDM1 was presented at SABCS 2008. [1] To be eligible for this trial, patients were required to have
metastatic, HER-2-positive breast cancer and tumor progression during prior therapy with trastuzumab and chemotherapy. Patients were
treated with TDM1 at a dose of 3.6 mg/kg every 3 weeks. The assembled cohort of 107 women had extensive prior therapy. They had
received a median of 76 weeks of trastuzumab; 68% had previously received anthracyclines and 55% had previously been treated with
lapatinib.
Side effects of TDM1 included fatigue and thrombocytopenia. Approximately 25% of patients had epistaxis, and about the same percentage
had an eye-tearing/conjunctivitis disorder. Grade 3 or 4 toxicity was rare. These patients had baseline left ventricular ejection fraction values
greater than 50% and had not experienced trastuzumab-related cardiotoxicity. However, none developed clinically apparent heart disease.
The primary study endpoint was response rate. TDM1 yielded an overall response rate of 39%, with 27% of patients having confirmed
responses on repeat imaging. A response rate of 38% was seen among those patients previously treated with lapatinib.
These response rates certainly seem robust for a patient population with tumor progression on prior trastuzumab plus chemotherapy. TDM1 is
being evaluated in other phase 2 trials among heavily treated patients and in earlier stages of metastatic disease.
Neratinib
Neratinib is a multikinase inhibitor targeted to epidermal growth factor receptor (EGFR), HER-2, and HER-4. Unlike lapatinib, which is a
reversible inhibitor of HER-2 and EGFR, neratinib binds irreversibly to those kinases. Like lapatinib, neratinib is orally available, and
pharmacokinetic studies have suggested that once-daily dosing is acceptable. In phase 1 development, common side effects included diarrhea,
nausea, and fatigue.
On behalf of a group of international collaborators, this author reported on a multinational, multicenter, open-label trial of neratinib in women
with HER-2-positive metastatic breast cancer.[2] This trial included 2 cohorts of women: a group with prior trastuzumab treatment (although
not necessarily trastuzumab-resistant disease), and a group of patients that was trastuzumab-naive. These patients had received substantial
prior chemotherapy, averaging 2 regimens, for metastatic disease. Each cohort received oral neratinib at a dosage of 240 mg/day. The major
toxicity associated with neratinib was diarrhea, which affected 85% of patients to some degree and caused grade 3 or 4 symptoms in about
one third of patients. With growing clinical experience, liberal use of antidiarrheal agents such as loperamide, and dose modification in 15%
of patients, the symptom proved manageable. Only 1 patient discontinued the study because of diarrhea. Other toxicities were quite mild and
included nausea, fatigue, and an acneiform rash.
Treatment with neratinib resulted in a 26% response rate in women with prior trastuzumab treatment and a 55% response rate in trastuzumab-
naive patients. The primary study endpoint was 16-week progression-free survival (PFS), which was 60% and 77% for the prior-trastuzumab
and no-prior-trastuzumab groups, respectively. The median time to progression was 40 weeks in the trastuzumab-naive group compared with
23 weeks in the trastuzumab-treated cohort.
This degree of activity in both trastuzumab-naive and trastuzumab-treated patients was quite impressive and compares favorably with prior
reports of single-agent anti-HER-2 therapies. Neratinib is now being evaluated in phase 2 studies in combination with a variety of
chemotherapy agents and in a phase 3 study against the combination of lapatinib plus capecitabine.
Lapatinib and Endocrine Resistance
One of the challenges in endocrine treatment has been overcoming resistance to antiestrogen therapies. Laboratory studies have identified
links in intracellular signaling between the estrogen receptor (ER) pathway and other growth factor receptor pathways in breast cancer cells,
including EGFR and HER-2 pathways. Furthermore, in vivo models of breast cancer cell growth have suggested that combined inhibition of
ER and EGFR or HER-2 pathways might promote long durations of tumor control compared with inhibition of either set of pathways alone.
These observations set the stage for EGF30008, a trial of the aromatase inhibitor letrozole with or without the addition of the dual-kinase
inhibitor, lapatinib, as treatment for patients with ER-positive metastatic breast cancer. [3] This large, randomized trial included patients with or
without HER-2-positive tumors, as long as the tumor was ER positive. Of a total of 1286 study participants, 219 had HER-2-positive breast
cancer and the remainder had HER-2-negative lesions as judged by fluorescence in situ hybridization or immunohistochemistry (< 3+).
In the HER-2-positive cohort, adding lapatinib improved response rates and PFS compared with letrozole alone. The response rates improved
from 15% to 28%; PFS increased from 3 to 8 months. This result is qualitatively similar to the previous findings from the TAnDEM trial, in
which patients with ER-positive, HER-2-positive breast cancer received anastrozole alone or anastrozole plus trastuzumab, and those who
received the combination had higher response rates and time to progression.
In the HER-2-negative cohort, the addition of lapatinib had no overall advantage compared with letrozole alone. However, in the group of
patients who had recently received tamoxifen therapy, and thus might arguably have endocrine-resistant breast cancer, a trend suggesting
improved response and PFS for the addition of lapatinib to letrozole was noted. This finding was of interest, inasmuch as several reports over
the years have suggested that HER-2 overexpression might be an acquired event associated with resistance to endocrine therapy. Whether
lapatinib might add to antiestrogen treatments specifically in cases of endocrine-resistant breast cancer is being formally tested in CALGB
40302, a randomized trial of fulvestrant with and without lapatinib for the treatment of metastatic ER-positive breast cancer in patients who
have received prior aromatase inhibitor therapy.
How Risky Are Small HER-2-Positive Tumors?
The major adjuvant trials of trastuzumab have centered on high-risk, node-negative or node-positive breast cancer. The benefit of
trastuzumab in patients with small, node-negative but HER-2-positive cancers is not well established because the natural history of these
lesions is not well known. Investigators from the M.D. Anderson Cancer Center reported on outcomes of tumors 1 cm or smaller as a function
of HER-2 status.[4] This observational cohort did not receive either chemotherapy or trastuzumab, and thus the study does not permit one to
know how each of these interventions might be of benefit. What was observed, however, was that prognosis clearly depended on HER-2
status. For HER-2-negative tumors, the 10-year risk for recurrence-free survival with T1abN0 breast cancer was 88% if the tumor was ER
positive and was 80% if "triple negative." However, if the tumor was HER-2 positive, 10-year recurrence-free survival was only 62%.
This observation suggests that even small tumors that are HER-2 positive carry a substantial risk for recurrence and might benefit from
adjuvant treatment with chemotherapy and trastuzumab. This is consistent with current guidelines from the National Comprehensive Cancer
Network, which suggest consideration of chemotherapy and trastuzumab for HER-2-positive tumors that measure between 6 and 10 mm. A
prospective study conducted at the Dana-Farber Cancer Institute and affiliated sites is testing the effectiveness of paclitaxel plus trastuzumab
for stage 1, HER-2-positive tumors.
Summary
Anti-HER-2 therapy remains a field of vital clinical investigation. New agents from both the antibody-based and small molecular/tyrosine
kinase inhibitor-based domains are in development. Emerging data raise fascinating questions about the interplay of ER and HER-2 signaling
pathways that are being explored in ongoing clinical trials. Meanwhile, the risk for HER-2-positive lesions continues to be marked in the
absence of trastuzumab, underscoring the value of that agent in treating early-stage breast cancer.

Understanding the Mechanisms Behind Trastuzumab Therapy for Human

Epidermal Growth Factor Receptor 2-Positive Breast Cancer; Spector NL,
Blackwell KL; Journal of Clinical Oncology (JCO) (Nov 2009) J Clin Oncol
PURPOSE: Targeted therapy with the humanized monoclonal antibody trastuzumab has become a mainstay for human epidermal
growth factor receptor 2 (HER2) -positive breast cancer (BC). The mechanisms of action of trastuzumab have not been fully
elucidated, and data available to date are reviewed here. The impact of the mechanisms of action on clinical benefit also is discussed.
METHODS: An extensive literature review of trastuzumab and proposed mechanisms of action was performed. RESULTS: At least
five potential extracellular and intracellular antitumor mechanisms of trastuzumab have been identified in the preclinical setting. These
include activation of antibody-dependent cellular cytotoxicity, inhibition of extracellular domain cleavage, abrogation of intracellular
signaling, reduction of angiogenesis, and decreased DNA repair. These effects lead to tumor cell stasis and/or death. Clinical benefit
from trastuzumab-based therapy in both early and advanced BC has been demonstrated. The benefit of trastuzumab use beyond
progression has also been shown, which indicates the need for continuous suppression of the HER2 pathway. Targeting both HER2,
with various approaches, and other pathways may enhance the clinical benefit observed with trastuzumab and overcome potential
resistance. Novel combinations include pertuzumab (a HER2 dimerization inhibitor), lapatinib (a HER1/HER2 tyrosine kinase
inhibitor), bevacizumab (an antiangiogenic agent), tanespimycin (a heat shock protein inhibitor), antiestrogen therapies, and an
antibody-drug conjugate (trastuzumab-DM1). CONCLUSION: Trastuzumab is the foundation of care for patients with HER2-positive
BC. Emerging data from studies of other targeted agents may provide alternative treatment combinations to maximize the clinical
benefit from trastuzumab and prevent or delay resistance. The continued development of trastuzumab highlights promising treatment
approaches for the future.
Fluorouracil, epirubicin, and cyclophosphamide with either docetaxel or vinorelbine, with or
without trastuzumab, as adjuvant treatments of breast cancer: final results of the FinHer Trial.
Joensuu H, Bono P, Kataja V, Alanko T, Kokko R, Asola R, Utriainen T, Turpeenniemi-Hujanen T, Jyrkkiö S,
Möykkynen K, Helle L, Ingalsuo S, Pajunen M, Huusko M, Salminen T, Auvinen P, Leinonen H, Leinonen M,
Isola J, Kellokumpu-Lehtinen PL.Department of Oncology, Helsinki University Central Hospital, Helsinki,
Finland. heikki.joensuu@hus.fi J Clin Oncol. 2009 Dec 1;27(34):5685-92. Epub 2009 Nov 2.
PURPOSE: Docetaxel has not been compared with vinorelbine as adjuvant treatment of early breast cancer.
Efficacy and long-term safety of a short course of adjuvant trastuzumab administered concomitantly with
chemotherapy for human epidermal growth factor receptor 2 (HER2) -positive cancer are unknown. PATIENTS
AND METHODS: One thousand ten women with axillary node-positive or high-risk node-negative breast
cancer were randomly assigned to receive three cycles of docetaxel or vinorelbine, followed in both groups by
three cycles of fluorouracil, epirubicin, and cyclophosphamide (FEC). Women with HER2-positive cancer (n =
232) were further assigned to either receive or not receive trastuzumab for 9 weeks with docetaxel or
vinorelbine. The median follow-up time was 62 months after random assignment. RESULTS: Women assigned
to docetaxel had better distant disease-free survival (DDFS) than those assigned to vinorelbine (hazard ratio
[HR] = 0.66; 95% CI, 0.49 to 0.91; P = .010). In the subgroup of HER2-positive disease, patients treated with
trastuzumab tended to have better DDFS than those treated with chemotherapy only (HR = 0.65; 95% CI, 0.38
to 1.12; P = .12; with adjustment for presence of axillary nodal metastases, HR = 0.57; P = .047). In exploratory
analyses, docetaxel, trastuzumab, and FEC improved DDFS compared with docetaxel plus FEC (HR = 0.32; P =
.029) and vinorelbine, trastuzumab, and FEC (HR = 0.31; P = .020). The median left ventricular ejection
fraction of trastuzumab-treated patients remained unaltered during the 5-year follow-up; only one woman
treated with trastuzumab was diagnosed with a heart failure. CONCLUSION: Adjuvant treatment with
docetaxel improves DDFS compared with vinorelbine. A brief course of trastuzumab administered
concomitantly with docetaxel is safe and effective and warrants further evaluation.

HER2 Status Predicts Recurrence of Small Breast Cancers

NEW YORK (Reuters Health) Nov 06 - In women treated for small (1 cm or less), node-negative breast cancers, HER2 positivity is strongly
linked to recurrence and poorer disease-free survival, according to the results of two studies reported in the November 2nd online issue of the
Journal of Clinical Oncology.
In the first study, Dr. Ana M. Gonzalez-Angulo, from MD Anderson Cancer Center, Houston, and colleagues assessed the outcomes of 965
women who were treated for T1a,bN0M0 breast cancers from 1990 to 2002.
Seventy-seven percent of subjects had hormone receptor-positive tumors and 10% had HER2-positive tumors. None of the subjects were
treated with adjuvant chemotherapy or trastuzumab.
During a median follow-up period of 74 months, there were 72 recurrences. The 5-year recurrence-free survival rates for patients with HER2-
positive and -negative tumors were 77.1% and 93.7%, respectively (p < 0.001). The corresponding 5-year distant recurrence-free survival
rates were 86.4% and 97.2% (p < 0.001).
After accounting for hormone receptor status, T stage, and other factors, HER2 positivity increased the risks of overall and distant recurrence
by 2.68- and 5.3-fold, respectively.
"Patients with HER2-positive T1a,bN0M0 tumors have a significant risk of relapse and should be considered for systemic, anti-HER2,
adjuvant therapy," the researchers conclude.
The second study, by Dr. Giuseppe Curigliano from Istituto Europeo di Oncologia, Milan, Italy, and colleagues, was a similar investigation in
2130 women treated for T1a,bN0M0 from 1999 to 2006.
One hundred fifty women had HER2-positive tumors, including 79 with hormone receptor-positive tumors and 71 with hormone receptor-
negative tumors. None of the patients received adjuvant trastuzumab.
During a median follow-up period of 4.6 years, HER2 positivity was tied to reduced disease-free survival for hormone receptor-positive
tumors. With such tumors, the 5-year disease-free survival rates for HER2-positive and -negative tumors were 92% and 99%, respectively.
With hormone receptor-negative tumors, the corresponding rates were 91% and 92%.
After accounting for pT1 stage, HER2 positivity in patients with hormone receptor-positive disease increased the risk of disease recurrence
by 5.1-fold.
The absolute risk of recurrence at 5 years is low in patients with HER2 positive, T1a-b breast cancer, the authors conclude. Still, HER2
positivity coupled with hormone receptor positivity markedly increases the risk of recurrence, they add.
J Clin Oncol 2009.
HER-3 Overexpression is Prognostic of Reduced Breast Cancer Survival: A Study of
4046 Patients
Connie G. Chiu, MD; Hamid Masoudi, MD; Samuel Leung, MSc; David K. Voduc, MD, FRCPC; Blake Gilks,
MD, FRCPC; David G. Huntsman, MD, FRCPC; Sam M. Wiseman, MD, FRCSC
Posted: 07/05/2010; Annals of Surgery. 2010;251(6):1107-1116. © 2010 Lippincott Williams & Wilkins
Abstract and Introduction
Abstract
Introduction: Advances in molecular biology have led to the identification of potential markers of prognostic
and therapeutic importance in human cancers. HER-2 testing and targeted therapy now represents a critical
cornerstone in the management of breast cancer. The objectives of the current study were to determine the
frequency and prognostic significance of HER-3 over-expression and HER-4 over-expression by invasive breast
cancer.
Methods: Tissue microarrays were constructed using clinically annotated formalin-fixed and paraffin-
embedded tumor samples from 4046 patients diagnosed with invasive breast carcinoma with a median 12.5
years of follow-up. Type 1 growth factor receptor family members HER-1, HER-2, HER-3, and HER-4
expression levels were determined by immunohistochemistry, and HER-2 status was further resolved by
fluorescent in-situ hybridization. The study cohort was randomly divided and analyzed as a core data set and a
validation data set.
Results: HER-3 over-expression was identified in 10.0% of tumors and was a significant marker of reduced
patient breast cancer-specific survival on univariate analysis (P = 1.32 × 10−5). Furthermore, in tumors with
normal expression levels of HER-1 and HER-2, the overexpression of HER-3 had a significant negative
prognostic effect on disease-specific survival (HR: 1.541, 95% CI: 1.166–2.036, P = 2.37 × 10−3) independent
of patient age at diagnosis, Estrogen receptor status, tumor grade, tumor size, nodal status, and the presence of
lymphatic or vascular invasion by cancer. HER-4 overexpression was identified in 78.2% of breast cancers and
was not a significant marker of patient survival (P = 0.214). Results of all statistical tests were positively
confirmed in the validation data set analysis.
Conclusions: HER-3 status is an important prognostic marker of disease-specific survival in patients with
invasive breast cancer. Accordingly, evaluation of the HER-3 expression level may identify a subset of patients
with a poor disease prognosis, and who could undergo further evaluation for the efficacy of HER-3 targeted
anticancer agents.
Introduction
The utilization of clinicopathologic and tumor molecular characteristics to determine patient prognosis and
response to treatment represents a critical cornerstone in the current management of breast cancer. Recognized
breast cancer disease prognosticators include: patient age, tumor grade, tumor size, lymph node status, and
lymphatic or vascular invasion by cancer.[1–4] The recent development and widespread clinical application of
HER-2 testing and HER-2 targeted anticancer drugs, such as trastuzumab (Herceptin, Genetech Inc., South San
Francisco, CA) to breast cancer, underscores the importance of cancer biomarker discovery.[5,6]
HER-2 is a transmembrane receptor that functions in conjunction with other members of the type 1 growth
factor receptor (T1GFR) family.[7] The T1GFR family consists of 4 known members: HER-1 (also known as
epidermal growth factor receptor, EGFR, and c-erb B-1), HER-2 (c-erb B-2), HER-3 (c-erb B-3), and HER-4
(c-erb B-4). The T1GFRs are transmembrane receptors with an extracellular ligand-binding domain, and an
intracellular tyrosine kinase domain, that exist as monomers in their inactivate form. Upon ligand binding the
T1GFRs form dimers (with themselves or other family members) and initiate a signaling cascade through
activation of its tyrosine kinase, leading to cellular proliferation and transformation.[8–10] For breast cancer,
HER-2 is the preferred dimerization partner for other T1GFRs,[11] and it exerts increased signaling potency
through a reduced rate of ligand dissociation and receptor internalization.[12–14]
Despite the well-recognized role of HER-2 in tumorigenesis and cancer progression,[10] this receptor is only
active upon dimerization with other T1GFR members.[15,16] Despite there being greater than 30 ligands that have
been identified that bind the T1GFRs, there are no reported ligands that bind HER-2.[16,17] Similarly, HER-3
must also form heterodimers for cellular signaling because it lacks intrinsic tyrosine kinase activity, although it
has the ability to bind ligand.[18,19] This reciprocal relationship between HER-2 and HER-3 illustrates the unique
evolution of the T1GFR family.[20] In particular, HER-3 has been found to be the preferred dimerization partner
for HER-2,[11] and together they form the most mitogenic couplet among all the T1GFR family members.[21]
The cooperative signaling of HER-2 and HER-3 in breast cancer oncogenesis has been demonstrated in multiple
transgenic animal models. In an analysis of lysates derived from mammary tumors of HER-2 transgenic mice,
protein levels of HER-3 were identified to be elevated when compared with adjacent normal tissue, while HER-
1 and HER-4 protein levels remained largely unchanged.[22] Furthermore, in breast cancer cell lines
overexpressing HER-2, the blockade of HER-3 gene expression led to the loss of the proliferative state that was
similar to the levels observed when HER-2 gene expression was blocked. Interestingly, blockade of HER-1
gene expression blockade did not influence breast cancer cell growth.[23] Additionally, HER-3 has been found to
be coupled with potent mitogenic pathways involved in T1GFR signaling.[24]
The current study was carried out to validate the observations made in a prior study carried out by our group in
which archival tumors from 242 patients with invasive breast cancer were characterized for T1GFR family
expression by immunohistochemistry (IHC) utilizing tissue microarrays (TMAs).[25] HER-3 over-expression
was identified in 12.0% of tumors and was significantly associated with decreased breast-cancer-specific
survival by both univariate and multivariate analyses. HER-4 overexpression was not significantly associated
with patient survival. The current study evaluated a much larger breast cancer patient cohort with an extensive
patient follow-up period.
Currently, HER-2 cellular signaling has been reported to be critically dependent on the expression of other
TIGFR family members, and in particular, HER-2/HER-3 heterodimers represent the most mitogenic couplet
among all T1GFR dimers or heterodimers. Furthermore, HER-2 expression status of the primary breast tumor
has also been reported to be of prognostic and therapeutic utility for breast cancer patients, and has been widely
incorporated into recent clinical practice. The objectives of the current study were to determine the frequency
and prognostic significance of HER-3 overexpression and HER-4 overexpression by invasive breast cancer.

Repeat FISH Testing of Breast Tissue Not Cost-Effective for Her-2/neu Determination
November 4, 2009 (Chicago, Illinois) — Universal testing of breast cancer tissue for Her-2/neu status with fluorescence in situ hybridization
(FISH), as some have proposed, does not increase the identification of candidates for Her-2/neu-directed therapy and is not cost-effective,
investigators from Loyola University Medical Center in Maywood, Illinois, announced here at the American Society for Clinical Pathology
2009 Annual Meeting.
There is currently no consensus about Her-2/neu testing on specimen type, the use of multiple-specimen testing (dual testing), or the utility of
universal FISH, noted lead author Kelli Ann Hutchens, MD, who is now a dermatopathology fellow at State University of New York in
Brooklyn. The senior author of the study was Henry Brown, MD.
"The American Society of Clinical Oncology and College of American Pathologists algorithm provides a standard for testing (FISH for
immunohistochemistry [IHC] 2+ or equivocal), but it is not conclusive with regard to testing additional specimens or the use of universal
FISH," Dr. Hutchens said.
"At our institution, we have frequently been doing universal testing, that is, using FISH regardless of the immunohistochemistry results, and
have been testing more often, doing IHC and sometimes FISH on both biopsy and excision specimens," she said. "We usually did this
because of the clinician's or patient's request. It's hard to say no to a breast surgeon."
But the pathology department became concerned about an "unvalidated approach," she said, which led them to evaluate the sensitivity and
the cost of Her-2/neu testing on biopsy and excision specimens and the use of universal FISH.
The study involved 45 patients with invasive breast cancer found on both core biopsy and excision specimens; each specimen was tested for
Her-2/neu with IHC and some specimens were tested with FISH. Cases were evaluated for frequency of FISH testing, regardless of IHC
result, dual FISH testing on biopsy and excision specimens, and concordance of IHC and FISH results.
They also determined the cost of testing to the laboratory, the standard reimbursement for testing, and the patient expense. Cost of IHC was
assessed at 2.5 times the direct cost, and standard reimbursement from Medicare and unreimbursed costs were determined. The cost of FISH
was obtained from the reference lab and calculated as a patient cost for the unstained slides sent to a reference lab for analysis.
Concordance Very High Between Tests
There was 95.5% concordance (43 of 45) when IHC was performed on both biopsy and excision specimens, 100% concordance (12 of 12)
when FISH was performed on both, and 97.5% concordance (39 of 40) between determinant IHC and FISH.
There were 2 discordant cases. One patient overexpressed the protein without gene amplification (i.e., IHC-positive and FISH-negative),
which is reported in the literature to occur in about 3% of cases. The second patient was IHC-positive on the biopsy and negative on the
excision sample, which could represent a fixation error, thickness of tissue, or other factor, she suggested.
These concordance rates were "acceptably high and similar to [those in] the literature," Dr. Hutchens noted.
Importantly, universal FISH testing did not result in the increased identification of tumors that would potentially be trastuzumab-responsive,
she reported. Nor did dual testing of the biopsy and excision specimens with IHC or FISH result in increased identification of Her-2/neu
positivity.
Universal FISH Not Cost-Effective
"Testing beyond using IHC on a single excision specimen and FISH for equivocal cases only results in unwarranted costs to laboratories and
patients and should not be performed," Dr. Hutchens concluded.
Each IHC test cost the laboratory $194.56, for which the standard reimbursement is $52.36, resulting in a $142.20 loss for each test
performed. FISH testing is directly billed to the patient, at a cost of $794.00 per test.
"Dual testing on the biopsy and excisional specimens did not yield a significant increase in sensitivity, and resulted in $6399 in unreimbursed
costs to the laboratory," she said. "Performing FISH on determinant IHC specimens resulted in $31,760 in additional costs to patients."
Had clinicians followed the algorithmic guidelines for Her-2/neu testing, unreimbursed costs to the lab would have been reduced by $6399,
and costs to patients would have been reduced by $41,288. The total savings would be $47,687 for these 45 patients, translating into a savings
of $105,971 per 100 patients, the investigators concluded.
"Excess testing has cost us and our patients," Dr. Hutchens observed. "Our goal is now to use this study as a platform to say that additional
testing is unnecessary and is costing our labs, our patients, and our healthcare system."
Session moderators agreed that pathologists are often pressed by surgeons and oncologists to do multiple tests for Her-2/neu, and said this
information could help them abide by current guidelines. "This information is valuable in the current healthcare environment, to be able to
say to your clinicians that we have evidence that allows you to do fewer studies and expect the same results," said Dennis O'Malley, MD,
from Clarient Diagnostics in Aliso Viejo, California.
Rohit Bhargava, MD, from Magee-Women's Hospital of the University of Pennsylvania Medical Center in Pittsburgh, pointed out that in
cases of ductal carcinoma in situ, universal FISH testing is clearly not indicated "and you can plainly so 'no' in this case," he said. With
neoadjuvant chemotherapy becoming the norm, IHC testing is increasingly being recommended for the core needle biopsy, rather than the
excision biopsy. "FISH should be done on a case-by-case basis," he said.
American Society for Clinical Pathology (ASCP) 2009 Annual Meeting: Abstract 86. Presented October 30, 2009.

Sequential Trastuzumab Does Poorly in European Breast Cancer Study

NEW YORK (Reuters Health) Dec 02 - In women with axillary node-positive breast cancer, giving trastuzumab after the end of adjuvant
chemotherapy and radiation did not significantly reduce their risk of relapse, European researchers report online in the Journal of Clinical
Oncology.
The report, by Dr. Marc Spielmann of the Institut Gustave Roussy, Villejuif, France, and colleagues, noted that almost all previous trials of
trastuzumab in similar populations reported a statistically significant benefit, with risk reductions ranging from 36% to 58%.
Regarding possible reason(s) for their findings, the authors point out that "the most robust data for trastuzumab efficacy came from trials that
evaluated a concomitant schedule" rather than a sequential one.
Subjects in the multicenter study were drawn from among 3,010 women with axillary node-positive nonmetastatic breast cancer who had
been randomized to receive one of two chemotherapy regimens (either fluorouracil, epirubicin and cyclophosphamide or epirubicin and
docetaxel) plus radiation (if breast surgery had been conservative).
The 528 women with tumors that over-expressed human epidermal growth factor receptor 2 (HER2) were randomized a second time, to
receive either a one-year course of trastuzumab, or observation.
Trastuzumab was given as an 8 mg/kg loading dose and a maintenance dose of 6 mg/kg every three weeks for up to 18 cycles. The HER2-
positive women had a median age of 48 years.
Three-quarters of those slated to get trastuzumab received it for at least six months. The main reason for discontinuing trastuzumab was
cardiac events (41 patients), although no deaths from cardiac causes were reported.
After a median follow-up of 47 months, trastuzumab treatment was associated with a nonsignificant 14% decrease in the risk of relapse and
with no difference in the risk of death. Three-year disease-free survival rates were 81% with trastuzumab and 78% with observation. Three-
year overall survival rates were 95% with trastuzumab and 96% in controls.
Going back to their point that earlier reports showed a benefit of trastuzumab when it was given with, rather than after, chemotherapy, the
researchers add: "Preclinical data suggest that, in addition to exerting direct antiproliferative effect on cancer cells, the concomitant use of
trastuzumab could increase the taxane sensitivity of cancer cells."
J Clin Oncol 2009.

Lapatinib monotherapy in patients with relapsed, advanced, or metastatic breast

cancer: efficacy, safety, and biomarker results from Japanese patients phase II
studies
M Toi1,2, H Iwata3, Y Fujiwara4, Y Ito5, S Nakamura6, Y Tokuda7, T Taguchi8, Y Rai9, K Aogi10, T Arai11,
J Watanabe12, T Wakamatsu13, K Katsura13, C E Ellis14, R C Gagnon14, K E Allen14, Y Sasaki15 and S Takashima10
British Journal of Cancer (2009) 101, 1676–1682. Correspondence: Dr M Toi, E-mail: toi@kuhp.kyoto-u.ac.jp
BACKGROUND:
HER2-positive metastatic breast cancer (MBC) relapsing after trastuzumab-based therapy may require continued HER2 receptor
inhibition to control the disease and preserve the patients' quality-of-life. Efficacy and safety of lapatinib monotherapy was evaluated
in Japanese breast cancer patients after trastuzumab-based therapies.
METHODS:
In studies, EGF100642 and EGF104911 evaluated the efficacy and safety of oral lapatinib given 1500 mg once daily in patients with
advanced or MBC. All patients progressed on anthracyclines and taxanes; HER2-positive patients had also progressed on trastuzumab.
RESULTS:
For HER2-positive tumours (n=100), objective response rate was 19.0% (95% confidence interval (CI): 11.8–28.1) and clinical benefit
rate (CBR) was 25.0% (95% CI: 16.9–34.7). One out of 22 HER2-negative tumour was documented as complete response (n=22). The
median time-to-progression (TTP) in the HER2-positive and HER2-negative groups was 13.0 and 8.0 weeks (P=0.007); median
overall survival was 58.3 and 40.0 weeks, respectively. The most frequent adverse event was diarrhoea. TTP and CBR were
significantly associated with HER2 expression. Patients with tumours harbouring an H1047R PIK3CA mutation or low expression of
PTEN derived clinical benefit from lapatinib.
CONCLUSION:
Lapatinib monotherapy had shown anti-tumour activity in Japanese patients with HER2-positive MBC that relapsed after trastuzumab-
based therapy, including those with brain metastases. Patients benefiting from lapatinib may have biomarker profiles differing from
that reported for trastuzumab.

Time to First Tumor Progression as Outcome Predictor of a Second

Trasuzumab-Based Therapy beyond Progression in HER-2 Positive
Metastatic Breast Cancer.
Metro G, Giannarelli D, Gemma D, Lanzetta G, Ciccarese M, Papaldo P, Gamucci T, Lorusso V, Mottolese M, Magnolfi E, Cognetti F, Fabi A.
Division of Medical Oncology, Regina Elena Cancer Institute, Rome, Italy.
In a previous analysis performed on a cohort of 37 HER-2 positive metastatic breast cancer (MBC) patients treated with trastuzumab beyond
progression, we found that a second trastuzumab-based therapy is associated with a considerable response rate and preserved time to progression as
compared with a first trastuzumab-based therapy. In the present study, we extended the analysis to a total of 69 patients treated in four different italian
Institutions, also trying to identify clinical predictors of sensitivity to a second trastuzumab-based therapy beyond progression. Efficacy results on the
overall population confirmed that a second trastuzumab-based therapy beyond progression is an active regimen (27.5% of responses and 6.5 months
of time to progression, respectively). Median time to progression to the first trastuzumab therapy (TTP1) identified two groups of patients with
different sensitivity to trastuzumab beyond progression (group A, TTP1 >/= 8 months and group B, TTP1 < 8 months) in terms of time to second
progression and post-progression survival (group A versus group B showed respectively a time to second progression of 7.6 versus 4.7 months, p =
0.05, and a post-progression survival of 31.7 months versus 21.8 months, p = 0.04). In the multivariate analysis, only TTP1 was a predictor of time to
second progression and post-progression survival. Despite the recent approval of lapatinib plus capecitabine for trastuzumab-progressing patients, it
is still reasonable to offer trastuzumab beyond progression to HER-2 positive MBC patients, because these data confirm the potential utility of such a
conduct. In the clinic, time to first tumor progression may represent a useful tool to identify patients who are more likely to benefit from trastuzumab
beyond progression. Breast J. 2009 Nov 2. [Epub ahead of print]

Trastuzumab treatment beyond brain progression in HER2-positive metastatic breast cancer

I. H. Park1, J. Ro1,*, K. S. Lee1, B. H. Nam2, Y. Kwon1 and K. H. Shin1
1
Center for Breast Cancer
2
Center for Clinical Trials, National Cancer Center, Goyang, Gyeonggi, Korea
*
Correspondence to: Dr J. Ro, Center for Breast Cancer, National Cancer Center, 111 Jungbalsan-ro, Ilsandong-gu, Goyang-si,
Gyeonggi-do, 410-769, Korea. Tel: +82-31-920-1610; E-mail: jungsro@ncc.re.kr
Background: Although trastuzumab therapy improves survival in patients with human epidermal growth factor
receptor 2 (HER2)-positive metastatic breast cancer, 40% of patients develop brain metastasis (BM) even when
extracranial disease is under control. We studied whether trastuzumab therapy beyond or after BM was
beneficial to patients with BM.
Patients and methods: The effect of trastuzumab on survival after BM was analyzed in 78 HER2-positive
breast cancer patients. Patients were grouped according to trastuzumab therapy; no treatment and treatment
before and after BM were diagnosed.
Results: Overall survival after the diagnosis of BM as well as time to progression (TTP) of intracranial tumors
was prolonged in patients who received trastuzumab after BM was diagnosed. Conversely, BM occurred much
later in patients who received trastuzumab before BM. In the multivariate Cox regression model, age at BM <50
years, disease-free interval 24 months, TTP of intracranial tumor 4.8 months, and trastuzumab treatment after
BM were significantly associated with longer survival after the onset of BM.
Conclusions: Trastuzumab therapy after the onset of BM in HER2-positive breast cancer patients is associated
with a significant survival benefit after BM diagnosis compared with patients who never received or completed
trastuzumab before the BM diagnosis.
Key words: brain metastasis, HER2-positive breast cancer, trastuzumab
Received for publication May 21, 2008. Accepted for publication June 30, 2008.

Phase II Trial of Weekly Docetaxel, Vinorelbine, and Trastuzumab in the First-Line

Treatment of Patients With HER2-Positive Metastatic Breast Cancer
Jeffrey R. Infante; Denise A. Yardley; Howard A. Burris III; F. Anthony Greco; Cindy P. Farley; Charles Webb;
David R. Spigel; John D. Hainsworth
Published: 05/29/2009
Abstract
Background: The combinations of trastuzumab/docetaxel and trastuzumab/vinorelbine are highly active in the
treatment of patients with HER2-positive metastatic breast cancer (MBC). We investigated the feasibility and
safety of a 3-drug combination of trastuzumab, docetaxel, and vinorelbine as first-line therapy in this patient
group.
Patients and Methods: Sixty patients with previously untreated, measurable HER2-positive MBC
(immunohistochemistry 3+ and/or fluorescence in situ hybridization positive) were treated with docetaxel 30
mg/m2 intravenously (I.V.) and vinorelbine 25 mg/m2 I.V. on days 1 and 8 of each 3-week cycle. Trastuzumab
was given weekly (4-mg/kg loading dose followed by 2 mg/kg/week). Patients were evaluated after 6 weeks;
responders/stable patients continued treatment until progression.
Results: Patients received a median of 11 treatment cycles (range, 1-22 cycles). Forty-one of 60 patients (68%)
had major responses (16 complete responses [27%], 25 partial responses [42%]). An additional 13 patients
(22%) had stable disease for ≥ 6 months. After a median follow-up of 58 months, median progression-free
survival was 12 months (95% CI, 9.1-16.3 months), and the median overall survival was 40.8 months (95% CI,
25-not reached). Neutropenia (72% grade 4) was the most common hematologic toxicity; 8 patients were
hospitalized for febrile neutropenia. A total of 67% of patients required dose modifications for neutropenia
during cycles 1 or 2. Other grade 3/4 toxicities included fatigue (12%), hyperglycemia (7%), and myalgias
(7%). There were no treatment-related deaths.
Conclusion: The combination of trastuzumab, docetaxel, and vinorelbine is highly active as first-line treatment
for patients with HER2-positive MBC. However, this regimen offers no obvious advantages over other less
myelosuppressive trastuzumab-containing regimens, and its routine use is not supported by the study.
Introduction
Trastuzumab, a humanized monoclonal antibody targeting the HER2 receptor, is a highly effective targeted
agent for the 25%-30% of patients with breast cancer who overexpress HER2. There is a high correlation
between fluorescence in situ hybridization (FISH) analysis and 3+ immunohistochemistry (IHC) staining in
determining HER2 positivity.[1] In 2002, Vogel et al showed that the objective response rate (ORR) of single-
agent trastuzumab was 26% (95% CI, 18%-34%) in previously untreated HER2-positive metastatic breast
cancer (MBC).[2] The median overall survival (OS) in this trial was approximately 2 years.
In vivo data reported by Mohsin et al suggest trastuzumab produces its therapeutic benefit by affecting survival
pathways, decreasing nuclear pAkt, and inducing apoptosis.[3] A number of chemotherapeutic agents, including
the platinum agents, taxanes, and vinorelbine, are synergistic with trastuzumab in preclinical models.[4,5] The
addition of trastuzumab to standard chemotherapy also improves response rate and duration of response in the
first-line treatment of patients with MBC. In a randomized trial, treatment with ment of patients with MBC. In a
randomized trial, treatment with trastuzumab plus paclitaxel produced a higher response rate (50% vs. 32%) and
longer median time to disease progression (7.4 months vs. 4.6 months) than did treatment with paclitaxel alone.
[6]
Trastuzumab has since become a standard component of first-line chemotherapy for patients with MBC who
overexpress HER2.
Although the trastuzumab/paclitaxel combination was the first to demonstrate clinical benefit, preclinical
experiments showed that trastuzumab has a higher level of synergy with docetaxel or vinorelbine.[4] Excellent
results have been subsequently reported with the 2-drug combination of trastuzumab and vinorelbine in the
treatment of patients with HER2-positive MBC. Chan reviewed > 450 assessable patients across 12 phase II
trials and 1 phase III trial and found the response rate to be 51%-86% in first-line treatment with this
combination.[7] When reported, the median time to progression (TTP) and OS were also favorable (10 months
and 25 months, respectively). Neutropenia occurred in approximately 50% of patients and was the most
frequent grade 3/4 toxicity. The neutropenia was usually of limited duration and resulted in hospitalization for
febrile neutropenia in ≤ 4% of patients in all reported studies. Nonhematologic toxicities (including cardiac
toxicities) were also uncommon.
Docetaxel administered with trastuzumab is also a very active combination. In patients with HER2-positive
disease treated first-line with docetaxel on an every-3-week schedule in combination with trastuzumab, the
M77001 study group reported a response rate of 61% (95% CI, 50%-71%), a median TTP of 11.7 months, and
an OS of 31.2 months.[8] The rate of grade 3/4 neutropenia was 32%; however, the rate of febrile neutropenia
was 23% with this combination. Even higher rates of neutropenia have been reported with this dosing schedule.
[9]
Weekly schedules of docetaxel in combination with trastuzumab have markedly less grade 3/4
leukopenia/neutropenia (< 10%) while maintaining ORRs > 60%.[10,11]
In this phase II trial, performed through the Minnie Pearl Cancer Research Network, we attempted to improve
upon the efficacy of the trastuzumab/vinorelbine combination by adding weekly docetaxel. The weekly
schedule of docetaxel was chosen in hopes of allowing the administration of the full efficacious dose of all 3
individual drugs. The results of this phase II trial of feasibility, toxicity, and efficacy in the first-line treatment of
patients with HER2-positive MBC are reported herein.

Vaccine Reduces Rates of Recurrence and Mortality in Women With HER2/Neu-Positive

Breast Cancer: Presented at AACR
SAN DIEGO -- April 14, 2008 -- A preventive HER2/neu peptide (E75) vaccine is showing great promise in the
prevention of breast cancer recurrence and reducing mortality when recurrences do occur in women with
HER2/neu-positive breast cancer, researchers reported here at the American Association for Cancer Research
(AACR) Annual Meeting 2008.
Breast cancer patients who received the E75 vaccine experienced a boost in their immunity, with a rise in T-
lymphocytes, and this translated into decreased breast cancer recurrence and a 50% reduction in mortality at 30
months, said Linda C. Benavides, MD, Resident in General Surgery, Brooke Army Medical Center, San
Antonio, Texas.
In particular, women with low-expressing HER2/neu tumours who were vaccinated had better immunological
and clinical responses, with decreased breast cancer recurrence and zero mortality. This result "surprised,
delighted, and excited" the researchers, Dr. Benavides said on April 14.
"The fact that HER2 low-expressors responded so favourably not only underscores the difference in mechanism
between the vaccine versus antibody therapy like trastuzumab, but it also offers the hope of additional adjuvant
therapy to the largest subset of breast cancer patients if proven in the upcoming phase 3 trial," she said in a press
briefing.
HER2/neu is a source of immunogenic peptides and is overexpressed in 30% of patients with early-stage breast
cancer. Dr. Benavides and her colleagues tested the vaccine, a 9-amino-acid protein, to determine its efficacy in
boosting immunity and in reducing recurrence and mortality rates in 163 node-negative and node-positive
patients demonstrating all levels of HER2/neu expression.
Of the 94 women that received the vaccine, 30 women were HER2/neu overexpressors and 64 were low-
expressors. HER2/neu overexpressors were determined to express more than 2.0 HER2/neu tumours on
fluorescent in situ hybridisation (FISH) and more than 3 HER2/neu tumours on immunohistochemistry (IHC).
HER2/neu low-expressors included patients with IHC results showing no tumours to 2 HER2/neu-positive
tumours.
The remaining 71 patients served as unvaccinated controls. Of these, 22 were overexpressors of HER2/neu and
49 were low-expressors.
The women were vaccinated once a month over 6 months, and were given boosters every 6 months.
All patients showed an immunological response to the vaccine, as measured by delayed-type hypersensitivity
reactions. However, vaccinated overexpressor patients showed a decreased number of E75-specific CD8+ T
cells compared with their low-expressor counterparts.
At a median follow-up of 30 months, disease recurrence rates were similar between vaccinated and
nonvaccinated overexpressors (18% and 14%, respectively; P = .7). However, mortality rates were better in the
vaccinated overexpressors than nonvaccinated overexpressors (25% vs 50%, P=NS), Dr. Benavides said.
Importantly, recurrence of breast cancer was substantially lower among the vaccinated patients with low
HER2/neu expression, who experienced an 11% recurrence rate compared with 18% for controls.
The mortality rate among low-expressors with recurrent disease was 0% among vaccinated patients versus 38%
among the control group (P = .08).
Dr. Benavides said that these findings are very encouraging for the more than 50% of breast cancer patients
whose tumours fall into the HER2/neu low-expressing category and who are not eligible for trastuzumab
treatment.
"It would be wonderful to be able to offer these patients adjuvant treatment, which is something they have not
had previously."
[Presentation title: Response to a Preventive HER2/Neu Peptide (E75) Vaccine Based on HER2/neu Status.
Abstract 2545]

High efficacy of pre-operative trastuzumab combined with paclitaxel following doxorubicin

& cyclophosphamide in operable breast cancer. Paluch-Shimon S, Wolf I, Goldberg H, Evron E,
Papa MZ, Shabtai M, Barsuk D, Yosepovich A, Modiano T, Catane R, Kaufman B. The Institute of
Oncology, Chaim Sheba Medical Center, Tel Hashomer, Israel. Acta Oncol. 2008 Apr 30:1-6.
Background. Trastuzumab in combination with adjuvant chemotherapy improves disease free survival and
overall survival in HER2 over-expressing breast cancer patients. Data concerning the use of trastuzumab in the
neo-adjuvant setting is limited. We aimed to compare outcome of HER2 over-expressing breast cancer patients
treated with either standard chemotherapy, consisting of doxorubicin, cyclophosphamide and a taxane to
outcome of patients treated with the same chemotherapy regimen with the addition of trastuzumab in
concurrence with paclitaxel. Methods. We conducted a retrospective review of all consecutive HER2 over-
expressing breast cancer patients treated at the participating institutions during the study period and received
neo-adjuvant therapy. Allocation to trastuzumab was not based on clinical parameters and was approved only by
part of the insurers. Clinical and pathological characteristics, as well as response rate and type of surgery were
analyzed. Results. Thirty seven patients received chemotherapy alone and 24 patients received chemotherapy
and trastuzumab. A similar distribution of age, clinical stage and histology was noted in both groups. The rate of
pathological complete response (pCR) was significantly higher among the trastuzumab-treated group compared
to chemotherapy-alone group (75 vs. 24% respectively, p=0.0002). pCR in the breast was noted in 18 of 24
(75%) compared to 10 of 36 (28%, p=0.0005) and pCR in the axillary lymph nodes was noted in 19 of 20 (95%)
compared to 8 of 28 (29%, p=0.0001), in the trastuzumab group compared to the chemotherapy-alone group
respectively. The safety profile was similar between both groups and no clinical cardiotoxicity were noted.
Conclusions. The addition of trastuzumab to standard chemotherapy in the neo-adjuvant setting improves
pathological complete response rates in HER2 over-expressing breast cancer patients.

Vaccine Reduces Rates of Recurrence and Mortality in Women With HER2/Neu-Positive

Breast Cancer: Presented at AACR
SAN DIEGO -- April 14, 2008 -- A preventive HER2/neu peptide (E75) vaccine is showing great promise in the
prevention of breast cancer recurrence and reducing mortality when recurrences do occur in women with
HER2/neu-positive breast cancer, researchers reported here at the American Association for Cancer Research
(AACR) Annual Meeting 2008.
Breast cancer patients who received the E75 vaccine experienced a boost in their immunity, with a rise in T-
lymphocytes, and this translated into decreased breast cancer recurrence and a 50% reduction in mortality at 30
months, said Linda C. Benavides, MD, Resident in General Surgery, Brooke Army Medical Center, San
Antonio, Texas.
In particular, women with low-expressing HER2/neu tumours who were vaccinated had better immunological
and clinical responses, with decreased breast cancer recurrence and zero mortality. This result "surprised,
delighted, and excited" the researchers, Dr. Benavides said on April 14.
"The fact that HER2 low-expressors responded so favourably not only underscores the difference in mechanism
between the vaccine versus antibody therapy like trastuzumab, but it also offers the hope of additional adjuvant
therapy to the largest subset of breast cancer patients if proven in the upcoming phase 3 trial," she said in a press
briefing.
HER2/neu is a source of immunogenic peptides and is overexpressed in 30% of patients with early-stage breast
cancer. Dr. Benavides and her colleagues tested the vaccine, a 9-amino-acid protein, to determine its efficacy in
boosting immunity and in reducing recurrence and mortality rates in 163 node-negative and node-positive
patients demonstrating all levels of HER2/neu expression.
Of the 94 women that received the vaccine, 30 women were HER2/neu overexpressors and 64 were low-
expressors. HER2/neu overexpressors were determined to express more than 2.0 HER2/neu tumours on
fluorescent in situ hybridisation (FISH) and more than 3 HER2/neu tumours on immunohistochemistry (IHC).
HER2/neu low-expressors included patients with IHC results showing no tumours to 2 HER2/neu-positive
tumours.
The remaining 71 patients served as unvaccinated controls. Of these, 22 were overexpressors of HER2/neu and
49 were low-expressors.
The women were vaccinated once a month over 6 months, and were given boosters every 6 months.
All patients showed an immunological response to the vaccine, as measured by delayed-type hypersensitivity
reactions. However, vaccinated overexpressor patients showed a decreased number of E75-specific CD8+ T
cells compared with their low-expressor counterparts.
At a median follow-up of 30 months, disease recurrence rates were similar between vaccinated and
nonvaccinated overexpressors (18% and 14%, respectively; P = .7). However, mortality rates were better in the
vaccinated overexpressors than nonvaccinated overexpressors (25% vs 50%, P=NS), Dr. Benavides said.
Importantly, recurrence of breast cancer was substantially lower among the vaccinated patients with low
HER2/neu expression, who experienced an 11% recurrence rate compared with 18% for controls.
The mortality rate among low-expressors with recurrent disease was 0% among vaccinated patients versus 38%
among the control group (P = .08).
Dr. Benavides said that these findings are very encouraging for the more than 50% of breast cancer patients
whose tumours fall into the HER2/neu low-expressing category and who are not eligible for trastuzumab
treatment.
"It would be wonderful to be able to offer these patients adjuvant treatment, which is something they have not
had previously."
[Presentation title: Response to a Preventive HER2/Neu Peptide (E75) Vaccine Based on HER2/neu Status.
Abstract 2545]

Survival in patients with brain metastases from breast cancer: the importance of HER-2 status.
Eichler AF, Kuter I, Ryan P, Schapira L, Younger J, Henson JW. Department of Neurology, Pappas Center for Neuro‐Oncology,
Massachusetts General Hospital, Boston, Massachusetts. Cancer. 2008 Mar 24
BACKGROUND: Brain metastases (BM) are the most common intracranial tumors in adults. To the authors'
knowledge, established prognostic factors for survival after the diagnosis of BM in breast cancer patients do not
take into account HER-2 status, which may have increasing relevance in the trastuzumab therapy era.
METHODS: The authors identified 83 patients with breast cancer and new parenchymal BM diagnosed
between January 1, 2001 and December 31, 2005 who were treated at Massachusetts General Hospital. Survival
was estimated using the Kaplan-Meier method and curves were compared using the log-rank test. A Cox
proportional hazards model was used to determine independent predictors of survival. RESULTS: The median
overall survival from the time of BM was 8.3 months. On univariate analysis, HER-2-positive patients were
found to have prolonged survival after BM compared with HER-2-negative patients (17.1 months vs 5.2
months). Patients with triple negative disease had a median survival of 4.0 months, compared with 11.2 months
for all other patients. Additional predictors of improved survival on univariate analysis included </=3 BM,
controlled or absent systemic disease, and controlled local disease. On multivariate analysis, only HER-2 status,
number of BM, and local disease status remained independent predictors of survival. CONCLUSIONS: HER-2
status is a strong predictor of survival after the diagnosis of BM. The survival of breast cancer patients with BM
appears to be improving, but a better understanding of both the predictors of brain recurrence and the delayed
effects of treatment is needed to properly counsel patients regarding the risk-benefit ratio of various treatment
modalities. Cancer 2008. (c) 2008 American Cancer Society.
Randomized phase III trial of weekly compared with every-3-weeks paclitaxel for metastatic
breast cancer, with trastuzumab for all HER-2 overexpressors and random assignment to
trastuzumab or not in HER-2 nonoverexpressors: final results of Cancer and Leukemia
Group B protocol 9840. Seidman AD, Berry D, Cirrincione C, Harris L, Muss H, Marcom PK, Gipson G, Burstein H, Lake
D, Shapiro CL, Ungaro P, Norton L, Winer E, Hudis C. Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY
10021, USA. seidmana@mskcc.org J Clin Oncol. 2008 Apr 1;26(10):1642-9.
PURPOSE: Phase II trials suggested that weekly paclitaxel might be more effective and less toxic than every-3-
weeks administration for metastatic breast cancer (MBC). Cancer and Leukemia Group B (CALGB) protocol
9840 was initiated to address this question. Subsequently trastuzumab was demonstrated to improve outcomes
of paclitaxel therapy for human epidermal growth factor receptor-2 (HER-2)-positive patients, and was
therefore incorporated. Because inhibition of HER-family signaling had potential efficacy even without HER-2
overexpression, we randomly assigned for trastuzumab in this population. PATIENTS AND METHODS:
Patients were randomly assigned to paclitaxel 175 mg/m(2) every 3 weeks or 80 mg/m(2) weekly. After the first
171 patients, all HER-2-positive patients received trastuzumab; HER-2 nonoverexpressors were randomly
assigned for trastuzumab, in addition to paclitaxel schedule. A total of 577 patients were treated on 9840. An
additional 158 patients were included in analyses, for combined sample of 735. The primary end point was
response rate (RR); secondary end points were time to progression (TTP), overall survival, and toxicity. Primary
comparisons were between weekly versus every-3-weeks paclitaxel, and trastuzumab versus no trastuzumab in
HER-2 nonoverexpressors. RESULTS: In the combined sample, weekly paclitaxel was superior to every-3-
weeks administration: RR (42% v 29%, unadjusted odds ratio [OR] = 1.75; P = .0004), TTP (median, 9 v 5
months; adjusted HR = 1.43; P < .0001), and survival (median, 24 v 12 months; adjusted HR = 1.28; P = .0092).
For HER-2 nonoverexpressors, trastuzumab did not improve efficacy. Grade 3 neuropathy was more common
with weekly dosing (24% v 12%; P = .0003). CONCLUSION: Weekly paclitaxel is more effective than every-3-
weeks administration for MBC. Trastuzumab did not improve efficacy for HER-2 nonoverexpressors.
Neurotoxicity is a treatment-limiting toxicity for weekly paclitaxel.

HER2 in well differentiated breast cancer: is testing necessary?

Haines GK 3rd, Wiley E, Susnik B, Apple SK, Frkovic-Grazio S, Reyes C, Goldstein LC, Dadmanesh F, Gown
AM, Nadji M, Bracko M, Tavassoli FA. Department of Pathology, Yale University School of Medicine, EP2-
611 20 York Street, New Haven, CT, 06510, USA, k.haines@yale.edu. Breast Cancer Res Treat. 2008 Jan 18
Background In addition to providing a timely and accurate diagnosis, pathologists routinely provide prognostic
and predictive information to assist in the treatment of patients with invasive breast cancer. As our
understanding of breast cancer at the molecular and genetic level improves, sophisticated new treatment options
have become available to patients. The demonstrated improvements in disease-free and overall survival with the
use of trastuzumab (Herceptin) has made HER2 testing a standard of care in the evaluation of patients with
breast cancer. Specialized breast centers have accumulated sufficient experience to recognize that HER2
positive tumors tend to be of higher grade and to be estrogen receptor negative, whereas well-differentiated
breast cancers rarely are HER2 positive. Methods To determine whether HER2 testing is necessary in well-
differentiated breast cancer, we analyzed the frequency of HER2 positivity among 1,162 cases from 7 major
breast centers or commercial laboratories in the United States and Europe. Results Well-differentiated breast
cancers, defined by either nuclear grading or the Scarff-Bloom-Richardson system, rarely are HER2 positive
(mean 1.6%, range 0-2.8%). Conclusions Given the low rate of well differentiated HER2 positive tumors,
falling within the range reported for false negative IHC tests for HER2, and the absence of published data
demonstrating a beneficial effect of trastuzumab therapy in this subset of patients, HER2 testing should not be
considered a standard of care for all patients with well-differentiated breast cancer.

Prognostic significance of HER-2 status in women with

inflammatory breast cancer. Dawood S, Broglio K, Gong Y, Yang WT, Cristofanilli M, Kau SW, Meric-
Bernstam F, Buchholz TA, Hortobagyi GN, Gonzalez-Angulo AM; for the Inflammatory Breast Cancer Research Group. Department
of Breast Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas. Cancer. 2008 Feb 25
BACKGROUND: Inflammatory breast cancer (IBC) is a rare, aggressive form of breast cancer with poorly
understood prognostic variables. The purpose of this study was to define the prognostic impact of HER-2 status
on survival outcomes of patients with IBC. METHODS: In all, 179 patients with IBC, diagnosed between 1989
and 2005, with known HER-2 status, and treated with an anthracycline-based chemotherapy regimen without
trastuzumab, were included in the analysis. Patients with HER-2-positive disease who received trastuzumab at
the time of disease recurrence were included. Survival outcomes were estimated by the Kaplan-Meier product
limit method and compared across groups using the log-rank statistic. A Cox proportional hazards model was
fitted to determine the association of survival outcomes with HER-2 status after adjusting for patient and tumor
characteristics. RESULTS: A total of 111 patients (62%) had HER-2-negative disease and 68 (38%) had HER-2-
positive disease. The median follow-up among all patients was 35 months. At the time of the analysis, 62
patients (55.9%) with HER-2-negative disease and 42 patients (61.8%) with HER-2-positive disease had a
recurrence. Thirty-one patients (73.8%) with HER-2-positive disease who had a disease recurrence went on to
receive trastuzumab. On univariate analysis, no statistically significant difference was observed for either
recurrence-free survival (P = .75) or overall survival (P = .24) between patients who had HER-2-positive disease
and those who had HER-2-negative disease. In a multivariate model, HER-2 status did not appear to
significantly affect recurrence-free survival (hazards ratio [HR] of 0.75; 95% confidence interval [95% CI],
0.46-1.22 [P = .241]). In the multivariate model, patients with HER-2-positive disease had a decreased hazard of
death (HR of 0.56; 95% CI, 0.34-0.93 [P = .024]) compared with patients with HER-2-negative disease.
CONCLUSIONS: HER-2 status, in the absence of trastuzumab, did not appear to significantly affect
recurrence-free survival. After adjusting for other characteristics, the addition of trastuzumab in the metastatic
setting significantly improved survival in the HER-2-positive group above and beyond that of the HER-2-
negative group. This gives us further insight into the biology of this aggressive disease and underlines the major
effect of targeted intervention. Cancer 2008. (c) 2008 American Cancer Society.

Estimating the magnitude of trastuzumab effects within patient

subgroups in the HERA trial. Untch M, Gelber RD, Jackisch C, Procter M, Baselga J, Bell R, Cameron
D, Bari M, Smith I, Leyland-Jones B, de Azambuja E, Wermuth P, Khasanov R, Feng-Yi F, Constantin C, Mayordomo JI, Su CH, Yu
SY, Lluch A, Senkus-Konefka E, Price C, Haslbauer F, Sahui TS, Srimuninnimit V, Colleoni M, Coates AS, Piccart-Gebhart MJ,
Goldhirsch A; for the HERA Study Team. Helios Klinikum Berlin Buch, Academic Hospital of the University Charite
Berlin, Berlin, Germany. Ann Oncol. 2008 Feb 21
BACKGROUND: Trastuzumab (Herceptin(R)) improves disease-free survival (DFS) and overall survival for
patients with human epidermal growth factor receptor 2 (HER2)-positive early breast cancer. We aimed to
assess the magnitude of its clinical benefit for subpopulations defined by nodal and steroid hormone receptor
status using data from the Herceptin Adjuvant (HERA) study. PATIENTS AND METHODS: HERA is an
international multicenter randomized trial comparing 1 or 2 years of trastuzumab treatment with observation
after standard chemotherapy in women with HER2-positive breast cancer. In total, 1703 women randomized to
1-year trastuzumab and 1698 women randomized to observation were included in these analyses. Median
follow-up was 23.5 months. The primary endpoint was DFS. RESULTS: The overall hazard ratio (HR) for
trastuzumab versus observation was 0.64 [95% confidence interval (CI) 0.54-0.76; P < 0.0001], ranging from
0.46 to 0.82 for subgroups. Estimated improvement in 3-year DFS in subgroups ranged from +11.3% to +0.6%.
Patients with the best prognosis (those with node-negative disease and tumors 1.1-2.0 cm) had benefit similar to
the overall cohort (HR 0.53, 95% CI 0.26-1.07; 3-year DFS improvement +4.6%, 95% CI -4.0% to 13.2%).
CONCLUSIONS: Adjuvant trastuzumab therapy reduces the risk of relapse similarly across subgroups defined
by nodal status and steroid hormone receptor status, even those at relatively low risk for relapse.

HER2 Status Influences Response to Paclitaxel in Patients With Node-

Positive Breast Cancer
October 15, 2007 — Adding paclitaxel to adjuvant chemotherapy provides little benefit for women
with human epidermal growth-factor-receptor type 2 (HER2)–negative, estrogen-receptor-positive,
node-positive breast cancer, according to a new report. Researchers found that the addition of paclitaxel
to adjuvant doxorubicin plus cyclophosphamide did not give this group of patients a disease-free
survival advantage. The study appears in the October 11 issue of the New England Journal of
Medicine.
However, in an accompanying editorial, Anne Moore, MD, a professor of clinical medicine at the Weill
Medical College of Cornell University, in New York, pointed out that this study is "not a call to
abandon taxanes" for this patient population. Instead, she noted, it is just a signal that the days of a
"one-size-fits-all" treatment for breast cancer patients are coming to a close.
Dr. Moore writes that researchers need to consider alternative methods of administering paclitaxel.
"The 3-week schedule of treatment with paclitaxel is not the only way to include a taxane in adjuvant
therapy," she writes, noting that in more recent trials "dose-dense therapy," which uses the same doses
of doxorubicin plus cyclophosphamide and paclitaxel every 2 weeks instead, has shown better efficacy
than the same regimen administered every 3 weeks. Some adjuvant trials have administered paclitaxel
weekly and adopted an alternative taxane.
"It would be of great value if the investigators in charge of these more recent trials analyzed their
results retrospectively with respect to HER2 and estrogen-receptor status," she writes.
Studies have shown that adjuvant chemotherapy can improve both disease-free and overall survival in
patients with early-stage breast cancer, and the 2 most active agents used are anthracyclines and
taxanes. Results of the Cancer and Leukemia Group B (CALGB) 8541 trial showed that it was also
highly beneficial to increase the dose of a doxorubicin-based regimen, from a relatively low dose of
30 mg/m2 of body-surface area to 60 mg/m2, which is now considered standard.
"In this clinical trial, we attempted to answer 2 questions," said lead author Daniel F. Hayes, MD,
clinical director of the breast oncology program at the University of Michigan Comprehensive Cancer
Center, in Ann Arbor.
"The first question was whether there was any benefit to doses of doxorubicin higher than 60 mg/m2,
which our group had shown earlier to be better than 30 mg/m2," Dr. Hayes told Medscape Oncology.
"The answer to that was no, nor did we see any benefit according to the HER2 or estrogen-receptor
status."
The second question was whether there was any benefit to adding paclitaxel after adjuvant treatment
with doxorubicin plus cyclophosphamide treatment. "The overall answer to that was yes, and our data
suggest that it is confined to women who were either estrogen-receptor negative or HER2 positive," he
said. "To put it another way, there was no apparent benefit for those who are estrogen-receptor positive
and HER2 negative. The emphasis is on the word 'apparent'; we are being very cautious about these
findings."
To address these questions, Dr. Hayes and colleagues randomly selected 1322 stored tissue specimens
that had been obtained from women with node-positive breast cancer who had participated in the
CALGB 9344 trial. The women had been randomly assigned to receive doxorubicin 60, 75, or
90 mg/m2 of body-surface area plus cyclophosphamide 600 mg/m2 for 4 cycles. This regimen was
followed by either 4 cycles of paclitaxel 175 mg/m2 or observation.
The researchers observed that there was no interaction between HER2 status and higher doses of
doxorubicin. The 5-year disease-free survival rate among HER2-positive women was 63% whether
they had received the 60- or 90-mg/m2 dose. It was also similar for patients with HER2-negative tumors
(72% 60 mg and 69% 90 mg).
However, they did find that the addition of paclitaxel was associated with significantly better survival
in patients with HER2-positive, estrogen-receptor-negative tumors. A small subgroup of women with
HER2-positive, estrogen-receptor-positive tumors showed some improvement in survival with
paclitaxel, but the addition of paclitaxel did not appear to benefit patients with estrogen-receptor-
positive, HER2-negative cancers. This subgroup accounted for more than half of the patients in this
study.
"This is part of a growing body of literature suggesting that we can tailor adjuvant treatment for
patients with newly diagnosed breast cancer," said Dr. Hayes. "We already know that estrogen-negative
patients do not benefit from antiestrogen therapy like tamoxifen or the aromatase inhibitors, and the
HER2-negative patients do not benefit from anti-HER2 therapy, like herpceptin or, more recently,
lapatinib."
Additional studies are beginning to show that these 2 markers, as well as others, can be useful in
helping physicians prescribe appropriate chemotherapy, he added. "This is an overall trend toward
individualized therapy, rather than one size fits all."
The study was supported by grants from the National Institutes of Health, the Breast Cancer Research
Foundation, and the Fashion Footwear Charitable Foundation of New York/QVC Presents Shoes on
Sale (to Dr. Hayes). The research for the CALGB 9344 trial was supported in part by grants from the
National Cancer Institute
N Engl J Med. 2007; 357:1496-1506, 1547-1549.

Clin Oncol (R Coll Radiol). 2005 Dec;17(8):630-5.

High efficacy of gemcitabine and cisplatin plus trastuzumab in patients with HER2-
overexpressing metastatic breast cancer: a phase II study.
Stemmler HJ, Kahlert S, Brudler O, Beha M, Muller S, Stauch B, Heinemann V.
Department of Medicine III, Klinikum Grosshadern, University of Munich, Germany.
Joachim.Stemmler@med.uni-muenchen.de
AIMS: Effective and tolerable regimens are sought specifically in women who have been pre-treated with
anthracyclines and taxanes. Gemcitabine and cisplatin plus trastuzumab has shown synergistic activity in vitro,
and provides a new mechanism of drug interaction. This multicentre phase II study aimed to evaluate the
efficacy and tolerability of gemcitabine and cisplatin plus trastuzumab in previously treated patients with
metastatic breast cancer (MBC). MATERIALS AND METHODS: Previously treated patients with human
epidermal growth factor receptor 2 (HER2) overexpressing MBC were enrolled in a multicentre phase II study
(DAKO Hercep Test 3+). Treatment consisted of gemcitabine (750 mg/m2), cisplatin (30 mg/m2) given on days
1 and 8 every 3 weeks, and trastuzumab (4 mg/kg loading dose, 2 mg/kg weekly). RESULTS: Twenty patients
were recruited, all of whom had previously received chemotherapy (12 pre-treated with taxanes, 18 pre-treated
with anthracyclines seven pre-treated with taxanes and trastuzumab). A median of six cycles of the study
treatment was delivered. There were eight partial responses, for an overall response rate of 40% (95%
confidence interval 16.5-63.5%). The clinical benefit rate (complete response plus partial response plus stable
disease) was 80% (95% CI 54.2-95.8%). The response rate in patients who had already received a trastuzumab-
based regimen for MBC was 57.1% (95% CI 7.7-100%). Median time to progression was 10.2 months, and
median overall survival was 18.8 months. Main toxicities were leukopenia (grade 3 in 55% of patients) and
thrombocytopenia (grade 3 in 35% and grade 4 in 5% of patients). Non-haematological toxicity was rarely
severe. CONCLUSIONS: Combination chemotherapy with gemcitabine and cisplatin plus trastuzumab is well
tolerated and active in patients with HER2 overexpressing MBC, even after prior exposure to anthracyclines
and taxanes.

HER2 Overexpression Linked to Breast Cancer Response to Anthracycline

NEW YORK (Reuters Health) May 17 - Amplification of the human epidermal growth factor receptor type 2 (HER2) gene and
overexpression of its product are associated with clinical responsiveness to anthracycline-containing chemotherapy, Canadian
investigators report.
According to their report in the New England Journal of Medicine for May 18, previous studies have demonstrated that the
combination of cyclophosphamide, epirubicin and fluorouracil (CEF) used to treat breast cancer led to increased survival compared
with a regimen of cyclophosphamide, methotrexate and fluorouracil (CMF). CEF is more toxic and more expensive, however.
Lead author Dr. Kathleen I. Pritchard, from the University of Toronto in Ontario, and her team theorized that CEF preferentially
benefited tumors that amplified HER2. To test their theory, they examined tumor specimens from women who participated in the
Mammary.5 randomized trial involving premenopausal women with node-positive breast cancer.
They examined the HER2 status of 639 tumor specimens four ways, with immunohistochemical analysis using CB11 antibody and
TAB 250 antibody, fluorescence in situ hybridization (FISH), and polymerase-chain-reaction (PCR) analysis.
Immunohistochemical analysis showed that 18% to 20% amplified HER2, while PCR was positive in 31% and FISH in 26%.
According to FISH results, women with HER2 amplification had decreased relapse-free and overall survival compared with those
without HER2 amplification.
However, cancers that amplified HER2 had a superior response to CEF than to CMF (hazard ratio for relapse, 0.52, p = 0.003; HR for
death, 0.65, p = 0.06).
In contrast, tumors that did not amplify HER2 did not differ significantly in their response to chemotherapy with CEF or with CMF.
After adjusting for age, nodal status, estrogen-receptor levels, type of surgery, and tumor size, the hazard ratio for the interaction
between treatment and amplification remained significant for relapse-free and overall survival.
Dr. Pritchard's group advises that "patients whose tumors do not exhibit amplification or overexpression of HER2 could be treated
with the less toxic regimen of CMF, whereas those with tumors that show amplified or overexpressed HER2 should receive dose-
intensive anthracycline-containing regimens such as CEF."
While acknowledging that these findings "represent a step forward in anthracycline tailoring," Dr. Martine J. Piccart-Gebhart, from
Universite Libre de Bruxelles, Brussels, points out that, with the advent of the anti-HER2 monoclonal antibody trastuzumab,
anthracyclines may not even be required.
She concludes, "The time has come to divide breast cancer into clinically relevant molecular subgroups, to prioritize the clinical
questions applicable to each subgroup, and to strengthen collaboration between clinicians and laboratory scientists in identifying
molecular signatures that can predict the success or failure of treatment." She writes that the use of genomics and proteomics may be
particularly beneficial in this process.
N Engl J Med 2006;354:2103-2111,2177-2179.

HER2-Positive Breast Cancer Patients Benefit From Lapatinib

Plus Capecitabine Combination: Presented at ECCO
BARCELONA, SPAIN -- September 27, 2007 -- The combination of lapatinib and capecitabine appears to be a
superior treatment option to capecitabine alone in women with HER2-positive advanced breast cancer,
researchers reported here at the 14th European Cancer Society (ECCO).
Notably, the data showed that the addition of lapatinib helped reduce the likelihood of secondary brain
metastases, according to John Crown, MD, Medical Oncologist, St. Vincent's University Hospital, Dublin,
Ireland.
Dr. Crown and colleagues evaluated the use of lapatinib combined with capecitabine compared with
capecitabine alone in 339 women with advanced or metastatic HER2-positive breast cancer who had previously
been treated with anthracyclines, taxanes, and trastuzumab, but were capecitabine naive. All of them had
measurable disease by RECIST criteria.
Patients were randomized to oral lapatinib 1250 mg once daily continuously plus oral capecitabine 2000
mg/m2/day on days 1 to 14 every 3 weeks or oral capecitabine 2500 mg/m2/day on days 1 to 14 every 3 weeks.
Patients remained on treatment until there was evidence of disease progression or unacceptable toxicity.
Results showed a median time to progression of 27 weeks in the lapatinib-capecitabine combination group
versus 19 weeks in the capecitabine-alone group (P =.00013). Overall response rates were 24% and 14%,
respectively (P =.017).
The addition of lapatinib to capecitabine also appeared to thwart the risk of brain metastases (2% vs 11%,
respectively). "We were particularly encouraged by this finding since brain metastases develop in up to a third
of women with HER2-positive metastatic breast cancer, and only 20% of these patients are alive 1 year later
with presently available treatment options," Dr. Crown said during his presentation on September 25th.
Lapatinib increased the frequency of grade 1 and 2 diarrhea by 21% but otherwise did not appreciably alter the
toxicity profile of capecitabine, he said.
Genetic analysis data obtained in 167 patients showed that in women assigned to combination therapy, elevated
HER2 expression correlated positively with response rates and time to progression. "This means that patients
who have higher activity in the genes linked to HER2 signaling and apoptosis will gain greater clinical benefit
from using lapatinib and capecitabine," Dr. Crown said.
Lapatinib is an oral tyrosine kinase inhibitor of epidermal growth factor receptor/HER2 that was recently
approved in the United States, Switzerland, and several other countries worldwide for use in combination with
capecitabine for HER2-positive advanced/metastatic breast cancer in patients who were previously treated with
taxanes, anthracyclines, and trastuzumab-based therapy.
[Presentation title: Lapatinib (L) Plus Capecitabine (C) in HER2+ Advanced Breast Cancer (ABC): Report of
Updated Efficacy and Gene-Array Data. Abstract 2096]

Adjuvant Therapy for HER2-Normal Early-Stage Breast Cancer

Introduction
Several studies of adjuvant therapy for HER2-normal early-stage breast cancer were reported at the 30th Annual
San Antonio Breast Cancer Symposium (SABCS). Prominently featured topics included the evolving role of
taxanes in the adjuvant chemotherapy strategy and the feasibility, safety, and efficacy of specific chemotherapy
strategies among older patients who have historically been underrepresented in clinical trials. Selected
highlights on adjuvant hormone therapy and results from bone mineral density management trials also will be
reviewed.
Adjuvant Taxane Studies
Taxanes and anthracyclines represent the most active cytotoxic agents in breast cancer but are also associated
with clinically significant toxicity. Consequently, investigators aim to identify specific subgroups of women
who are likely to derive significant benefit from specific regimens. The implication is that treatment
recommendations may be tailored to the individual patient and the biology of her breast cancer so that those
women who are likely to benefit are offered appropriate treatment while those who are not may be spared
potential toxicity. To date, these subgroups have not been clearly defined. The identification of specific
subgroups that benefit from taxane-containing regimens has proven particularly challenging. Although a recent
meta-analysis and a pooled analysis[1,2] demonstrated significant survival benefits with taxane-containing
strategies overall, no benefits were reported by specific subgroup. Furthermore, the adjuvant taxane data to date
have been inconsistent. For example, benefits were observed with adjuvant paclitaxel in CALGB 9344, NSABP
B28, and GEICAM 9906 and with adjuvant docetaxel in PACS 01 and BCIRG 001.[3-7] However, no disease-free
survival (DFS) or overall survival (OS) benefits were demonstrated with the addition of docetaxel in ECOG
2197 or NSABP B27.[8,9] Moreover, ECOG 1199,[10] which evaluated weekly vs every-three-weeks schedules of
paclitaxel or docetaxel after 4 cycles of doxorubicin and cyclophosphamide (AC) once every 3 weeks, has not
demonstrated any benefits specific to either taxane or taxane schedule to date. Thus, investigators continue in
their efforts to delineate the optimal taxane-containing regimen and to define subgroups of women who are
likely to benefit from adjuvant taxane strategies.
Sequential Taxane Strategies
It has been postulated that the difficulty in identifying specific subsets of patients who are likely to benefit from
taxane-containing regimens is confounded, in part, by significant variations in adjuvant study designs. Many of
the sequential taxane trials to date have evaluated 6 cycles of an anthracycline-containing regimen, such as 5-
fluorouracil, epirubicin, and cyclophosphamide (FEC) vs 3 cycles of an anthracycline-containing regimen
followed by 3 cycles of docetaxel (eg, FEC-D)[6] or 6 cycles of an anthracycline-containing regimen, such as 5-
fluorouracil, doxorubicin, and cyclophosphamide (FAC) vs 6 cycles of a taxane-containing regimen, such as
docetaxel, doxorubicin, and cyclophosphamide (TAC)[7] with improved outcomes demonstrated in favor of the
taxane-containing regimens (Table). Many North American studies, however, have evaluated 4 cycles of AC
with or without 4 sequential cycles of paclitaxel or docetaxel in the adjuvant and neoadjuvant settings.[3,4,9] Thus,
investigators in the Taxotere as Adjuvant Chemotherapy Trial (TACT)[11] hypothesized that a sequential
docetaxel-containing chemotherapy regimen would result in improved outcomes when controlling for duration
of therapy by evaluating 8 cycles of FEC or E-CMF (epirubicin-cyclophosphamide/methotrexate/5-fluorouracil)
vs 4 cycles of FEC followed by 4 cycles of docetaxel among 4162 women with node-positive or high-risk node-
negative breast cancer in a randomized phase 3 study. However, after a median follow-up period of 51.8
months, there was no significant difference in DFS (hazard ratio [HR] = 0.97) or OS (HR = 0.98). Furthermore,
and as expected in a trial that is negative overall, subgroup analyses by estrogen receptor (ER) and HER2 status
revealed no benefits in favor of either regimen.
Table. Selected Adjuvant Taxane Trials
Nonanthracycline-Containing Regimens
Anthracyclines have been the foundation of many conventional adjuvant chemotherapy regimens for more than
a decade. However, the small but significant long-term risk of anthracycline-mediated cardiotoxicity and acute
myelogenous leukemia are of ongoing clinical concern. Consequently, investigators are exploring the efficacy
of nonanthracycline-containing regimens. The results of one such study, US Oncology 9735, were originally
reported at SABCS 2005 and updated for publication thereafter.[12,13] This study evaluated 4 cycles of every-3-
weeks adjuvant AC at conventional doses (60/600 mg/m2) vs 4 cycles of docetaxel and cyclophosphamide
(TC, 75/600 mg/m2) in 1016 women with node-positive and node-negative breast cancer. In the published
analysis, after a median follow-up period of 5.5 years, TC was associated with significant 5-year DFS benefits
(86% vs 80%, HR = 0.67; P = .015) but no OS benefits. TC was associated with increased rates of myalgia,
arthralgia, edema, and febrile neutropenia, whereas AC was associated with more nausea and vomiting and 1
case of congestive heart failure. This study was updated at SABCS 2007 after a 7-year median follow-up period.
[14]
The previously reported DFS benefits with TC proved sustained (81% vs 75%, P = .033), and a statistically
significant OS benefit was now reported (87% vs 82%, P = .032). Consequently, many clinicians consider TC as
an adjuvant therapy option for patients in whom adjuvant chemotherapy is indicated but anthracycline safety is
a concern. It is important to note, however, that since the inception of this study, several regimens that are more
effective than AC have been identified, including dose-dense AC-T.[15] The efficacy of these third-generation
regimens has not yet been directly evaluated against TC. Furthermore, it is difficult to reconcile the results from
US Oncology 9735 with other studies, such as the TACT study[11] and ECOG 2197,[16] in which 4 cycles of
doxorubicin and docetaxel (with docetaxel administered at 60 mg/m2, a lesser dose than that used in US
Oncology 9735) proved equivalent to 4 cycles of conventional AC.
Adjuvant Chemotherapy for Elderly Patients
Although more than 50% of women are older than 60 years of age at the time of their breast cancer diagnosis,
older women are historically underrepresented in adjuvant chemotherapy trials. This issue was highlighted in a
recent retrospective review[17] of 4 large, randomized, cooperative group trials that demonstrated that older
women derived the same proportional breast cancer recurrence and mortality benefits from the more intensive
regimens as their younger counterparts. In US Oncology 9735,[14] 16% of enrolled study patients were 65 years
of age or older. Consequently, one of the components of the recent US Oncology 9735 analysis was an
unplanned analysis of treatment efficacy by patient age. Consistent with the findings of the cooperative group
retrospective analysis, proportional DFS and OS benefits were demonstrated for women 65 years of age or older
compared with women younger than 65 years of age. Other reported studies focusing on adjuvant chemotherapy
for older patients with breast cancer included a feasibility study of capecitabine monotherapy among women
aged 70 years or older, a feasibility and cardiac safety study of pegylated liposomal doxorubicin among women
aged 65 years or older, and a retrospective analysis of adjuvant AC chemotherapy among patients older than 70
years.[18-20] It is anticipated that further studies addressing adjuvant chemotherapy decision analysis in older
patients will be reported in the coming years.
Adjuvant Hormone Therapy
Longer-Duration Tamoxifen
Tamoxifen remains a mainstay of hormonal therapy for premenopausal (and some postmenopausal) women
with hormone receptor-positive breast cancer. However, the optimal duration of tamoxifen therapy has not been
clearly elucidated. At SABCS 2007, preliminary results from the Adjuvant Tamoxifen: Longer Against Shorter
(ATLAS) trial were reported.[21] In this multicenter, international study, 11,500 women completing
approximately 5 years of tamoxifen were randomized to an additional 5 years of tamoxifen or cessation of
therapy. Although, ideally, only women with confirmed ER-positive disease should have been enrolled in this
study, regional differences in ER testing resulted in a 59% rate of confirmed ER positivity, with 41% untested
for ER status. Furthermore, halfway through the study period, only 83% of women randomized to continue
tamoxifen remained on therapy. Although the data are not yet complete beyond 10 years after initiation of
tamoxifen therapy, a trend toward recurrence and breast cancer-specific mortality benefit was reported for the
10-year tamoxifen cohort. The implication is that the conventional strategy of 5 years of adjuvant tamoxifen
developed largely on the basis of NSABP B14[22] may not be the ideal duration of therapy. However, the ATLAS
data are not yet adequately mature to address the question of duration, and further updates are anticipated.
Tamoxifen and/or Aromatase Inhibitors
An updated analysis from the Arimidex, Tamoxifen Alone or in Combination (ATAC) trial[23] of 5 years of
adjuvant anastrozole vs tamoxifen among more than 6000 postmenopausal women was reported. In a previous
report, after 68 months of follow-up, anastrozole was associated with statistically significant benefits in DFS,
time to recurrence, and incidence of new contralateral primary breast cancers compared with tamoxifen.[24]
Furthermore, as with other aromatase inhibitors (AIs), anastrozole was generally well tolerated and
demonstrated a more favorable toxicity profile compared with tamoxifen. However, until recently, it was
uncertain whether the treatment benefits and relative safety of anastrozole would persist beyond 5 years. At this
update, ATAC results[23] based on 100 months of follow-up showed that the absolute difference in recurrence
actually increased from 2.8% after 5 years to 4.8% after 9 years, making ATAC the first adjuvant AI study to
demonstrate a significant long-term carry-over effect after completion of therapy. However, although ATAC has
the longest follow-up data for an adjuvant AI trial to date, no OS advantage has yet been observed.
Bone Mineral Density Preservation
One of the significant clinical concerns associated with AI administration is the potential for AI-induced
declines in bone mineral density (BMD) and the risk of fracture. However, it was not known whether AI-
associated fracture risk persisted following completion of therapy. The ATAC investigators reported that
although the risk of fracture was significantly increased with anastrozole compared with tamoxifen during the 5
years of treatment, fracture rates declined and appeared to converge in years 5 through 10.[23] The implication is
that while fracture risk is increased during AI therapy, the risk does not appear to persist significantly after
therapy is completed.
Bisphosphonate Coadministration With AI Therapy
Fracture risk reduction during AI therapy remains an ongoing area of investigation. One approach to preventing
AI-induced declines in BMD is coadministration of bisphosphonates. In the Austrian Breast and Colorectal
Cancer Study Group-12 (ABCSG-12) study,[25] 1801 premenopausal women with hormone receptor-positive
breast cancer who were treated with surgery and monthly goserelin were randomized to 3 years of treatment on
1 of 4 treatment arms: tamoxifen, tamoxifen and zoledronic acid (ZA), anastrozole, or anastrozole and ZA. ZA
was administered at 4 mg intravenously every 6 months. On average, an 11.3% decline in BMD was detected at
3 years compared with baseline for women who did not receive ZA and was more pronounced for the subgroup
receiving an AI compared with tamoxifen. BMD improved (-6.8%) but was still diminished from baseline at 5
years. Conversely, women treated with ZA demonstrated no change in BMD at 3 years (+.3%, P = .85) and
increased BMD at 5 years (+3.9%, P = .02). However, among the ZA-treated patients, 1 possible and 2
confirmed cases of osteonecrosis of the jaw, a rare but known complication of bisphosphonate administration,
were reported.
An updated analysis of the Z-FAST study after 36 months was also reported.[26] In this study, 602
postmenopausal women with early-stage breast cancer were randomized to receive upfront or delayed ZA with
adjuvant letrozole. Women randomized to the delayed group received ZA only if a marked decline in BMD or a
symptomatic or asymptomatic fracture was noted at annual follow-up. At 12, 24, and 36 months, BMD
increases were significant in both treatment groups. Of note, however, at 36 months there was no difference in
symptomatic or asymptomatic fracture rates between the 2 groups. Although the lack of a significant difference
may be a function of the modest sample size in this study, it does support the strategy of delaying bone-targeted
therapies until symptoms arise, particularly given the small but potentially devastating risk of osteonecrosis of
the jaw with bisphosphonate administration.
Conclusions
Several studies of adjuvant chemotherapy and hormone therapy for HER2-normal early-stage breast cancer
were recently reported. Evidence for taxane-containing adjuvant chemotherapy strategies continues to evolve,
although the optimal strategy and the specific subgroups of women who are likely to derive benefit from such
strategies have not yet been determined. However, mounting evidence suggests that regardless of the
chemotherapy regimen considered, age should not be an absolute contraindication to systemic therapy,
inasmuch as older women appear to derive benefits proportional to those demonstrated among younger women.
Further studies specifically addressing risk-benefit stratification in this cohort are anticipated.
This activity is supported by an independent educational grant from Susan G. Komen for the Cure.

What's New in HER2-Targeted Therapy for Breast Cancer?

HER2 as a Prognostic and Predictive Marker: Background
Over the last decade, the human epidermal growth factor receptor (EGFR)2 (HER2)became established not only
as a prognostic marker but also as a predictive factor for early-stage and metastatic breast cancer.[1] Its clinical
utility as a predictive marker to identify candidates for therapy with trastuzumab, the humanized monoclonal
antibody, or lapatinib, a dual-target tyrosine kinase inhibitor, assumes the availability of high-quality testing and
accurate determination of HER2 status. Accurate testing can be accomplished with either
immunohistochemistry (IHC) or in situ hybridization (ISH) assays that rely on fluorescence for probe
visualization (eg, fluorescent in situ hybridization [FISH]) in formalin-fixed, paraffin-embedded tissue.
Approximately 18% to 20% of newly diagnosed breast cancers are expected to overexpress HER2 (ie, are
HER2-positive). Poor concordance of central vs local HER2 testing has not improved much over time,[2] and
was one of several factors that led organizations, such as the American Society of Clinical Oncology (ASCO)
and the College of American Pathologists (CAP), to issue guidelines in regard to HER2 testing.[1] Since then,
retrospective data from unplanned subset analyses (1 metastatic[3] and 2 adjuvant[4,5] trials) reported at the 2007
ASCO annual meeting suggested that trastuzumab benefit might extend to subsets of patients with metastatic
HER2-negative disease, defined on the basis of local testing; these patients were subsequently found to have
HER2 polysomy.[3] Benefit may also extend to all patients in the adjuvant setting found to have HER2-positive
or HER2-negative disease upon post hoc central retesting, including samples that had been deemed HER2-
positive by the original reference laboratory used for trial enrollment.[5] Another unplanned analysis suggested
that adjuvant trastuzumab may not be beneficial in patients who had been originally considered HER2-positive
on the basis of gene amplification by FISH, but who lacked protein overexpression by IHC.[4]
How Should HER2 Positivity Be Defined?
Updates from the North American Intergroup trial N9831 and the International Herceptin Adjuvant (BIG 01-01,
HERA) trial were presented at the December 2007 San Antonio Breast Cancer Symposium (SABCS). Reinholz
and colleagues[6] presented an analysis of 1888 patients enrolled in N9831 that examined the correlation
between HER2 gene copy, chromosome 17 anomalies, and disease-free survival (DFS). Among patients who
did not receive trastuzumab, those with increased copies of chromosome 17 (polysomy 17 or 17p) had a 34%
worse DFS (P = .04) when compared with those with a normal number of copies of chromosome 17 (17n). In
contrast, patients treated with trastuzumab had a significant improvement in DFS whether their tumors were
found to have 17p (hazard ratio [HR] = 0.52, P = .0006) or 17n (HR = 0.37, P = .0004). This larger adjuvant
dataset contradicts findings from the smaller metastatic dataset presented by Kaufman and colleagues[3] at the
2007 ASCO meeting, and suggests that 17p in the absence of gene amplification or protein overexpression
might not be predictive for trastuzumab benefit.
A separate presentation at the 2007 SABCS meeting focused on the HERA trial,[7] in which patients with HER2
IHC 2+ or 3+ positivity that was based on local testing, with centrally confirmed IHC 3+ or FISH-positive
disease, were randomized to trastuzumab or observation upon completion of adjuvant chemotherapy (3-year
DFS 80.4% vs 74.4%, HR = 0.64). Data presented at the SABCS meeting suggested possible heterogeneity in
treatment effect with respect to assessments of HER2 positivity, and showed an HR for DFS at 3 years of 0.51
(95% confidence interval [CI], 0.29-0.92) for patients determined to be IHC 2+ locally and FISH-positive
centrally and of 0.78 (95% CI, 0.53-1.14) for patients tested IHC 3+ locally and FISH-positive centrally.[8]
These data differ from those presented by Perez and colleagues[4] at the 2007 ASCO meeting that indicated a
lack of benefit for patients considered HER2-positive by gene amplification (FISH-positive) without protein
overexpression (IHC < 3+).
Adjuvant Trastuzumab: Evolving Data
The first results of a new adjuvant trial (PACS-04)[9] were presented as a late-breaking abstract at the 2007
SABCS meeting by French investigators from the Fédération Nationale des Centres de Lutte Contre le Cancer
(FNCLCC). This trial was based on the now published PACS-01 trial,[10] which reported a benefit from 3 cycles
of 5-fluorouracil, epirubicin 100 mg/m2, and cyclophosphamide (FEC100), every 21 days, followed by 3 cycles
of docetaxel instead of 6 cycles of FEC100 (n = 1999, 5-year overall survival [OS] 90.7% vs 86.7%,
respectively, P = .017). The PACS-04 trial randomized 3010 patients with lymph node-positive breast cancer
between February 2001 and August 2004 to receive 6 cycles of FEC100 or 6 cycles of concurrent epirubicin 75
mg/m2 and docetaxel (ED75), repeated every 3 weeks. At the end of 6 cycles, 528 patients with HER2-positive
disease (according to central testing) were randomized to receive 1 year of trastuzumab given every 3 weeks or
observation, following completion of adjuvant chemotherapy and radiation therapy. After a median follow-up of
48 months, a trend was observed during the first 18 months favoring trastuzumab; however, there was not a
significant difference in DFS. This finding stands in contrast to data published or reported from 5 other adjuvant
trials of trastuzumab. Possible explanations for the PACS-04 findings may include (1) its smaller sample size
when compared with the other trastuzumab adjuvant trials, with the exception of the small FinHER trial,[11]
which used a brief course of trastuzumab; (2) a possible interaction between time and efficacy as well as total
treatment duration; and (3) the unresolved issue of sequential or concomitant use of chemotherapy and
trastuzumab (tested in N9831 but not yet reported).
The HER2 Signaling Pathway -- Many Potential Targets
The 2007 SABCS meeting also included a mini-symposium dedicated to the HER2 signaling network, which
consists of a complex structure of 4 receptors and 11 ligands that could serve as potential targets for modulation
at various levels along the pathway. This topic was reviewed in a comprehensive lecture by C.K. Osborne, who
explored how primary or acquired resistance may develop in HER2-positive breast cancer.[12] He also described
existing agents that target the HER2 pathway, such as trastuzumab, which targets the extracellular domain of the
HER2 receptor; the dimerization inhibitor antibody pertuzumab, which blocks the homodimerization of HER2
and the heterodimerization of HER2 with other members of the HER family; and the recombinant chimeric
monoclonal antibody cetuximab, which binds to and competitively inhibits the ligand binding site of EGFR,
thereby inhibiting ligand-dependent downstream signaling and inducing receptor downregulation.
Tyrosine kinase inhibitors, such as gefitinib, erlotinib (HER1 inhibitors), and lapatinib (a HER1/HER2
inhibitor), influence the signaling pathway by interacting with the intracellular domain of the receptors of
HER1, HER2, and HER4. To date, the HER3 receptor has not been found to have an intracellular tyrosine
kinase; in the case of HER2, no natural ligand has been described. The rationale for combining these different
drugs to circumvent the development of alternative pathways was tested in preclinical studies with xenograft
models. These studies found that multidrug combinations targeting various levels of the signaling pathway are
more efficient in suppressing the epidermal growth factor-related signals. As a result, various clinical trials in
the metastatic, adjuvant, and neoadjuvant setting are currently under way to explore improved therapies for
patients with HER2-positive disease.
New Approaches to Overcoming Trastuzumab Resistance
Fumoleau and colleagues[13] presented one such study as a late-breaking abstract. The study authors tested the
combination of pertuzumab and trastuzumab in a phase 2 study of women with advanced HER2-positive breast
cancer that had progressed on trastuzumab. The 42 patients enrolled had been exposed to 3 or fewer prior
regimens (including trastuzumab ) and were then treated with standard doses of trastuzumab, ie, weekly or
every 3 weeks, plus pertuzumab (420 mg/kg every 3 weeks after a loading dose of 840 mg/kg). This
combination resulted in 1 complete response, 5 partial responses, and 7 patients with stable disease for longer
than 6 months. Although adverse events, such as diarrhea (57% of patients), nausea/vomiting (33%), fatigue
(31%), and rash (28%), were seen in 34 of 42 patients, most (80%) were grade 1 or 2.
A novel approach to potentially overcoming HER2 resistance was proposed by Osipo and colleagues[14] with
gamma-secretase inhibitors that are based on cell lines that explored the cross talk between HER2 and Notch-1.
Notch-1 is an oncogene frequently overexpressed in higher proliferating tumors and is important for the survival
of breast tumor-initiating cells. Another approach this time in patients with advanced HER2-positive breast
cancer, was tested by Krop and colleagues,[15] who presented the results of a phase 1 study of a HER2 antibody-
drug conjugate (ADC). Trastuzumab-DM1 (T-DM1) is a tumor-activated prodrug linked to the HER2 antibody
trastuzumab. Tumor-activated prodrugs use tumor-targeting antibodies to deliver a potent, cell-killing agent
specifically to cancer cells, in this case the antimicrotubule maytansinoid derivative DM1. DM1 binds to tubulin
in a manner similar to vinca alkaloids, but was found to be 20-100 times more potent than vincristine. The
linkage of DM1 to the antibody trastuzumab improves its therapeutic window by targeting and prolonging drug
exposure of the ADC to tissues of interest.[16] Data presented at the SABCS meeting were based on 19 patients
treated with ADC given intravenously every 3 weeks at 6 dose levels. The maximum tolerated dose for this
schedule was 3.6 mg/kg, and grade 2 or higher adverse events at this dose level were rare (eg,
thrombocytopenia, anemia, and transaminase elevations). Phase 2 trials are ongoing.
Overall, these studies highlight the crucial therapeutic role of interventions targeting the HER2 pathway. Even
more important, they emphasize the significance of properly characterizing the various breast cancer tumor
types and the need for adequate predictive marker testing in routine clinical practice.
This activity is supported by an independent educational grant from Susan G. Komen for the Cure.

New Trastuzumab Regimen for Early-Stage Breast Cancer Appears

to Have Low Rate of Cardiotoxicity
March 14, 2008 (New York, NY) – A new regimen of "dose-dense" chemotherapy plus the HER-2
antibody trastuzumab (Herceptin, Genentech/Amgen) has shown low levels of cardiotoxicity in the
adjuvant setting in the treatment of breast cancer [1].
The study, published in the March 10, 2008 issue of the Journal of Clinical Oncology, was conducted
by a group led by Dr Chau Dang (Memorial Sloan-Kettering Cancer Center, New York, NY).
"Our regimen of dose-dense doxorubicin and cyclophosphamide followed by paclitaxel and
trastuzumab is feasible and is not likely to increase the incidence of cardiac events compared with
established regimens and so should be considered an appropriate option for patients with HER-2–
positive early-stage breast cancer," Dang commented to heartwire.
She explained that "dose-dense" doxorubicin and cyclophosphamide followed by paclitaxel, which
involves giving these drugs every two weeks, has been shown to eradicate tumor cells and improve
survival more effectively than the traditional three–week cycle. Dang's team therefore wanted to
explore the safety of this regimen combined with trastuzumab.
In the current phase 2 trial, 70 patients (mean age 49 years) with HER-2 positive breast cancer were
treated with dose-dense doxorubicin/cyclophosphamide (60/600 mg/m2) every two weeks followed by
paclitaxel (175 mg/m2) every two weeks, with pegfilgrastim (6 mg on day 2). Trastuzumab was started
with the first paclitaxel cycle (4 mg/kg bolus followed by 2 mg/kg weekly). At the completion of
paclitaxel, trastuzumab was administered every three weeks at 6 mg/kg to complete a year's duration.
Just one case of heart failure
Results showed that 64 patients (91%) completed one year's treatment with trastuzumab. Median left
ventricular ejection fraction (LVEF) was 68% at baseline, 67% at two months, 66% at six months, 65%
at nine months, and 66% at 18 months (posttreatment). Five patients (7%) experienced asymptomatic
LVEF decline, and three of these discontinued treatment for this reason. In the two others, trastuzumab
was held temporarily, and both patients had adequate LVEF recovery one month later and were
successfully rechallenged with trastuzumab. Only one patient (1.4%) experienced heart failure during
treatment and discontinued trastuzumab. Two other patients had arrhythmias while receiving
trastuzumab (one with atrial fibrillation with pericarditis and one with sinus bradycardia), but these two
patients did not meet the criteria for cardiac events. There were no cardiac deaths.
In terms of breast-cancer efficacy, with a median follow-up of 25 months, two patients (3%) have
developed progressive disease.
Dang noted that previous large trials of doxorubicin/cyclophosphamide given every three weeks plus
paclitaxel and trastuzumab in the adjuvant setting have shown a cardiotoxicity rate of 2% to 4%, with
only 68% of patients completing one year of trastuzumab treatment. "Our results are better than that,
with a cardiotoxicity rate of 1.4%, showing that combining Herceptin with this better dose-dense
chemotherapy regimen does not increase cardiotoxicity," she commented to heartwire.
But the researchers caution that only 16% of the patients in this study were over 60 years old, and since
older age was found to be a significant risk factor for cardiac toxicity, more data or longer follow-up of
this smaller group of patients is warranted.
They point out that the adjuvant trials using trastuzumab generally demonstrated approximately 50%
improvement in disease-free survival and that, given such efficacy, the 4% incidence of heart failure
and very rare cardiac deaths seen in the four large adjuvant trials of trastuzumab is "acceptable."
Noting that they do not expect cardiac events to exceed 4% with continued follow-up of their study and
that further randomized trials of either the dose-dense chemotherapy schedule or the use of trastuzumab
 are likely to be acceptable to clinicians, they conclude: "Hence, our regimen should be considered an
appropriate option for patients with HER-2–positive early-stage breast cancer."
This study was supported by Genentech and Amgen. Dang and several other authors consult for and
have received honoraria and research funding from Genentech and Amgen.
1. Dang C, Fornier M, Sugarman S, et al. The safety of dose-dense doxorubicin and
cyclophosphamide followed by paclitaxel with trastuzumab in HER-2/neu overexpressed/amplified
breast cancer. J Clin Oncol 2008; 26:1216-1222. Abstract

Adjuvant Therapy for HER2-Positive Breast Cancer: An

Expert Interview With Dr. Harold Burstein
Harold J. Burstein, MD, PhD
Medscape Hematology-Oncology. 2008;
Editor's Note:
In 2005, results of 4 adjuvant breast cancer trials[1-4] demonstrated unequivocably that the monoclonal antibody
trastuzumab plus chemotherapy significantly reduced disease recurrence in patients whose tumors
overexpressed the HER2 protein. Prognosis for women with HER2-positive disease has improved substantially
since then, and research in this area has been extremely active. Margie Miller, Group Editorial Director for
Medscape Oncology, recently sat down with Harold J. Burstein, MD, PhD, Assistant Professor of Medicine at
Harvard Medical School in Boston, Massachusetts, as well as a member of the Medscape Oncology Editorial
Board, to talk about some of the treatment issues that clinicians continue to grapple with and how ongoing
research may inform therapeutic strategies for women with HER2-overexpressing breast cancer in the future.
The overall theme of the conversation was, "What do clinicians need to know in 2008 and 2009?"
Medscape: To provide a bit of contextual background, can you clarify whether HER2 overexpression in
breast cancer, regardless of tumor size, nodal status, or hormonal sensitivity, is considered a significant
negative prognostic marker, automatically classifying a patient as having high-risk disease?
Dr. Burstein: Historically, patients with HER2-positive tumors have done much less well than those with
HER2-negative tumors. That was part of Dr. Dennis Slamon's original observation in 1987[5] and remains true to
this day. Women who are diagnosed with HER2-positive disease in 2008 will be candidates for adjuvant anti-
HER2 therapy. Having said that, the trastuzumab adjuvant trials[1-4] typically enrolled patients with node-
positive disease and/or other high-risk factors. We actually have very few data on smaller, node-negative Stage I
tumors that are HER2-positive. Because the threshold for detection of a breast tumor is about 1 cm, we don't
usually see women with smaller lesions, although we do encounter them on occasion.
We've all wondered whether there is some sort of size threshold below which adjuvant treatment may not be
necessary. Historically, the line in the sand has been drawn at 5 or 6 mm. Treatment guidelines, such as the
NCCN [National Comprehensive Cancer Network] Breast Cancer Guidelines,[6] indicate that tumors smaller
than 5 mm wouldn't warrant adjuvant chemotherapy. Guidelines also indicate that adjuvant treatment should be
considered for patients with small tumors -- approximately 10 mm -- when other high-risk features, such as lack
of hormone receptors, high grade, or HER2 overexpression, are present.
Medscape: What are some of the questions that ongoing research is seeking to answer and that are likely
to affect how clinicians treat patients?
Dr. Burstein: On a practical, clinical level, practitioners are still interested in the optimal duration of
trastuzumab treatment. We have data from most of the adjuvant trials that looked at 1 year of trastuzumab
therapy, which has emerged as the standard. Nevertheless, we know that a shorter course can be effective. In the
FinHER trial,[7] a limited exposure of 9 weeks of chemotherapy plus trastuzumab was better than nothing at all.
And, we are waiting for final data from the HERA trial,[3,4] which looked at 0, 1, or 2 years of trastuzumab-based
treatment. Those data may be available as early as December of this year.
One of the complexities inherent in interpreting those data centers on the fact that the HERA trial administered
trastuzumab sequentially, after the chemotherapy component of the adjuvant regimen. Many of us believe that
that may be a less effective way -- compared with concurrent administration -- of giving trastuzumab. So,
whatever the results, the question of the duration of trastuzumab, when it is given concurrently, will remain
unresolved by this trial.
We have been involved in a study looking at the potential benefit of adjuvant treatment for patients with lower-
risk HER2-positive tumors. Patients are offered a combination of paclitaxel for 12 weeks plus standard duration
of trastuzumab (52 weeks). The accrual goal is about 400 patients, and we hope to discover whether this shorter,
simpler adjuvant regimen will adequately protect these women from disease progression. Compared with a
standard adjuvant course, such as doxorubicin/cyclophosphamide (AC) followed by paclitaxel for 20 weeks or
more plus trastuzumab, this abbreviated regimen is attractive, and the multicenter trial is accruing briskly.
Moreover, avoiding the anthracycline (ie, AC) part of the standard regimen may spare the patient the risk of
cardiotoxicity.
Medscape: Trastuzumab is usually given either with or after chemotherapy. What should clinicians know
about selecting the chemotherapy backbone for combination with trastuzumab?
Dr. Burstein: Determining the best adjuvant chemotherapy program to link trastuzumab with is very much an
open question. In clinical practice, AC followed by a taxane plus trastuzumab or docetaxel, carboplatin, and
trastuzumab (TCH) have emerged as the most commonly used regimens. The discussion primarily focuses on
the risks of cardiotoxicity.
Medscape: Can you elaborate about how clinicians should prevent or manage cardiotoxicity when
selecting a chemotherapy regimen?
Dr. Burstein: The BCIRG 006 trial[2] suggested that there was a lower risk, about 1%, of cardiomyopathy with
the TCH regimen compared with the 2% risk expected with the AC followed by taxane plus trastuzumab
regimen. So, while there was a difference, it was a pretty small numerical difference. In addition, the National
Surgical Adjuvant Breast and Bowel Project (NSABP) and the North American Intergroup have proposed risk
factors that may help identify patients who are at risk for cardiomyopathy: older than 60-65 years of age,
borderline pre-existing cardiac function (ejection fraction, 50% to 55%), and pre-existing heart disease,
particularly hypertension. I think that those are variables that can inform our treatment choices. In patients with
pre-existing cardiac risk factors, it may be helpful to obtain a cardiology consult. I still feel quite comfortable
using AC followed by a taxane and trastuzumab for most women with HER2-positive disease because they tend
to be younger than 65 years of age and are generally in good health, with no hypertension and a strong ejection
fraction at baseline.
One of the dilemmas with the BCIRG 006 trial was that it was not powered to really compare the efficacy of the
AC arm with that of the TC arm. It is likely that trastuzumab is such a potent drug that it becomes the trump
card, and the issue of the chemotherapy backbone matters less. We don't actually know that.
Finally, the TCH regimen is often characterized as the "non-anthracycline" regimen, which, of course, it is, but
there were some other differences between the 2 regimens used in BCIRG 006. There was a longer period of
overlap between chemotherapy and trastuzumab in the TCH arm (18 weeks) than in the AC arm (12 weeks);
they used carboplatin (instead of cyclophosphamide) in the non-anthracycline arm, which may or may not be a
necessary component of the regimen and may have influenced the results; and, perhaps most importantly, the
trastuzumab was administered up front instead of after the 4 cycles of anthracycline-based chemotherapy. So
there were many differences between the regimens used in BCIRG 006 that can't be attributed to
"anthracycline" vs "non-anthracycline."
Medscape: Has the question of concurrent vs sequential trastuzumab been resolved?
Dr. Burstein: The issue of concurrent trastuzumab vs sequential has not been resolved. The data that were
originally presented from the North American Intergroup Trial and the B 31 trial[1] suggest that concurrent
therapy is better than sequential therapy. Many of us have tilted that way. We've also been impressed that a very
short exposure to concurrent chemotherapy and trastuzumab, as in the FinHER trial, seems to be effective.
Nevertheless, there are data showing that some trastuzumab therapy -- concurrent or sequential -- is better than
none. We know from practice pattern data that the majority of patients in the United States are receiving
concurrent therapy. In Europe and elsewhere, however, the pattern of starting with the chemotherapy backbone
followed sequentially by trastuzumab is still in use.
Medscape: Are there any patients for whom a sequential program might be considered more prudent?
Dr. Burstein: It's an interesting question. There may be a slightly lower risk of cardiomyopathy with
sequentially administered trastuzumab than concurrent, but that has not been well established.
Medscape: How would you advise clinicians to manage a dropping ejection fraction during adjuvant
trastuzumab-based treatment?
Dr. Burstein: First of all, we have to remember to monitor cardiac ejection fraction! Typically, ejection fraction
should be measured at baseline, after the AC or TC phase of the regimen and before the trastuzumab is added,
and then after the taxane/trastuzumab and before starting the maintenance phase. We do see some patients who
have asymptomatic declines in ejection fraction. Usually these are fairly modest, from 67%, for example, to
59%. Because we know that trastuzumab is such a powerful drug, we are generally willing to tolerate those
minor asymptomatic changes, as long as the ejection fraction remains well above normal. Where it gets trickier
is when the patient is having symptoms; in which case, the trastuzumab should be stopped, at least for the short
term. Another challenging situation occurs when the patient is still asymptomatic but the drop in ejection
fraction is more substantial and dips below the lower limits of normal. In some cases, although the patient is
asymptomatic, the decline in ejection fraction -- while still within the lower limits of normal -- is dramatic. In
those cases, one has to individualize therapy on the basis of the risk of the tumor, where the patient is in her
trastuzumab treatment course, and what other cardiac risk factors she has. A cardiology consult is usually very
helpful at this point. I also think that it's prudent to interrupt the treatment at some point to determine whether
the ejection fraction recovers.
Medscape: Is there a role for assessment of topoisomerase II-alpha gene (TOP2A) in helping to select
adjuvant chemotherapy for high-risk early breast cancer?
Dr. Burstein: At the moment, there really are no clear reasons to use TOP2A to select treatment for early-stage
breast cancer. TOP2A traffics near the HER2 oncogene and is a potential target of anthracyclines. Retrospective
work from the UCLA group and others[8] has suggested that TOP2A may account for the relationship between
anthracycline sensitivity and HER2-positive breast cancer. At the moment, though, it's not a clinically relevant
test. Those with HER2-positive disease are going to receive trastuzumab with either of the 2 chemotherapy
options. In contrast, for those who are HER2-negative, TOP2A gene amplification is rare. The question thus
arises as to whether women with HER2-negative disease need anthracyclines. That's an area where we are likely
to see more data emerging to suggest that other non-anthracycline regimens may be adequate. Having said that,
anthracyclines remain the backbone of our active chemotherapy regimens, both in the United States and world-
wide. We'll probably be seeing declining use of anthracyclines over time, as other regimens come along, but for
most women with high-risk early breast cancer, anthracyclines and taxanes remain important drugs, and TOP2A
should not be used to select therapy outside of a clinical trial.
Medscape: How should other adjuvant therapies, such as endocrine therapies and bisphosphonates, be
integrated into adjuvant treatment for patients with HER2-positive disease?
Dr. Burstein: About half of HER2-positive tumors will also be hormone receptor-positive, and there's no reason
to handle endocrine treatment differently in these patients. The emerging bisphosphonate data are very exciting.
As we saw at ASCO 2008, the ABCSG 12 randomized study[9] looked at young women who received endocrine
therapy, with or without bisphosphonates. And the data suggested that those who received the bisphosphonates
had a lower risk of disease recurrence. These are certainly very provocative data. We expect data within the next
6-12 months from the AZURE trial, which is a larger study of bisphosphonates in the adjuvant setting. If the
results are confirmatory, we will probably be using bisphosphonates more frequently in the adjuvant setting.
Medscape: Would you describe ongoing research that is exploring how to improve outcomes in women
with HER2-positive breast cancer?
Dr. Burstein: The global adjuvant studies, the neo-ALTTO and ALTTO trials,[10] are looking at: (1) trastuzumab
alone vs (2) lapatinib alone vs (3) the combination vs (4) trastuzumab and lapatinib administered sequentially.
Clearly, the questions being evaluated are whether the dual-kinase inhibitor lapatinib will do as well as
trastuzumab and whether there is anything to be gained by using both agents. There have been some
provocative data from the metastatic setting by Dr. Joyce O'Shaughnessy and colleagues[11] suggesting that the
combination of lapatinib plus trastuzumab appeared to be better than lapatinib alone in patients who had
previously received trastuzumab-based therapy. So one of the questions that is raised is whether we really need
this complicated 4-arm ALTTO trial when a simpler design, looking at trastuzumab alone vs trastuzumab plus
lapatinib, might give us the answers we are looking for. The other point is that there are preliminary reports both
from Memorial Sloan-Kettering Cancer Center and the Intergroup that the combination of trastuzumab plus
lapatinib plus paclitaxel, as originally scripted in the ALTTO protocol, was associated with prohibitive
toxicities, such as diarrhea, that prevented patients from successfully completing their full courses of therapy.
Although the drug doses have since been reduced, these findings serve as a reminder that just because drugs are
characterized as targeted therapies or biologicals doesn't mean that they lack side effects. Clinicians should be
very cautious about pairing up these drugs just for the sake of trying to do something different. We learned a
similar lesson earlier this year when a combination of sunitinib and bevacizumab caused an unexpected
thrombocytopenic purpura.
I think the most important biological issue still to be addressed for trastuzumab-based therapy in HER2-positive
disease is identifying which tumors are going to prove resistant and which are very sensitive. We've made a
great deal of progress selecting patients based on HER2 status, and there has been a substantial effort invested
in improving HER2 testing. I think we have a pretty good handle on how to define a HER2-positive tumor.
Nevertheless, of the women with HER2-positive disease who received trastuzumab in the adjuvant trials, a
substantial fraction will experience recurrent disease. We'd like to understand the underlying biology better.
Perhaps these women would benefit from different therapy or should be offered new agents as part of a clinical
trial. Understanding the biology of those who recur, and identifying them, are important goals.

Change in HER2 Status May Explain Resistance to Trastuzumab

September 9, 2008 — Some women with HER2-positive breast cancer who initially respond well to
trastuzumab (Herceptin, Roche/Genentech) eventually stop responding to the drug. Why this happens is unclear,
but a new study offers a possible explanation. Trastuzumab works only on HER2-positive tumors, but the study
found that during therapy, some tumors convert from HER2-positive to HER2-negative status.
The finding was reported at the 2008 Breast Cancer Symposium, in Washington, DC, by Elizabeth Mittendorf,
MD, assistant professor of surgical oncology at the University of Texas MD Anderson Cancer Center, in
Houston.
"We don't yet know on a molecular level what causes tumors to change," Dr. Mittendorf said, but the change in
status could explain resistance to trastuzumab therapy. She emphasized that more research is needed, but in the
meantime it is important to keep this phenomenon in mind, "so that we can provide patients with the most
appropriate targeted therapy for their cancer's biology."
"This highlights yet again the importance of obtaining tissue," commented Eric Winer, MD, director of the
Breast Oncology Center at the Dana-Farber Cancer Institute, in Boston, Massachusetts. "There are still many
questions about this finding," he said. "Were these tumors heterogenous to begin with? Maybe trastuzumab
knocked out all the HER2-positive cells and left the HER2-negative ones behind? Or was it really a conversion
of status?"
Whatever the mechanism involved, resistance to trastuzumab is a real problem, and "we need to figure out
which drug to use next," Dr. Winer commented. He was moderating a presscast organized by the American
Society for Clinical Oncology, a cosponsor of the meeting.
The new finding comes from a study of 143 patients with early-stage or locally advanced breast cancer, all of
whom initially tested positive for HER2 status. After neoadjuvant chemotherapy (with a taxane and
anthracycline) in addition to trastuzumab, all patients underwent surgery. Half the patients achieved a complete
pathologic response, with no evidence of invasive disease in the breast or lymph nodes at the time of surgery.
Another 23 patients who did not have a complete pathologic response had pre- and posttreatment tissue samples
available for analysis. Of these, 30.4% were found to have converted from HER2-positive to HER2-negtaive
status by the time they had surgery.
Follow-up data (from a median of 10.2 months) suggest that these tumors are more aggressive, Dr. Mittendorf
commented. Compared with patients who achieved a complete pathologic response, patients who did not were 3
times more likely to have their cancer recur (2.8% vs 11.3% of patients).
The finding suggests that any residual tumor found at the time of surgery should be reassessed for HER2 status,
the researchers commented. There also needs to be some consideration given to what adjuvant therapy should
be recommended this patient population.
The researchers have disclosed no relevant financial relationships.
2008 Breast Cancer Symposium: Abstract 150.
Neratinib shows robust antitumor activity in advanced HER2-positive breast cancer
20.01.09
New oral drug is irreversible inhibitor of tyrosine kinase inhibitors ErbB1
Neratinib (HKI-272) is an orally administered irreversible inhibitor of the tyrosine kinase inhibitors ErbB1
(epidermal growth factor receptor; EGFR) and ErbB2 (HER2). Dr Harold J Burstein from Dana-Farber Cancer
Institute, Harvard Medical School, presented at the 2008 San Antonio Breast Cancer Symposium results of the
open-label, two-arm phase II trial of the efficacy and safety of neratinib (240 mg daily oral dose) in 136 patients
with advanced HER2-positive breast cancer (stage IIIB, IIIC, or IV).
ErbB2 gene amplification in tumor tissue by fluorescence in situ hybridization was required for study entry.
Patients with prior treatment with trastuzumab were assigned to arm A and those who had no prior treatment
with trastuzumab or any other ErbB2-targeted drug were assigned to arm B. The primary endpoint was
progression-free survival (PFS) at 16 weeks.
There were 127 evaluable patients for the efficacy analysis. The objective response rate (CR or PR) achieved in
arm A (prior trastuzumab treatment) was 26% and was 56% in arm B (no prior trastuzumab). The 16-week PFS
rate in arm A was 60% and median PFS was 23 weeks. The 16-week PFS rate in arm B was 77% with a median
PFS of 40 weeks. Adverse events of any grade in more than 15% of patients were diarrhea, nausea and
vomiting, fatigue, headache, and rash. The most common adverse event, diarrhea, occurred in 93% of patients
and was manageable and reversible.
Neratinib demonstrated robust antitumor activity in patients who had received prior treatment with trastuzumab
and in those with no prior trastuzumab treatment. These results warrant further study to determine the role of
neratinib.

Application withdrawn for adjuvant docetaxel treatment of patients with operable breast cancer whose
tumors overexpress HER2
21.11.08
EMEA notified as manufacturer withdraws its application for an extension of indication
for docetaxel
Sanofi-Aventis Pharma SA has formally notified the European Medicines Agency (EMEA) of its decision to
withdraw its application for an extension of indication for the centrally authorized medicines Taxotere
(docetaxel) 20 mg/0.5 ml and 80 mg/2 ml concentrate and solvent for solution for infusion, and Docetaxel
Winthrop (docetaxel) 20 mg/0.5 ml and 80 mg/2 ml concentrate and solvent for solution for infusion.
Taxotere and Docetaxel Winthrop were expected to be used for the adjuvant treatment of patients with operable
breast cancer whose tumors overexpress HER2 in the following combinations:
- In combination (given simultaneously) with trastuzumab, following a chemotherapy regimen based on
doxorubicin and cyclophosphamide
- In combination with trastuzumab and carboplatin.
Taxotere was first authorized in the European Union on 27 November 1995. Docetaxel Winthrop was
authorized on 20 April 2007, following an informed consent application to the Taxotere application.
The EMEA received the applications for the extension of indication for Taxotere and Docetaxel Winthrop on 20
December 2007. On 24 July 2008, the Committee for Medicinal Products for Human Use (CHMP) adopted a
negative opinion, recommending that the extension of indication for the medicines be refused. Following this,
the company requested a re-examination of the opinion, which was under review by the CHMP at the time of
the withdrawal.
The company officially stated that the withdrawal was based on the CHMP's opinion that the study design did
not adequately define the contribution of docetaxel.

Trastuzumab-treated advanced breast cancer patients and brain metastases: just a little alert
Recently, some authors reported the high frequency of localizations to the central nervous system (CNS) in
HER-2-positive breast cancer patients [1]. There are three hypotheses to explain such phenomenon: (i) these
patients have a poorer prognosis and their disease has a more aggressive behavior with a much higher tropism
for the CNS; (ii) trastuzumab can optimally control disease outside the blood–brain barrier but this antibody
does not cross it; and (iii) trastuzumab prolongs survival of patients and so we can appreciate also brain
metastases, frequently a late manifestation of disease.
In our little series with 12 of 52 (23%) HER-2-positive patients developing CNS involvement during or after
treatment with trastuzumab, there is not a prolongation of survival to justify the onset of brain metastases: half
patients had their CNS localizations within only 16 months from the beginning of trastuzumab for metastatic
disease. On the other hand, we may emphasize the fact that endocranial metastases often develop in presence of
disease control in other body sites obtained with the antibody (8 of 12 cases were complete or partial responses
in our series).
In conclusion, our alert is that we must pay attention to HER-2-positive trastuzumab-treated patients with
periodical computed tomographic imaging of the brain and treat CNS metastases with adequate, and when
indicated, aggressive measures because of a possible prolongation [2] of survival (continuation of trastuzumab
associated with a different cytostatic agent + whole-brain or stereotactic radiotherapy ± surgery). All but three
patients are alive in our series with >31 months survival in a case from the diagnosis of cerebral involvement.
Whether the high frequency of brain metastases is merely related to the aggressiveness of HER-2-positive
disease, often associated with other unfavorable biologic parameters (estrogen receptor negativity, poor
differentiation, and high proliferative index) or has other explanations, remains a challenge for researchers [3],
like the need for a preventive approach (mostly for the patients in the adjuvant setting).
U. Torresi Department of Oncology, Ospedale Macerata, Via Santa Lucia 2, 62100 Macerata, Italy (E-mail: umberto57@comeg.it

Trastuzumab in pregnancy associated with poor fetal outcome

Trastuzumab (Herceptin®), an mAb targeting the epidermal growth factor receptor HER2, is used as standard of
care in patients with HER2-overexpressing tumors. A relevant number of younger women with childbearing
potential are being treated with this immunoglobulin (IgG1) antibody. We report a patient with metastatic breast
cancer who was treated with trastuzumab during pregnancy. The baby was born preterm and developed a severe
respiratory distress and capillary leak syndrome with fatal outcome.
The patient was diagnosed at the age of 29 with a 3-cm left breast mass. A biopsy showed an infiltrating ductal–
lobular carcinoma, G2, estrogen receptor positive and progesterone receptor negative. HER2 overexpression (3+
DAKO score). In a clinical trial, neo-adjuvant chemotherapy with three cycles of epirubicin 150 mg/m2 every 2
weeks, followed by three cycles of paclitaxel 250 mg/m2 every 2 weeks, was applied. In the surgical specimen,
no remaining tumor was found (ypT0 ypN0). The patient received three cycles of combination chemotherapy
with cyclophosphamide, methotrexate and fluorouracil after surgery followed by endocrine treatment with
tamoxifen. She presented 1.5 years later with pulmonary metastases. After 24 administrations of vinorelbine
(Navelbine®) 25 mg/m2 and trastuzumab 2 mg/kg weekly, she developed a complete remission. Therapy with
trastuzumab was continued with 6 mg/kg every 3 weeks. Seven months after cessation of vinorelbine, the patient
reported to be pregnant. According to fetal growth development, the patient was in the 23rd week of gestation.
Detailed anatomical ultrasound scan showed no abnormalities. To evaluate the patient’s prognosis, a magnetic
resonance scan was carried out which showed two cerebral metastases and radiation of the brain was planned.
After detailed counseling including her prognosis, the patient decided to continue pregnancy.
Four weeks after diagnosis of pregnancy, the patient presented with oligohydramnion and vaginal bleeding.
Fetal lung maturation was induced with corticosteroids. One week later, a caesarean section had to be carried out
due to strong vaginal bleeding although no abruption of the placenta could be diagnosed. The female newborn
infant weighed 1015 g (57th percentile for 27 weeks of gestation), pH value of the umbilical artery was 7.48 and
APGAR score 8/7/6. The placenta showed no abnormalities by histological examination. The newborn infant
developed respiratory failure necessitating mechanical ventilation, uncommonly strong capillary leak syndrome,
persisting infections and necrotizing enterocolitis. The baby died due to multiple organ failure 21 weeks after
delivery.
As HER2 is expressed in embryofetal tissue, it might be critical to fetal development. In murine knockout
studies, deletion of the HER2 gene was fatal to embryos at early gestation due to cardiac and neural dysfunction.
Trastuzumab has been assigned as a category B pregnancy risk on the basis of trials in monkeys which showed
no apparent fetal harm [1]. The possibility of fetal damage when an antibody to HER2 is administered has not
been excluded.
To our knowledge, information on fetal outcome after trastuzumab exposure in utero is limited to five case
reports. Watson [2] reported anhydramnion associated with trastuzumab application until 23 weeks of pregnancy
which was reversible after withdrawal of the drug. Labor was induced at 37 weeks, and the baby had normal
renal function after delivery and developed well. Fanale and co-workers [3] reported persistent oligohydramnios
during treatment with trastuzumab and vinorelbine at weekly intervals until induction of labor at 35 weeks’
gestation. Waterston and Graham [4] reported a normal pregnancy that resulted in a normal vaginal delivery of a
healthy baby after exposure to trastuzumab. The patient had received two cycles of trastuzumab before she
became pregnant. Trastuzumab therapy was discontinued.
Bader et al. [5] reported a patient who presented with metastatic breast cancer and was 17 weeks pregnant. At 26
weeks’ gestation, a combination of paclitaxel and trastuzumab every 3 weeks was induced. After two cycles of
therapy, the amniotic fluid had reduced to almost anhydramnion and fetal growth had stopped. After lung
maturation, a caesarean section was carried out at 32 weeks’ gestation. The preterm born (10th percentile)
showed signs of bacterial sepsis with hypotension, renal and respiratory failure. The further development was
normal. Shrim et al. [6] presented a patient with metastatic breast cancer who was treated with trastuzumab
during the first 24 weeks of pregnancy. A caesarean section was conducted at 37 weeks and resulted in a healthy
baby.
Our patient received 25 cycles of trastuzumab (6 mg/m2 every 3 weeks) before she became pregnant. After eight
more cycles, she reported to be pregnant. After one more cycle, the caesarean section was carried out. To our
knowledge, this is the highest dose of trastuzumab applied to a pregnant woman that has been reported (56
mg/kg total dose). We report reduction of amniotic fluid during treatment with trastuzumab in pregnancy which
has also been reported in other studies. Apart from the problems due to prematurity, the newborn showed an
unexpected strong capillary leak syndrome and respiratory insufficiency.
In conclusion, this case may indicate that trastuzumab in higher doses affects fetal development and results in an
impaired prognosis of the newborn despite the reassuring findings in other case reports. In the context of the
increasing number of patients treated with this drug including the adjuvant setting, this is of increasing clinical
relevance.

ErbB/HER ligands in human breast cancer, and relationships with their receptors, the bio-
pathological features and prognosis
F. Révillion1,*, V. Lhotellier1, L. Hornez1, J. Bonneterre2 and J.-P. Peyrat1 1 Laboratoire d'Oncologie Moléculaire Humaine2 Département de Sénologie, Centre Oscar
Lambret, Lille Cedex, France * Correspondence to: Dr F. Révillion, Laboratoire d'Oncologie Moléculaire Humaine, Centre Oscar Lambret, BP 307, 59020 Lille Cedex,
France. Tel: +33-3-20-29-59-59; Fax: +33-3-20-29-59-62; E-mail: f-revillion@o-lambret.fr

Abstract
Background: The aim of this study is to provide an expression profile of ErbB/HER ligands in breast cancer.
We analysed the relationships with their receptors, the bio-pathological features and prognosis.
Patients and methods: Epidermal growth factor (EGF), transforming growth factor- (TGF), amphiregulin
(AREG), betacellulin (BTC), heparin-binding EGF-like growth factor (HB-EGF), epiregulin (EREG) and
neuregulins1–4 (NRG1–4) were quantified in 363 tumours by real-time reverse transcription–polymerase chain
reaction using TaqMan probes.
Results: Ligands were detected in 80%–96% of the cases, except NRG3 (42%) and EREG (45.5%). At least one
ligand was expressed in 304 cases (cut-off: upper quartile). Almost all combinations of receptor and ligand co-
expressions were observed, but TGF is preferentially expressed in tumours co-expressing EGFR/HER3, NRG3
in those co-expressing EGFR/HER4, AREG and EREG in those co-expressing HER2/HER4. EGF and AREG
were associated with estradiol receptors, small tumour size, low histoprognostic grading, high HER4 levels.
TGF, HB-EGF and NRG2 were negatively related to these parameters. In Cox univariate analyses, EGF was a
prognostic factor.
Conclusion: Our study demonstrates that (i) ErbB/HER ligands, including BTC and EREG, are expressed in
most breast cancers; and (ii) TGF, HB-EGF and NRG2 high expressions are related to the biological
aggressiveness of the tumours.
Key words: breast cancer, EGF-related ligands, ErbB/HER receptors, expression profile, prognosis
introduction
The ErbB/HER receptors, also called type I growth factor receptors, are Epidermal growth factor (EGF)-
receptor (EGFR/c-erbB1/HER1), c-erbB2/HER2/neu, c-erbB3/HER3 and c-erbB4/HER4 [1]. Their activation,
resulting from the formation of homo- and heterodimers, depends on their ligands. Some of these ligands bind
exclusively to EGFR, such as EGF, transforming growth factor- (TGF) and amphiregulin (AREG), or bind
exclusively to HER4, such as NRG 3 and 4 (NRG3 and NRG4). Others have a dual specificity and bind either
both EGFR and HER4, such as betacellulin (BTC), heparin-binding EGF-like growth factor (HB-EGF) and
epiregulin (EREG), or bind both HER3 and HER4, such as NRG1 and NRG2. Putative ligands of HER2 have
been characterized [2] but, as yet, no ligand binding directly HER2 has been identified. However, it is
demonstrated that HER2 is the preferred heterodimerization partner of the three other receptors [3].
The ErbB/HER receptors are involved in development and progression of a variety of human cancers.
Therapeutic approaches, based on monoclonal antibodies (mAbs) and tyrosine kinase inhibitors, have therefore
been developed to target these receptors. In breast cancer, amplification and/or overexpression of HER2 are
observed in 25% of the cases [4], while they does not occur in normal tissue. Trastuzumab, a recombinant
humanized mAb directed against HER2, is routinely used for treatment of metastatic breast cancer in patients
with HER2-positive tumours. It also improves outcomes among women with surgically removed HER2-positive
breast cancer, when combined with adjuvant chemotherapy [5–7]. Despite the selection of the HER2-positive
metastatic breast cancer patients, the response rate to trastuzumab used as a single agent does not exceed 35%
[8], and ranges from 50% to 84% when combined with first-line chemotherapy [9–11]. This suggests that
additional biomarkers could be useful to better predict the response to trastuzumab.
Several lines of evidence indicate that the ErbB/HER ligands could be implicated in the unresponsiveness to the
treatments targeting HER2. The anti-HER2 murine mAb 4D5 does not inhibit the proliferation of the HER2
overexpressing breast cancer cells BT474, if treated with EGF, BTC and HRG [12]. A tissue microarray analysis
of breast cancer patients treated with combination of chemotherapy and trastuzumab demonstrated that response
to treatment depends on the expression of HER2, and also of the other receptors of the family, their ligands and
the activation of downstream signalling proteins [13]. Unresponsiveness to trastuzumab also seems to be
associated with a TGF-related mechanism of escape to trastuzumab-induced HER2 endocytosis and down-
regulation [14]. Interestingly, Menendez et al. [15] recently reported that patients with breast cancer
overexpressing heregulin and activated HER2, but without HER2 overexpression, could benefit from therapy
combining trastuzumab and chemotherapy. All these observations indicate that a better characterization of the
ErbB/HER ligand/receptor network in breast cancers could be useful to predict responsiveness or
unresponsiveness to the drugs targeting the ErbB/HER receptors.
We already reported the messenger RNA (mRNA) expression of the four ErbB/HER receptors in a large series
of human primary breast cancers [16]. In the present paper, we assess the mRNA expression of their 10 ligands
in the same tumour samples providing for the first time an expression profile of the whole ErbB/HER
ligand/receptor network in a large sample set of breast cancers. The relationships with ErbB/HER receptors, the
classical biological, clinico-pathological factors and the prognosis are presented.
discussion
In this study, we demonstrate that transcripts of EGF, TGF, AREG, BTC, HB-EGF, NRG2 and NRG4 are present
in almost all the human breast cancers, while 42%, 45.5% and 80% of these tumours express NRG3, EREG and
NRG1 mRNA. BTC and EREG expressions have never been reported as yet in breast cancer, and this is
therefore the first time that the transcripts of the 10 ErbB/HER ligands are simultaneously analysed.
Our results are in line with studies reporting that ErbB/HER ligands are expressed at mRNA and protein levels
in breast malignant tumours. EGF transcripts have been detected in 83% of breast cancers, and EGF protein in
15%–80% of the cases [17–19]. About 70% of the breast cancers expressed TGF mRNA [17], and TGF and
AREG proteins have been detected in 30%–80% of these tumours [17, 20]. The expression of the other ligands
is largely less documented. HB-EGF has been seen by immunohistochemistry in 53%–78% of breast cancers
[18, 21]. Dunn et al. [22] reported that the four NRG were expressed in breast cancers at both the protein and
mRNA levels.
It is well established that mRNA expression does not necessarily fit with protein expression. Indeed, gene
expression is regulated at many levels, including the post-transcriptional down-regulation by microRNAs [23].
However, we demonstrated a close correlation (P = 0.0067) between the HER2 gene expression assessed by
reverse transcription (RT)–PCR and oncoprotein expression determined by an enzyme immuno assay [24].
Moreover, several lines of evidence indicate that the mRNA expression of the ErbB/HER ligands in breast
cancer cell lines or breast cancer samples correlate with their amount of protein. Number of studies reported that
EGF and TGF mRNA expressions were in concordance with the expression of their corresponding proteins [17,
25]. Additionally, AREG expression assessed by Northern and/or dot blots was significantly associated with
AREG expression detected by immunohistochemistry [26]. Moreover, the NRG 1–4 protein expression was
related with expression of mRNA, as revealed by RT–PCR and in situ hybridization [22]. These observations led
us to assume that the ErbB/HER ligands mRNA quantified in the breast cancer samples might probably reflect
their protein expression.
EGF, TGF and HB-EGF are also produced by normal mammary cells [27–29]. The amount of EGF in serum
ranged from 0.2 to 1.14 ng/ml, while it was largely higher in mammary fluids (111–548 ng/ml) or milk (65–140
ng/ml), demonstrating an active production by epithelial cells [27]. Interestingly, high intracystic EGF levels
seem associated with an increased breast cancer risk in women with gross cystic disease of the breast [28].
The above results and the fact that the mammary epithelial tumour cells are the major tissue component in
primary breast cancers, indicate that the mRNA ligands quantified in the present study are probably expressed
by tumour cells. This is supported by numerous in vitro studies demonstrating that human breast cancer cell
lines express and produce EGF and TGF [17, 25]. In breast cancer samples, their expression has been visualized
on tumour cells [17, 18]. Similarly, HB-EGF and NRG1–4 expression seems localized in the epithelial breast
cancer cells [18, 21, 22]. BTC mRNA is expressed by the MCF7 breast cancer cells [30]. Although its
localization in breast cancer samples has never been reported, this observation provides indirect evidence that
the BTC mRNA quantified in the present study might indeed arise from the tumour cells. However, we cannot
exclude the possibility that the ErbB/HER ligands mRNA would be also expressed by the other cell types of the
tumour. For example, even if Lejeune et al. [26] reported that the immunological staining of AREG was
restricted to the tumour epithelium, Ma et al. [20] found expression of AREG in both invasive epithelial tumour
cells and stromal cells.
We observed that the mRNA levels of the different ligands are positively correlated to each other. These results
indicate that the ErbB/HER ligands share some common mechanisms of regulation, as already reported in the
literature, when these growth factors were considered separately [17]. We found that ligands binding HER3 were
expressed in 40% of the tumours, and ligands binding EGFR or HER4 in 75% of the cases. Our study also
revealed that at least one of the 10 ErbB/HER ligands was expressed at high levels in 85% of the breast cancers,
whatever its HER2 status. This finding suggests that HER2 might be activated in a large number of HER2-
positive and negative tumours via heterodimerization.
In the present series of biopsies, we previously reported the expression of the ErbB/HER receptors [16]: here we
demonstrate co-expression with their ligands. These observations provide additional evidence that the
ErbB/HER ligands might act on breast cancer cells via autocrine or paracrine pathways. We also demonstrate
that EGF and AREG correlated positively to the expression of the four ErbB/HER receptors. These results
corroborate in vitro data, demonstrating that EGF increases both protein and mRNA levels of EGFR [31].
Concerning the expression of the other ligands, we observed a similar positive correlation with EGFR while a
negative correlation was observed with HER3 and HER4. In a same way, an increase in EGFR mRNA induced
by TGF has been described [25]. Almost all combinations of receptors and ligands co-expressions were
observed, demonstrating that the expression profile of the ErbB/HER ligand/receptor network is complex. This
finding indicates that it would be helpful to evaluate this expression profile before administration of drugs
targeting the ErbB/HER receptors, instead of looking at the ErbB/HER ligand/receptor separately.
We demonstrated that the mRNA expressions of both EGF and AREG correlated positively with ER or PR
levels, ER- and PR-positive tumours expressing high levels of EGF and AREG as previously reported [17, 32].
Conversely, we found negative correlations between the other ligands and steroid receptors. These results were
confirmed by our observation that ER- and PR-negative tumours expressed higher levels of TGF, HB-EGF and
NRG2 than their positive counterparts. Similarly, the levels of TGF are higher in ER-negative than in ER-
positive human breast cancer cell lines [17, 25]. The relationships observed in the present study between
ErbB/HER ligands and steroid receptors are in agreement with previous reports demonstrating that some of these
growth factors are regulated by estradiol at either transcriptional and/or translational levels [17]. Interestingly,
we previously reported such strong correlations between the four ErbB/HER receptors and the steroid receptors
in breast cancer samples [16], and demonstrated that the mRNA expressions of the four ErbB/HER receptors
were down-regulated by estradiol and up-regulated by 4-OH tamoxifen in MCF-7 human breast cancer cells
[33].
Our results pointed out that elevated expressions of EGF and AREG are associated with small tumour diameter
and low histoprognostic grading. Conversely, TGF, HB-EGF and NRG2 high expressions are associated with
large tumour diameter and high histoprognostic grading. In contrast with our results, it has been reported that
HB-EGF expression was inversely related to biological aggressiveness of the breast carcinoma [21]. These
observations evidence a tumour population with a differentiated phenotype expressing EGF and AREG, HER3
and HER4, steroid receptors, with a small diameter, low histoprognostic grading and node negative. In
agreement with Pirinen et al. [34], EGF was found to be associated with a more favourable prognosis, in terms
of both overall and RFS in univariate analyses.
In conclusion, our study indicates that the 10 ErbB/HER ligands are co-expressed in a large number of breast
cancers and might bind their ErbB/HER receptors, leading to activation of either their own receptors (via
homodimerization) or of the other receptors of the family, including HER2 (via heterodimerization).

Gene expression profile and response to trastuzumab-docetaxel-based treatment in breast

carcinoma.
Végran F, Boidot R, Coudert B, Fumoleau P, Arnould L, Garnier J, Causeret S, Fraise J, Dembélé D,
Lizard-Nacol S. Br J Cancer. 2009 Sep 15. [Molecular Genetics Unit, Centre Georges François Leclerc, IFR-
Santé-STIC, Dijon Cedex, France.
Background:Resistance to trastuzumab is often observed in women with human epidermal growth factor
receptor 2 (HER2)-positive breast cancer and has been shown to involve multiple potential mechanisms. We
examined the ability of microarray analyses to determine the potential markers of pathological complete
response (pCR).Methods:We conducted an analysis of tumours from 38 patients with locally advanced HER2-
positive breast cancer who had received trastuzumab combined with docetaxel. Quantitative reverse
transcriptase (RT)-PCR was used to assess the expression of 30 key genes; microarray analyses were carried out
on 25 tumours to identify a prognostic gene expression profile, with 13 blinded samples used to validate the
identified profile.Results:No gene was found to correlate with response by RT-PCR. The microarray analysis
identified a gene expression profile of 28 genes, with 12 upregulated in the pCR group and 16 upregulated in
non-pCR. The leave-one-out cross-validation test exhibited 72% accuracy, 86% specificity, and 55% sensitivity.
The 28-gene expression profile classified the 13 validation samples with 92% accuracy, 89% specificity, and
100% sensitivity.Conclusion:Our results suggest that genes not involved in classical cancer pathways such as
apoptosis or DNA repair could be involved in responses to a trastuzumab-docetaxel-based regimen. They also
describe for the first time a gene expression signature that predicts trastuzumab response.British Journal of
Cancer advance online publication, 15 September 2009; doi:10.1038/sj.bjc.6605310 www.bjcancer.com.

Anthracycline-Trastuzumab Regimens for HER2/Neu-overexpressing Breast

Cancer: Current Experience and Future Strategies
D. Rayson; D. Richel; S. Chia; C. Jackisch; S. van der Vegt; T. Sute
Ann Oncol. 2008;19(9):1530-1539.
Abstract
Anthracycline-trastuzumab-containing regimens demonstrate significant clinical activity in human epidermal
growth factor receptor 2 (HER2)-positive breast cancer; however, the utility of this strategy is limited by
unacceptably high rates of significant cardiotoxicity, particularly with concurrent administration. Anthracycline-
induced cardiotoxicity is thought to be mediated primarily through increased myocardial oxidative stress,
modified partly by the activity of neuregulins. Trastuzumab-induced cardiotoxicity is thought to be mediated by
the ErbB/neuregulin system, with exposure to trastuzumab partly blocking the protective effect of neuregulins
on the myocardium. As a result, trastuzumab increases the risk of anthracycline-induced cardiotoxicity. Several
strategies have been adopted in attempts to minimize cardiotoxicity, including patient selection on the basis of
preexisting cardiac risk, monitoring of cardiac function during treatment, and early management of cardiac
dysfunction. The use of less cardiotoxic anthracyclines may be one strategy to lessen the risk of cardiotoxicity.
Liposomal doxorubicin products offer similar efficacy compared with conventional doxorubicin, with
significantly less cardiotoxicity, and have been successfully used in combination with trastuzumab in the
metastatic and neo-adjuvant setting. Clinical trials are currently underway to assess the safety of pegylated
liposomal doxorubicin during concurrent administration with trastuzumab compared with standard sequential
treatment using conventional doxorubicin in the adjuvant setting.
Introduction
HER2 is a proto-oncogene and member of the ErbB family of transmembrane tyrosine kinases. Approximately
15%-25% of patients with breast cancer have tumors that overexpress the HER2 protein or amplify the
HER2/neu gene. These HER2-positive tumors are associated with a more aggressive clinical course compared
with HER2-negative tumors.[1,2]
Current adjuvant treatment for HER2-positive tumors is centered on use of the anti-HER2 mAb trastuzumab,
either concurrent with or sequential to systemic chemotherapy. The addition of trastuzumab to standard adjuvant
chemotherapy yields significant improvements in both disease-free survival (DFS) and overall survival (OS)
compared with chemotherapy alone.[3-6]
Most of the published data support the preferential use of an anthracycline-containing adjuvant regimen for
individuals with HER2-positive tumors.[7-9] Concurrent anthracyclines and trastuzumab, however, are
contraindicated due to the observation of unacceptably high rates of cardiotoxicity in a large randomized trial in
the metastatic setting.[10] Due to this, and despite the observed clinical efficacy of concurrent anthracycline-
trastuzumab therapy, all large adjuvant trials have evaluated only the sequential strategy of administering
anthracyclines and trastuzumab.
Cardiotoxicity remains an important clinical issue even with sequential therapy, and strategies to minimize this
toxicity have been proposed.[11] An adjuvant anthracycline-trastuzumab regimen with less cardiotoxicity,
potentially allowing for concurrent administration, is an area of clinical relevance and potential value for
patients with HER2-positive breast cancer.
This review article will present the rationale for concurrent anthracycline-trastuzumab therapy, review available
clinical efficacy and cardiac safety data, outline the mechanisms of cardiotoxicity related to both agents, and
review potential strategies for minimizing cardiac risk with concurrent anthracycline and trastuzumab treatment
regimens.
Reationale for Adjuvant Anthracycline-trastuzumab Regimens for HER2-positive Disease
Before the introduction of HER2-targeted therapy, HER2-positive breast cancer was treated with protocols
similar to those employed for HER2-negative tumors. The development of the anti-HER2 mAb trastuzumab led
to clinical trials of trastuzumab in combination with systemic chemotherapy for the treatment of HER2-positive
metastatic breast cancer (MBC).
The selection of systemic chemotherapy for use in combination with trastuzumab was on the basis of preclinical
data demonstrating enhanced antitumor activity when trastuzumab was combined with doxorubicin or with the
taxane, paclitaxel.[12-14] These preclinical data were confirmed in the pivotal phase III trastuzumab study
involving women with HER2-positive MBC randomized to treatment with standard chemotherapy alone or
standard chemotherapy plus concurrent trastuzumab.[10] Anthracycline-naive women received doxorubicin plus
cyclophosphamide (AC) with or without trastuzumab (H). Women with prior exposure to anthracyclines
received paclitaxel (T) with or without trastuzumab. The addition of trastuzumab to either the anthracycline- or
taxane-based regimen led to a significant improvement in overall response rate (50% versus 32%; P < 0.001)
and OS (25 versus 20 months; P = 0.046) compared with the same chemotherapy alone. Although difficult to
compare directly due to more favorable baseline characteristics, results in the anthracycline group were
numerically superior to those observed in the taxane group, with an objective response rate of 42% for AC alone
and 56% for AC-H, versus 17% for T alone and 41% for TH. Despite demonstrable disease activity, however,
the utility of concurrent trastuzumab-anthracycline combinations was obviated by unacceptably high rates of
New York Heart Association (NYHA) class III/IV cardiotoxicity (16%). The taxane-trastuzumab combination
was also associated with an increased incidence of class III/IV cardiotoxicity, but at a lower rate (2%).[10,15]
Data indicating that patients with HER2-positive tumors may derive preferential benefit from anthracyclines in
the adjuvant setting come from multiple clinical trials. One of the earliest reports examining this issue, the
National Surgical Adjuvant Breast and Bowel Project (NSABP) protocol B-11, involved patients with lymph
node-positive, hormone receptor-negative breast cancer randomized to treatment with melphalan plus
fluorouracil with or without doxorubicin. In a retrospective analysis, patients with HER2-positive tumors had
improved DFS (relative risk (RR) = 0.60; P = 0.001), OS (RR = 0.66; P = 0.01), relapse-free survival (RFS; RR
= 0.58; P = 0.002), and distant DFS (RR = 0.61; P = 0.003) when treated with the doxorubicin-containing
regimen. There was no benefit to the addition of doxorubicin in the HER2-negative subset.[7]
The relationship between HER2 status and responsiveness to adjuvant anthracycline-containing therapy was
evaluated in premenopausal women with node-positive breast cancer enrolled in the MA-5 trial led by the
National Cancer Institute of Canada. In this study, patients were randomly assigned to treatment with
cyclophosphamide, epirubicin, and fluorouracil (CEF) or classic cyclophosphamide, methotrexate, 5-
fluorouracil (CMF). At median follow-up times of 5 and 10 years, outcomes were superior for those receiving
CEF.[16,17] In a recent report, tumor specimens from these trials were analyzed for HER2 status. For those with
HER2-positive tumors, CEF was superior to CMF, with hazard ratios (HRs) of 0.52 (P = 0.003) and 0.65 (P =
0.06) for RFS and OS, respectively. There was no observed difference between CEF and CMF in patients with
HER2-negative disease.[9] In a separate analysis, topoisomerase II alpha protein overexpression also predicted
for improved DFS and OS in patients treated with CEF versus CMF.[18]
A pooled analysis of the interaction between HER2 status and benefit of adjuvant chemotherapy as a function of
whether or not an anthracycline was administered as part of an adjuvant regimen included eight large
randomized controlled clinical trials that examined this issue, two of which were summarized above. The HR
for DFS was 0.71 [95% confidence interval (CI) 0.61-0.83; P = 0.001) and for OS was 0.73 (95% CI 0.62-0.85;
P < 0.001) favoring the inclusion of anthracyclines for HER2-positive disease. No significant benefit was
observed for anthracycline inclusion for HER2-negative disease with a HR for DFS of 1.0 (95% CI 0.9-1.11; P
= NS) and for OS of 1.03 (95% CI 0.92-1.16; P = NS). The test for interaction between HER2 status and receipt
of anthracyclines was significant for both DFS (χ2 = 13.7; P < 0.001) and OS (χ2 = 12.6; P < 0.001).[19]
Adjuvant Doxorubicin/Trastuzumab-clinical Data
Data from randomized controlled trials in HER2-positive disease provide clear evidence of a DFS and OS
benefit when trastuzumab is added to standard chemotherapy in the adjuvant setting ( Table 1 ).[3-5,20] Cardiac
safety was an important aspect of all the trials. Criteria for the definition of a cardiac event differed among trials
but concurrent trastuzumab-chemotherapy strategies consistently led to higher event rates compared with
strategies where trastuzumab was administered after completion of chemotherapy (e.g., as in the HERA trial).[3-
5,20-22]
Due to unacceptably high rates of cardiotoxicity observed in the metastatic setting as discussed previously,
[15]
all concurrent strategies avoid administration of trastuzumab during the anthracycline treatment period.
More recently, data from two adjuvant trials have led to controversy regarding the superiority of anthracyclines
in HER2-positive disease. In a phase III study, adjuvant docetaxel plus cyclophosphamide (TC) was associated
with an improved DFS and OS compared with AC. HER2 status was only assessed in a minority of patients and
interaction with treatment was not significant.[23,24]
Breast Cancer International Research Group (BCIRG) study 006 compared AC-docetaxel (T), AC-TH, and T
plus carboplatin plus H (TCH) in women with HER2-positive breast cancer ( Table 1 ). At the second interim
analysis, there were no statistically significant differences in DFS and OS rates between the two trastuzumab-
containing regimens (AC-TH and TCH; DFS 83% versus 82%; OS 92 versus 91%, respectively). Both
trastuzumab-containing regimens led to improved DFS and OS rates compared with the nontrastuzumab-
containing regimen. Grade III/IV congestive heart failure (CHF) was significantly more common with AC-TH
compared with TCH (P = 0.0015),[5] thus emphasizing the importance of maximizing cardiac safety for
anthracycline-trastuzumab regimens in the adjuvant setting.
The BCIRG 006 trial joins the MA.5 trial and others in which an association between topoisomerase II-
HER2/neu coamplification and anthracycline benefit has been demonstrated.[25-28] A systematic review of data
from published, randomized, controlled trials conducted in the adjuvant setting and reporting HER2 status
showed an incremental efficacy benefit for anthracycline-based therapies only when HER2 and topoisomerase
II are coamplified.[29] In BCIRG 006, 35% of patients had topoisomerase II-HER2 coamplification. Results from
the second interim analysis of this trial demonstrated that, in the coamplified population, DFS was not
statistically significantly different among the three arms (AC-T, AC-TH, and TCH). Conversely, in the non-
coamplified population, DFS was significantly poorer in the AC-T arm compared with AC-TH (P < 0.001) and
TCH (P < 0.001).[5] These results indicate that the anthracycline benefit was lost in patients with non-
coamplified tumors and has created an as yet unresolved controversy about the role of anthracyclines and the
potential utility of the TCH regimen in the treatment of breast cancer.
Cardiac Safety of Doxorubicin
Cardiotoxicity Rates with Conventional Doxorubicin
Comparisons of anthracycline-induced cardiotoxicity rates between studies are problematic due to
inconsistencies in patient populations, treatment regimens, definitions of cardiac toxic effects, and cardiac
assessment tools. However, available data clearly demonstrate an important risk of cardiotoxicity in patients
treated in either the adjuvant or metastatic setting with conventional anthracyclines alone or in combination
with standard chemotherapy or trastuzumab.
Doxorubicin Monotherapy. In a retrospective analysis of 630 patients with MBC or advanced small-cell lung
cancer treated with single-agent doxorubicin, the estimated cumulative percentage with symptomatic CHF was
5% at a cumulative dose of 400 mg/m2, 16% at 500 mg/m2, and 26% at 550 mg/m2. When all cardiac events
were considered [defined as (i) ≥20 point left ventricular ejection fraction (LVEF) decline from baseline; (ii) 10-
point LVEF decline from baseline to below the institution's lower limit of normal (LLN); (iii) LVEF decline ≥5
points to below the institution's LLN; or (iv) symptomatic CHF on study], the estimated cumulative incidence
was 7% at a lifetime doxorubicin dose of 150 mg/m2, 9% at 250 mg/m2, 18% at 350 mg/m2, 38% at 450 mg/m2,
and 65% at 550 mg/m2.[3]
AC Therapy. Adjuvant AC is also associated with decreases in LVEF. After a cumulative doxorubicin dose of
240 mg/m2 administered within the AC regimen in NCCTG N9831, 17% of 1536 patients had an asymptomatic
LVEF decline ≥10% but <20% compared with baseline and 7% had an asymptomatic decline ≥20% to below
the LLN.[31] Adjuvant trials incorporating trastuzumab concurrent with paclitaxel and following AC have
consistently observed that ∼7% of patients who complete four cycles of AC experience cardiotoxicity
precluding the subsequent administration of trastuzumab.[4,22] In addition, several trials have shown that a lower
LVEF before initiation of trastuzumab, as well as increasing age, increases the risk of treatment-associated
contractile dysfunction.[21,22]
Cardiac Safety of Doxorubicin-trastuzumab Combination Therapy
Trastuzumab monotherapy carries a risk of cardiotoxicity when administered to patients with metastatic disease,
with an incidence of cardiac dysfunction (symptomatic CHF, cardiomyopathy, or >10 point decrease in LVEF)
ranging from 2% to 9%.[15,32,33] The risk of trastuzumab-associated contractile dysfunction appears to be lower in
anthracycline-naive patients.[22]
In the anthracycline-trastuzumab arm of the pivotal trial in HER2-positive MBC, patients were treated for a
planned duration of six cycles (cumulative anthracycline dose 360 mg/m2), with further cycles administered at
investigator discretion. With this, the incidence of cardiac dysfunction and NYHA classes III-IV cardiotoxicity
(i.e., symptomatic CHF) was 27% and 16%, respectively.[10,15,34] Cardiotoxicity rates were lower in subsequent
trials conducted in patients with MBC after the risk of cardiotoxicity was recognized and concurrent
administration with anthracyclines was avoided. In an analysis of pooled data from six MBC trials, 11.6% of
patients treated with trastuzumab after prior anthracyclines experienced a fall in LVEF of ≥15 points to a level
<50%.[34]
Data on the risk of cardiotoxicity in the adjuvant setting continue to evolve. Recognition of cardiotoxic risk with
anthracycline-trastuzumab combinations has led to rigorous cardiac eligibility criteria for adjuvant trastuzumab
trials; most trials now require a normal postanthracycline LVEF before initiating treatment with trastuzumab.
Cardiac safety data from the individual trials of adjuvant sequential anthracycline-trastuzumab are shown in
Table 1 . The cumulative long-term risk of symptomatic or asymptomatic cardiac dysfunction in patients treated
in these trials is unknown as are the implications of less severe cardiac toxic effects not meeting the trial
definition of an event.[35] These issues are especially germane to patients treated in the adjuvant setting as long-
term increases in cardiotoxic risk may counterbalance a portion of the benefit of successful breast cancer
treatment.
The differences in rates of cardiac events and trastuzumab discontinuations between concurrent and sequential
strategies merits discussion. In an analysis of cardiac dysfunction in the NSABP B-31 trial carried out at a
median follow-up of 27 months, the cumulative incidence of class III/IV CHF 3 years after initiating treatment
with the TH portion of the AC-TH regimen was 4.1%. In this trial, 19% of women discontinued trastuzumab
treatment for cardiac reasons. Both post-AC LVEF and older age were found to be important predictors of
cardiotoxicity in this analysis.[22,36] In the N9831 trial comparing AC-T chemotherapy alone to the same
chemotherapy plus trastuzumab, either concurrent (with T) or subsequent to chemotherapy, the incidence of
grade III/IV cardiotoxicity was 2.8% and 3.3% for the trastuzumab-containing arms (trastuzumab sequential to,
versus concurrent with, paclitaxel) versus 0.3% for the nontrastuzumab arm. Factors associated with increased
risk of cardiac events included older age, lower baseline LVEF, and prior/current use of antihypertensive
medications.[36] In an analysis of cardiac dysfunction in the HERA trial carried out at a median follow-up of 12
months, the rate of severe (class III/IV) CHF in the trastuzumab arm was 0.6%. Trastuzumab was discontinued
for cardiac reasons in 4.3% of women.[21] A direct comparison of these trials is complicated by the use of
different methodologies; however, certain differences are of interest. First, the cardiac eligibility criteria for
beginning trastuzumab were more stringent in HERA where patients were required to have a LVEF ≥55%.[3] In
contrast, the LVEF threshold was effectively ≥50% in NSABP B-31 as patients were allowed to receive
trastuzumab if their LVEF was above the institution's LLN as long as they did not experience a drop in LVEF
from the prechemotherapy value of >15 percentage points.[22] Second, the amount of time elapsed between the
completion of anthracyclines (received by all patients in NSABP B-31/N9831 and 94% of patients in HERA)
and trastuzumab initiation was longer in the HERA trial. The median time between last dose of anthracycline
and trastuzumab was 89 days in the HERA trial compared with 21 days in NSABP B-31/N9831.[4,21,36] Thus, it is
possible that the longer elapsed time between administration of the anthracycline and trastuzumab may result in
less oxidative stress to the myocardium, supporting a potential role for anthracycline-associated oxidative stress
as a risk factor for trastuzumab-related cardiac dysfunction. As well, a longer elapsed interval may avoid the
blockade of erbB2-driven mechanisms involved in tissue rescue of acutely injured myocardium as a result of
anthracycline exposure, potentially mitigating observed cardiotoxicity.
Two neo-adjuvant studies incorporating anthracyclines and trastuzumab have documented significant pathologic
complete response (pCRs) rates in this patient population. Buzdar et al.[37] have updated their initial cohort,
treated preoperatively with paclitaxel followed by an anthracycline-based regimen (FEC75; 5-fluorouracil,
epirubicin, cyclophosphamide), to include a final patient sample of 64, of whom 45 received concurrent
chemotherapy plus trastuzumab for HER2-overexpressing disease. The pCR in this group was 60% (95% CI
44.3% to 74.3%) versus a pCR rate of 26.3% (95% CI 9% to 51%) in the nontrastuzumab arm. Median LVEF
values in the trastuzumab-receiving cohort declined from 65% at baseline to 60%, with the LVEF median and
range decreasing over time and a 95% CI of the probability of cardiac failure between 0% and 7.87%. The
NOAH trial, published in abstract form to date,[38] randomized a subset of patients with HER2-positive disease
to sequential neo-adjuvant chemotherapy (AT; doxorubicin-paclitaxel × 3, T; paclitaxel × 3 and CMF;
cyclophosphamide, methotrexate, 5-fluorouracil × 3) either with or without concurrent trastuzumab. Early
results indicate a significant improvement in pCR rates for the trastuzumab-containing arm (pCR 43% versus
23%; P = 0.002) with cardiotoxicity rates (LVEF decline by 10% or greater, congestive heart failure) of 15.7%
for the trastuzumab regimen versus 11.5% for the nontrastuzumab arm.
In addition to the analyses just discussed, there has been a meta-analysis of cardiac effects in >11 000 women
enrolled in adjuvant trials of chemotherapy plus trastuzumab including the five trials shown in Table 1 . When
considering only the arms in which trastuzumab was administered for 1 year, a significantly increased risk of
NYHA class III or IV CHF (RR, 7.05, 95% CI 3.88-12.83; P < 0.0001) was observed with an absolute
difference of 1.61% compared with the nontrastuzumab-containing treatment arms. The risk of asymptomatic
contractile dysfunction was also significantly increased (RR, 2.18, 95% CI 1.45-3.27; P = 0.00016). The
absolute OS benefit observed in the trastuzumab-treated cohort was 1.96% on the basis of relatively short-term
follow-up.[11] Both cardiac event rates and absolute OS benefits may change over time and will need to be more
fully elucidated before a more complete understanding of both the benefits and risks of anthracycline-
trastuzumab-containing adjuvant breast cancer regimens can be achieved.
Mechanisms of Cardiotoxicity
Anthracycline-induced cardiotoxicity is a progressive disease that evolves in a stepwise fashion, with changes
in cardiac ultrastructure occurring in advance of clinical manifestations of cardiac dysfunction.[39] Depending on
dose, pharmacokinetics, and type of anthracycline used, myocardial cell loss or functional damage can occur.
Initially, only a relatively modest decline in contractile function may occur because physiologic mechanisms
can compensate for myocardial cell loss and declines in pump function. Additional cardiac insult and secondary
damage may subsequently, over time, lead to left ventricular remodeling and symptomatic heart failure.
Compensatory mechanisms include activation of the neurohumoral pathways (such as the renin-angiotensin and
adrenergic system), myocardial hypertrophy, and possibly survival factors such as the neuregulin/ErbB system.
[40-42]
The exact changes that occur during the transition to symptomatic disease are not yet entirely elucidated.
[40,41]

Morphologic myocardial change following anthracycline treatment includes myocardial cell loss by necrosis or
apoptosis, myofibrillar loss as well as sarcoplasmic reticulum, and mitochondrial swelling.[43] The major
mechanism underlying these structural changes is anthracycline-induced oxidative stress with interventions
attenuating oxidative stress being generally cardioprotective.[44]
In addition to their expression in certain tumors, ErbB receptors are expressed in the myocardium where they
serve as receptors for neuregulins. Neuregulins are pivotal for myocyte survival in the stressed myocardium[45]
and it is likely that trastuzumab-induced cardiotoxicity results from interference with the action of neuregulin.[46]
Thus, the inhibition of ErbB2 signaling by trastuzumab in patients receiving doxorubicin may interfere with the
protective effects of neuregulin on the anthracycline-damaged myocardium. This may account for the increased
clinical cardiotoxicity observed with concurrent and sequential anthracycline-trastuzumab administration.[3-5,47]
Furthermore, studies conducted in rat cardiocytes demonstrate that the neuregulin/ErbB system, the target for
trastuzumab, can attenuate anthracycline-induced myocardial damage[46] by reducing anthracycline-associated
oxidative stress.[44] When myofibrillar structure was assessed in cultured adult rat ventricular myocytes,
doxorubicin induced a concentration-dependent increase in myofilament disarray and cell death.[46] This
suggests that cardiotoxicity is increased as myocardial doxorubicin concentration increases, likely due to higher
levels of oxidative stress.
Alternative Anthracycline-based Strategies
Epirubicin
Equipotent epirubicin is considered to be less cardiotoxic than conventional doxorubicin, with comparative
cardiotoxicity reported to be 1 : 1.8 in favor of epirubicin.[48] The concurrent administration of epirubicin plus
trastuzumab is being assessed in a multicenter phases I-II trial. The phase I portion of the study evaluated the
cardiac safety of up to six cycles of epirubicin (E, 60 or 90 mg/m2) and C (600 mg/m2) with or without H in
anthracycline-naive women with MBC. Those with HER2-positive disease received E60CH (n = 26) or E90CH
(n = 25), with HER2-negative patients receiving E90C and serving as controls (n = 23). Protocol-defined
cardiac toxicity (>10 point decrease in LVEF to <50%) occurred in three patients receiving trastuzumab (6%)
and in no patients in the control group. Two patients treated with E90CH experienced symptomatic CHF and
one patient treated with E60CH experienced an asymptomatic decrease in LVEF to <50%. Asymptomatic
decreases in LVEF >10% but with an LVEF ≥50% were reported in 48% of patients treated with E60CH and in
56% treated with E90CH compared with 24% in the control group.[49] Data from this phase I trial seem to
indicate similar issues regarding additive cardiotoxicity with concurrent epirubicin-trastuzumab as has been
observed with doxorubicin.
A large retrospective analysis suggests that epirubicin-associated cardiotoxicity may be more common than
previously thought. Of 1097 anthracycline-naive patients with MBC treated with epirubicin, 11.4% developed
≥grade II cardiotoxicity. For every 100 mg/m2 of epirubicin administered, the risk of cardiotoxicity increased
37%. Risk of cardiotoxicity developed at a progressively lower cumulative dose as a function of age (806
mg/m2 at age 40 versus 609 mg/m2 at age 70).[50]
Liposomal Anthracyclines
Liposomal anthracyclines have been developed in an attempt to improve the overall safety profile, and in
particular the cardiac safety profile, of conventional anthracyclines. Two liposomal doxorubicin formulations
are available: pegylated liposomal doxorubicin (PLD; Caelyx®, Schering Plough, Kenilworth, NJ; Doxil®, Ortho
Biotech, Raritan, NJ) and nonpegylated liposomal doxorubicin (LD; Myocet™; Zeneus Pharma Limited, Oxford,
UK and Sopherion Therapeutics, Princeton, NJ). Liposomal daunorubicin (DaunoXome®, Diatos, Paris, France)
is available in Europe and Brazil.
Liposome encapsulation alters the safety profile of anthracyclines by modifying their pharmacokinetics and
biodistribution. Following administration of a liposomal formulation, most of the doxorubicin in plasma is
encapsulated. Once in the tissue, encapsulated doxorubicin is released from the liposome. Due to their size
(100-180 nm in diameter), liposomes cannot escape the circulation through the tight capillary junctions found in
normal tissue such as the heart, but can escape through the weakened vasculature that feeds tumor cells.[51] Thus,
with a liposomal product, the drug is preferentially directed away from sites of toxicity to the site of action.
Adverse effects such as acute nausea and vomiting and cardiotoxicity are thought to be related to peak plasma
and tissue concentrations of free doxorubicin. The rationale for the observed reduction in nausea, vomiting, and
cardiotoxicity with liposomal formulations compared with conventional doxorubicin is on the basis of lower
plasma and tissue (particularly myocardial)-free doxorubicin concentrations.[52,53] Minimization of myocardial
exposure to free doxorubicin induces less myocardial oxidative stress compared with conventional doxorubicin.
This reduction in oxidative stress should attenuate doxorubicin-induced cardiotoxicity.[54,55]
Conventional liposomal formulations are cleared rapidly from plasma.[52] Pegylation of the liposome protects
the product from detection by phagocytes, thus increasing the plasma half-life and allowing for enhanced
accumulation in tumor.[56] Thus, while LD has a half-life of 2-3 h, PLD has a half-life in excess of 55 h.[51]
Monotherapy. Clinical data confirm that monotherapy with liposomal products is associated with similar
efficacy and reduced cardiotoxicity compared with conventional doxorubicin in women with MBC ( Table 2 ).
[57,58]
In these monotherapy studies, percentage LVEF decrease from baseline was correlated with cumulative
dose of both conventional anthracycline and the liposomal product, but the HR for cardiotoxicity consistently
favored the liposomal products.[57,58] In patients treated with PLD 50 mg/m2 every 4 weeks, there was a mean
decrease from baseline LVEF of 2%-3% and a median decrease from baseline LVEF of 2.5% (lifetime dose
<450 mg/m2) to 5% (lifetime dose ≥450 mg/m2) (Figure). At cumulative anthracycline doses of 450 mg/m2 or
more, there was a seven-fold greater mean percentage decrease in LVEF with conventional doxorubicin
compared with PLD. There were no cases of CHF in 254 patients treated with PLD.[57] In patients treated with
LD 75 mg/m2 every 3 weeks, the median LVEF decrease from baseline ranged from 0 (at a lifetime dose of 0-99
mg/m2) to 10% (at a lifetime dose ≥700 mg/m2). There were two cases of CHF in 108 patients treated with LD.
[58]

Figure.
Cardiac event rate in patients treated with pegylated liposomal doxorubicin (PLD) versus conventional
doxorubicin. At the same cumulative anthracycline dose, PLD is associated with a lower rate of cardiac events
(based on multiple-gated acquisition scan) during treatment than conventional doxorubicin (hazard ratio = 3.16;
95% confidence interval 1.58-6.31; P < 0.001 for comparison of cumulative anthracycline dose at the time of
first protocol-defined cardiac event). Data from a phase III study in 509 women receiving first-line treatment.
With permission from O'Brien et al.[57]

Concurrent Trastuzumab. Both liposomal doxorubicin products have been evaluated in combination with
trastuzumab in phase II studies for patients with HER2-positive MBC ( Table 3 ). A phase I/II study evaluated
LD (60 mg/m2 every 3 weeks) plus trastuzumab in patients with advanced breast cancer, some with prior
exposure to anthracyclines (38%) and trastuzumab (30%). Among 37 assessable patients, there was one case
each of symptomatic CHF and asymptomatic cardiotoxicity, both in patients with prior anthracycline exposure.
The overall tumor response rate was 58% (95% CI 41% to 75%).[59] A phase III study (M77035) is currently
evaluating the effect of first-line treatment with paclitaxel, LD, and trastuzumab in patients with metastatic or
locally advanced HER2-positive breast cancer.
Four studies have evaluated the cardiac effects of PLD administered concurrently with trastuzumab. A
multicenter phase II study was conducted in 30 patients with HER2-overexpressing MBC; 13 had prior
treatment with conventional anthracyclines at a mean cumulative dose of 251 mg/m2 of doxorubicin (range 180-
288 mg/m2) and 530 mg/m2 epirubicin (range 309-703 mg/m2). Cardiotoxicity was defined as (i) clinical signs
and symptoms of CHF with ≥10 point decline from baseline in LVEF to a value below the LLN, (ii) ≥15 point
decline from baseline in LVEF in an asymptomatic patient, or (iii) <10 point decline from baseline in LVEF in
an asymptomatic patient with an absolute value <45% on multiple-gated acquisition scan. After a mean of 5.5
cycles of PLD (50 mg/m2 every 4 weeks), cardiotoxicity was detected in three patients (10%), none of whom
developed symptomatic CHF and all of whom had received prior treatment with anthracyclines. The disease
response rate was 52% with an additional 38% experiencing stable disease (failure to acheive a response or
failure to demonstrate progressive disease following 2 cycles of PLD and trastuzumab) for >6 months for an
overall clinical benefit rate of 90%. With median follow-up of 13.9 months, the median PFS was 12.0 months
and median OS had not been reached.[60]
In a second study, concurrent PLD 30 mg/m2 and docetaxel 60 mg/m2 every 3 weeks plus trastuzumab 4 mg/kg
the first week followed by 2 mg/kg weekly thereafter were administered as first-line therapy to 48
anthracycline- and trastuzumab-naive patients with HER2-positive MBC. Forty-one patients with HER2-
negative MBC were treated with PLD plus docetaxel at the same dosage to serve as internal controls for
cardiotoxic end points. There were no significant differences in mean LVEF reductions between treatment arms.
After four and eight cycles of therapy, LVEF fell a mean of 2.4% and 5.3%, respectively, in the PLD plus
docetaxel arm and 2.0% and 5.3%, respectively, in the PLD, docetaxel and trastuzumab arm. No patient in
either group developed symptomatic CHF, but 9% of patients in the control group and 11% in the group
receiving PLD plus docetaxel plus trastuzumab experienced a LVEF decline ≥20% or a LVEF below the LLN
after eight cycles of therapy. A response rate of 46%, median duration of response of 16.3 months, and median
survival of 28 months were observed in the HER2-positive arm.[61] Two smaller studies have also been
conducted as detailed in Table 3 .[62,63]
Investigation of PLD Plus Trastuzumab in Adjuvant Therapy
On the basis of the previous discussion, if anthracycline-induced oxidative stress can be minimized by the use
of a liposomal doxorubicin product, the impact of the loss of the myocardial protective effects of neuregulin that
occurs with concurrent administration of trastuzumab may be reduced and cardiotoxicity minimized.
Collectively, data from adjuvant and metastatic trials indicate that substitution of a liposomal product for
conventional anthracyclines in standard chemotherapy regimens may allow for the safe, concurrent
administration of anthracyclines and trastuzumab in the adjuvant setting. This concept is being investigated in a
randomized phase II multinational trial. The Breast cancer Adjuvant Caelyx Herceptin (BACH) study will
evaluate the cardiotoxicity of a doxorubicin-based and a PLD-based adjuvant chemotherapy regimen in 180
women with operable, node-positive or high-risk node-negative HER2-positive breast cancer.
Following surgical removal of the tumor, patients will be randomly assigned in a 1 : 2 ratio to treatment with
four cycles of standard AC followed by weekly paclitaxel and trastuzumab or four cycles of PLD (35 mg/m2)[64]
and cyclophosphamide (CC), with concurrent weekly trastuzumab followed by weekly paclitaxel and ongoing
trastuzumab. After eight cycles of chemotherapy, further treatment will continue as per the standard of care of
the institution and at the discretion of the investigator. Thus, trastuzumab will be expected to continue for a total
of 1 year on the basis of current knowledge gleaned from prior large adjuvant trastuzumab trials.
The primary objectives are to determine the incidence of cardiotoxicity (based on ECG and LVEF
measurements) and the percentage of patients unable to receive trastuzumab over the planned cycles of
chemotherapy or for the full duration of 1 year, due to cardiac dysfunction.
Discussion
Trastuzumab-chemotherapy regimens have dramatically altered the natural history of HER2-positive breast
cancer. However, the long-term prognosis for patients with breast cancer depends not only on the efficacy of
anticancer treatment but also on the impact of treatment-induced toxic effects. Cardiotoxicity is a particularly
important issue given the large number of women with breast cancer receiving anthracyclines in the adjuvant
setting. While HER2-directed therapy provides significant clinical benefit for patients with HER2 positive
disease, it presents new concerns regarding cardiotoxicity, particularly when used in conjunction with, or
immediately following anthracycline-based chemotherapy.
Several strategies to reduce anthracycline-trastuzumab-induced cardiotoxicity have been proposed with key
elements including establishing stringent LVEF criteria for patient selection, monitoring cardiac function during
therapy, and discontinuing potentially cardiotoxic therapy when cardiotoxicity arises. Other strategies to impact
cardiotoxic risk may include using a less cardiotoxic anthracycline and initiating aggressive management of
cardiac dysfunction.
At present, the inclusion of anthracyclines in adjuvant chemotherapy regimens for patients with HER2-positive
breast cancer is controversial, primarily due to the cardiotoxicity associated with these regimens and the
potential efficacy of alternative, nonanthracycline-containing regimens such as TCH. Concurrent anthracycline-
trastuzumab administration has not been attempted in the adjuvant setting and it is therefore unknown whether
concurrent strategies might be more effective than regimens in which trastuzumab is administered sequentially
following completion of the anthracycline. Strong evidence indicates that anthracycline-induced increases in
myocardial oxidative stress are a major factor underlying anthracycline-associated cardiotoxicity and
trastuzumab-associated contractile dysfunction. Future trials incorporating lapatinib, an oral dual tyrosine
kinase inhibitor of EGFR/ErbB1 and HER2/ErbB2, with early reports of a favorable cardiac safety profile, may
expand the range of strategies for concurrent HER2 blockade with anthracycline administration.[65] Liposomal
anthracyclines may also allow for greater cardiac safety and results from the adjuvant BACH study evaluating
concurrent PLD, cyclophosphamide, and trastuzumab may serve to further develop this strategy and provide
insight into the potential benefits of concurrent anthracycline-trastuzumab use in the adjuvant treatment of
HER2-positive breast cancer.

The Role of Hormonal Therapy in the Management of Hormonal-Receptor-

Positive Breast Cancer With Co-Expression of HER2
Aleix Prat; Baselga
Nat Clin Pract Oncol. 2008;5(9):531-542.
Summary
Approximately half of breast cancers that overexpress human epidermal growth factor receptor 2 (HER2) also
express hormone receptors (HRs). Although HR positivity predicts efficacy of endocrine agents, preclinical and
clinical data suggest that HER2 overexpression confers intrinsic resistance to hormonal treatment. In addition,
HER2 overexpression is an independent adverse prognostic factor regardless of the hormonal status of the
tumor, indicating that patients with HR+/HER2+ breast tumors might not derive a benefit from single-agent
hormonal therapy. These data provided a strong rationale for exploring the targeting of both HR and HER2
signaling pathways in HR+/HER2+ breast tumors to optimize hormonal therapy and overcome resistance to anti-
estrogen therapy. Results from a randomized clinical trial that combined hormonal treatment with targeted anti-
HER2 therapy in postmenopausal women with HR+/HER2+ advanced breast cancer indicate that this novel dual-
targeting strategy significantly improves outcomes compared with endocrine treatment alone. Nonetheless,
other data suggest that it might achieve an inferior outcome compared with anti-HER2 therapy plus
chemotherapy. Therefore, targeting both the HR and HER2 signaling pathways upfront might not be the most-
effective therapeutic strategy in the management of HR+/HER2+ breast cancer. We discuss the clinical
implication of resistance to endocrine therapy, and describe new insights into the management of HR+/HER2+
advanced breast cancer.
Introduction
Each year more than 210,000 and 360,000 new cases of breast cancer are diagnosed in the US and Europe,
respectively.[1,2] More than two-thirds of these patients have hormone receptor (HR)-bearing tumors[3]—a
subgroup that benefits from endocrine therapy. Several hormonal strategies with different mechanisms of action
are currently available for the treatment of HR-expressing breast tumors.[4] Selective estrogen receptor (ER)
modulators, exemplified by tamoxifen, bind to ER and partially block its function. Other strategies, such as
aromatase inhibitors (AIs) luteinizing-hormone-releasing hormone agonists and ovarian ablation exert their
anti-hormonal activity by decreasing ligand levels. Finally, a third class of agents, represented by fulvestrant,
induce receptor degradation.
Tamoxifen has been the most widely used adjuvant hormone therapy for the past two decades, achieving a 39%
reduction in disease recurrence and a 31% reduction in mortality in ER+ early-stage breast cancer.[5] The recent
introduction of third-generation AIs in the adjuvant setting for postmenopausal patients, either initially, or
sequentially after tamoxifen, has produced better outcomes than the previous standard treatment of 5 years of
tamoxifen.[6,8,9] In addition, for postmenopausal patients with ER+ breast cancer, AIs have shown superior
efficacy in the neoadjuvant setting[10,11,12] and in advanced disease[13,14,15,16,17] compared with tamoxifen. The role
of fulvestrant is still being explored, however, it is currently approved for the treatment of HR+ metastatic breast
cancer in postmenopausal women who have experienced disease progression following anti-estrogen therapy.
[18,19,20]

Resistance to Hormonal Treatments

Despite the clinical benefit of hormonal treatment in patients with HR+ breast cancer, primary and secondary
resistance to endocrine therapy remains a significant clinical problem.[21] Phase III clinical trials of patients with
metastatic breast cancer show that only a third of all HR+ tumors respond radiologically to AIs given as first-line
treatments. Furthermore, even those tumors that initially respond to AIs eventually develop resistance, which
leads to disease progression and ultimately to patient death.[13,14,15,16,17] In the adjuvant setting, some patients also
relapse during and after 5 years of hormonal treatment.[6,7,8,9] There is, therefore, a strong rationale for the
identification of the mechanisms underlying endocrine resistance in order to improve the outcome of patients
with HR+ breast tumors.[22]
Several mechanisms of resistance to hormonal-therapy have been proposed,[23] and include the following:
downregulation of ER expression, ER mutations, altered expression of ER coregulators, and ligand-independent
activation of ER and coactivators by growth factor receptor kinases.[24,25] The human epidermal growth factor
receptor (HER) family of receptors involved in hormone resistance includes EGFR (also known as HER1 or
erbB1), HER2 (erbB2), HER3 (erbB3), and HER4 (erbB4).[26,27] In particular, HER2 overexpression and/or
amplification (HER2+) confers intrinsic resistance to endocrine treatment in preclinical models.[28,29] HER2 is a
ligandless receptor that forms homodimers and heterodimers with other members of the HER family, resulting
in receptor activation and phosphorylation of intracellular catalytic domains. This phosphorylation leads to
activation of signal transduction pathways that promote proliferation and survival such as the
phosphatidylinositol 3'-kinase (PI3K)/Akt/mTOR, the Erk1/2 mitogen-activated protein kinase (MAPK) and the
JAK/STAT pathways.[30] In experimental systems, HER2 overexpression drives malignant transformation of
mammary epithelial cells.[31] In patients, HER2 is overexpressed and/or amplified in 25% of breast tumors and
confers a more-aggressive clinical course and a worse survival.[32,33]
Anti-HER2 Therapies
The outcome of these highly aggressive tumors has markedly improved with the development of anti-HER2
therapies. Trastuzumab (Herceptin,1 Genentech, San Francisco, CA) is a recombinant humanized monoclonal
antibody that binds with high affinity to the extracellular juxtamembrane domain of HER2 and inhibits the
proliferation of human tumor cells that overexpress HER2.[34,35,36] The mechanisms underlying the antitumor
activity of trastuzumab are not clear, although it has been established that trastuzumab induces downregulation
of HER2 from the cell surface membrane, blockade of metalloprotease-induced proteolytic cleavage of HER2,
antibody-dependent cell-mediated cytotoxicity, and a decrease in angiogenic factors.[37] In patients with HER2+
tumors and advanced disease, trastuzumab has single-agent activity and improves survival in the first-line
setting when combined with chemotherapy.[38,39] In addition, a number of well-powered clinical trials have
demonstrated that administration of trastuzumab in the adjuvant setting, in combination with and/or sequentially
after chemotherapy, results in an improvement in recurrence-free survival as well as overall survival.[40,41,42,43]
Small molecule tyrosine kinase inhibitors (TKIs) of the HER2 receptor have also shown clinical activity.
Lapatinib (Tykerb,1 SmithKline Beecham, Cork, Ireland), a dual inhibitor of EGFR and HER2, has been shown
to increase survival in patients with advanced HER2+ breast cancer—in comparison with capecitabine treatment
alone, capecitabine treatment in combination with lapatinib improved survival in patients with disease
progression following anthracycline, taxane, and trastuzumab treatment regimens.[44]
In addition, other anti-HER2 agents have been shown to be clinically active in patients refractory to
trastuzumab.[45,46,47] Pertuzumab (Omnitarg,1 Genentech, San Francisco, CA) is a recombinant humanized
antibody currently in phase II and III clinical trials that binds to the dimerization domain of HER2 and inhibits
its heterodimerization with other HER family members.[48] Another agent currently under investigation,
trastuzumab-DM1, combines the antitumor activity of trastuzumab with a highly potent inhibitor of tubulin
polymerization, DM1.[49] Finally, inhibitors of heat shock protein 90, such as KOS-953 (Tanespimycin, Kosan
Biosciences Inc, Hayward, CA), promote ubiquitination and degradation of HER2.[50]
Crosstalk Between ER and HER2 Pathways
There is important crosstalk between ER and other receptor families, including but not restricted to the HER
family,[4] which may have important implications for the biology of breast cancer and response to therapy with
hormonal agents. The biological effects of estrogens on breast cancer cells are mediated through two nuclear
receptors known as ERα and ERβ. The binding of estrogen to ER induces phosphorylation of the receptor,
triggering receptor dimerization and recruitment of coregulatory proteins, and facilitating the binding of the
receptor to promoter regions of DNA.[51] Once activated, ERs modulate the transcription of genes that contain
an estrogen response element (ERE) in their promoters (referred to as the classical genomic signaling pathway).
[52]
The ER complex can also regulate gene transcription by coactivating other transcription factors like c-fos/c-
jun, which bind specific nonestrogen response-element promoters of AP1 responsive genes (referred to as the
nonclassical genomic signaling pathway).[53] Estrogen genomic signaling pathways induce the expression of
genes that encode proteins important for tumor growth, such as the insulin-like growth factor I receptor (IGF-
IR), cyclin D1, collagenase, insulin growth factor II (IGF-II), and VEGF.[53,54,55] Genes downregulated by
estrogens include the EGFR[56] and HER2;[57] many of the genes downregulated by estrogen signaling are
transcriptional repressors and/or members of the transforming growth factor (TGF)-β superfamily. [58]
The transcriptional effects of activated ER are modulated by coregulatory proteins that function as either
coactivators or corepressors of the ER complex.[59,60,61] These coregulatory proteins might be tissue specific,
which could explain the different effects of ER in different tissues.[62] For example, AIB1 is an ER coactivator
that is overexpressed in breast cancer cells compared with normal epithelial cells and is amplified in a small
proportion of breast tumors.[63] Patients with HR+ breast cancer and high levels of AIB1 expression experience a
substantially greater number of recurrences following tamoxifen treatment than do those with HR+ tumors and
lower levels of AIB1 expression.[64]
ER can also regulate cellular functions through nongenomic mechanisms known as membrane nongenomic
estrogen signaling.[4] This is where part of the crosstalk between ER and growth factor receptors seems to occur.
A small pool of ER is located in the cytoplasm and non-nuclear subcellular fractions, including mitochondria
and plasma membrane. This pool of ER functionally resembles growth factor ligands. Plasma-membrane-
associated ER increases the levels of second messengers such as cyclic AMP within minutes,[65] and activates
various tyrosine kinase receptors such as IGF-IR, EGFR, and HER2.[66,67,68] ER can also associate with cellular
kinases and adaptor molecules such as c-Src,1 Src homology and collagen homology protein[70,71] and PI3K.[67]
Finally, ER-induced signaling pathways might induce EGFR ligands such as TGFα[72] and cause downregulation
of EGFR[56] and HER2.[57]
The crosstalk between the ER and the growth factor signaling pathway is bidirectional. A variety of kinases
including MAPKs and Akt phosphorylate specific sites of the ER, leading to ligand-independent ER activation.
[24]
In addition, phosphorylation of ER coregulatory proteins by growth factor kinases regulates the ER signaling
pathway. For example, phosphorylation of AIB1 by MAPK increases ER-dependent transcription,[73] and
overexpression of AIB1 converts tamoxifen-bound ER into an estrogen agonist rather than an antagonist in
MCF7 breast cancer cell lines transfected with HER2 (MCF7/HER2+).[25] This finding suggests that the
crosstalk between the ER and growth factor signaling pathways has an important role in tamoxifen resistance.
The EGFR TKI gefitinib (Iressa,1 AstraZeneca, London, UK) and anti-HER2 antibodies eliminate this
ER/HER2 crosstalk and restore the antitumor effect of tamoxifen in MCF7 cells that express HER2.[25,74] In
addition, increased crosstalk between ER and HER2 may contribute to secondary resistance to tamoxifen in 10–
15% of HR+/HER2- breast tumors.[75]
Estrogen-deprivation therapies such as AIs abrogate genomic and non-genomic activities of ER and, therefore,
could eliminate the crosstalk generated in the presence of estrogen or tamoxifen in HER2+ breast cancer.[76,77]
Data from preclinical models, however, suggest that resistance to estrogen-deprivation therapies in HER2+
breast tumors might occur through at least two mechanisms: adaptation to an estrogen hypersensitive phenotype
and/or by ligand-independent recruitment of coactivator complexes to estrogen-responsive promoters.[4,78]
Thus, in HR+/HER2+ breast tumors a vicious cycle is established between ER genomic and non-genomic
mechanisms of action and the growth factor receptor network leading to enhanced cell proliferation and cell
survival (Figure 1). Since these two receptors systems have the capacity to activate each other, a rational
treatment strategy would be the combined targeting of both receptors.
Figure 1.
ER/GF signaling pathways and molecularly targeted agents for overcoming endocrine resistance. Estrogen
activates nuclear ER (genomic pathway) and ER in or near the membrane (non-genomic pathway). Membrane
associated ER binds to GF signaling components such as PI3K. E2 then activates GF signaling, activating key
molecules such as Akt or RAS, and downstream molecules such as mTOR, Raf, MEK and MAPK, which
promote cell proliferation and survival. In addition, signal-transduction molecules can phosphorylate and
activate ER and its co-regulators to enhance the nuclear genomic ER-mediated response. Abbreviations: AI,
aromatase inhibitors; Akt, protein kinase B; EGF, epidermal growth factor; EGFR, epidermal growth factor
receptor; ER, estrogen receptor; GF, growth factor; HER2, human epidermal growth factor receptor 2; MAPK
mitogen-activated protein kinase; MEK, MAPK kinase; MoAb, monoclonal antibodies; mTOR, mammalian
target of rapamycin; PI3K, phosphatidylinositol 3-kinase; TKI, tyrosine kinase inhibitors.

Endocrine Therapy in HER2+ Breast Cancer

An initial observation in breast-cancer cell lines transfected with HER2 is that HER2 confers resistance to
tamoxifen.[28] This observation has been subsequently confirmed by other groups,[25,29,75,79] and retrospective
analysis of clinical studies have shown a poorer outcome for patients treated with tamoxifen who express high
levels of HER2 than for HER2-negative patients.[80,81,82,83] In one of these studies, the primary tumors of 241
patients who were treated at first relapse with endocrine therapy were assessed by immunohistochemistry for
overexpression of HER2. In patients with HR+ primary tumors treated with tamoxifen (n = 170), HER2
overexpression was associated with a significantly shorter time-to-tumor progression (TTP; 5.5 months versus
11.2 months; P <0.001).[82] There was some initial enthusiasm that HER2+ tumors would be more sensitive to
AIs than to tamoxifen.[76] Careful analysis of published data, however, suggests that even with AIs, patients with
HER2+ disease have a poor response.[83,84,85,86,87,88] For example, a phase III trial of 916 patients[17] with advanced
breast tumors and an unknown HER2 status treated with first-line endocrine therapy showed superiority of
letrozole over tamoxifen in terms of TTP (9.4 months versus 6.0 months; P <0.0001) and overall response rate
(ORR; 32% versus 21%; P = 0.0002). Nevertheless, subsequent analysis of HER2 status[83] revealed that in
HER2+ patients there was no significant difference between those treated with letrozole and those treated with
tamoxifen in terms of ORR (17% versus 13%; P = 0.45) or clinical benefit[89] (33% versus 26%; P = 0.31),
although a strong trend towards a longer duration of response with letrozole was observed (6.1 months versus
3.3 months; P = 0.0596).[83] These poor results in the HER2+ subpopulation contrast with the median TTP
observed in the HER2-negative subgroup (12.2 months in letrozole-treated patients and 8.5 months in
tamoxifen-treated patients). In the second-line setting, 711 women with elevated serum concentrations of the
extracellular domain of HER2 who received megestrol acetate, fadrazole, or letrozole had a shorter TTP (3.0
months versus 6.0 months; P <0.0001) and lower ORR (7% versus 20%; P <0.0001) than did women who did
not have elevated levels of the extracellular domain of HER2 in serum.[84] Finally, early preliminary reports
from the Breast International Group 1-98 Study (BIG 1-98) and the Arimidex or Tamoxifen Alone or in
Combination (ATAC) trial, which compared tamoxifen with either letrozole or anastrozole, revealed that HER2+
status is associated with a significantly higher relapse rate, regardless of whether an AI or tamoxifen is
administered.[86,88]
A small retrospective neoadjuvant study suggested that AIs obtained higher response rates than tamoxifen in
HR+/HER2+ postmenopausal breast cancer.[76] The results of two subsequent studies, one of them by the group
of investigators who initially reported improved benefit with AIs, indicate that the clinical efficacy of AIs in this
context may be short-lived.[85,87] In the first study, known as the IMPACT trial,[11] treatment-associated changes
in the nuclear proliferation marker Ki-67 were measured in tumor biopsy specimens taken at baseline and after
2 weeks and 12 weeks of treatment with anastrozole and tamoxifen.[85] The mean suppression of Ki-67 by 2
weeks of hormonal treatment was greater in the anastrozole arm than in the tamoxifen arm in HR+/HER2+
tumors, but by 12 weeks the level of suppression in the two arms was similar. This increase in Ki-67 after 12
weeks of treatment with anastrozole may be indicative of an early mechanism of escape from the
antiproliferative effects of the AI in the HER2+ subpopulation. The second study supporting this hypothesis used
fluorescence in situ hybridization (FISH) to detect HER2 gene expression in tissue samples from 305
postmenopausal women with stage II/III ER+ breast cancer treated in two independent neoadjuvant endocrine-
therapy trials.[87] Response to letrozole, as assessed by clinical measurement, was not impaired by HER2-FISH-
positive status, indicating sensitivity to short-term estrogen deprivation. However, there was significantly less
Ki-67 suppression in HER2+ tumors following letrozole administration than in HER2-negative tumors. These
findings indicate that the efficacy of estrogen-deprivation therapies might be compromised in the short-term in
HR+/HER2+ breast cancers, suggesting that these tumors might display early resistance to single-agent hormonal
therapy.
In summary, a median TTP of 5.6– 11.2 months and an ORR of 17–32% were achieved in patients with
advanced breast cancer who were not stratified according to HER2 status and were treated with first-line
endocrine therapy ( Table 1 ).[14,15,16] When the HER2+ subgroup are retrospectively analyzed, the median TTP
and ORR for this group decreased to 3.3–6.1 months and 13–17%, respectively.[83] In the second-line advanced-
disease setting and in those with an unknown HER2-status, endocrine treatment achieved median TTP and ORR
of 4.8–5.6 months and 13–15%, respectively.[90,91,92] A further HER2+ subgroup analysis showed that median
TTP and ORR decreased to 3.0 months and 7%, respectively.[84] Taken together, these studies strongly suggest
that HR+/HER2+ breast cancer may be less responsive to tamoxifen and estrogen-deprivation therapies with AIs
than cancer negative for HR and HER2 expression, which could be an indication than HER2 overexpression
and/or amplification results in a dominant phenotype in ER+/HER2+ tumors.
Combined Anti-HER2 and Hormonal Therapy
HER2-targeted strategies in preclinical models have shown a therapeutic potential to subvert endocrine
resistance in HR+/HER2+ breast cancer. Although trastuzumab and chemotherapy has been the standard of care
for patients with advanced HER2+ breast cancer, an important question is whether the subgroup of patients with
HER2+ and HR+ breast tumors might also benefit from a combined anti-HER2 and hormone therapy approach.
If combined hormonal and anti-HER2 therapy were efficacious, this therapy could become an option for
patients with HR+/HER2+ disease. Two prospective clinical trials have been completed that address this issue. In
an initial single-arm phase II study,[93] 33 postmenopausal patients with HR+ and HER2+ advanced breast cancer
were treated with trastuzumab plus letrozole until disease progression or unacceptable toxicity. Most patients
(55%) had received prior adjuvant chemotherapy and tamoxifen, and 48% had developed a recurrence while
taking tamoxifen. In addition, the majority of patients had both soft tissue and visceral disease. The ORR with
the combination was 26%, and the median TTP was 5.8 months. The combination was well-tolerated without
unexpected toxicities. As is often the case with these types of single arm studies, the results were difficult to
interpret in the absence of a control arm.
The question of combined therapy has been addressed by a multicenter phase II/III study (TrAstuzumab in Dual
HER2 ER-Positive Metastatic breast cancer [TAnDEM trial]).[20,94] In this study, the benefit of adding
trastuzumab to an AI was evaluated. A total of 208 postmenopausal patients with ER+ and/or progesterone
receptor+ and HER2+ advanced breast cancer were randomized to first-line treatment with anastrozole plus
trastuzumab (n = 103) or to anastrozole monotherapy (n = 104). The primary end point was progression-free
survival (PFS). Approximately, 60% of patients had received prior endocrine therapy, and 45% and 30% of
patients had lung and liver metastatic disease, respectively. The median PFS was 4.8 months for the
combination group versus 2.4 months for anastrozole monotherapy (P = 0.0016). In the 147 evaluable patients
with measurable disease, the ORR was significantly higher in the combination group than in the anastrozole
group (20.3% versus 6.8%; P = 0.018). The clinical benefit rate, defined as the rate of complete response,
partial response and stable disease ≥6 months of duration, was also significantly higher in the combination arm
than in the monotherapy arm (42.7% versus 27.9%; P = 0.026). In terms of survival, the median overall survival
(OS) was prolonged by 4.6 months in patients receiving trastuzumab and anastrazole compared with patients
receiving anastrozole (28.5 months versus 23.9 months; P = 0.325). This improvement in survival was observed
despite crossover of 73 (70%) patients from the anastrozole arm to the combination arm at disease progression.
Treatment with the combination was manageable and well-tolerated. The incidences of the most frequent
adverse events were higher in the combination arm than in the monotherapy arm: fatigue was reported in 21%
of the combination group compared with 10% of the monotherapy group, while vomiting and diarrhea,
respectively, were noted in 21% and 20% of the combination group and 5% and 8% of the monotherapy group.
Congestive heart failure was reported in 3% of the patients in the combination arm.
The efficacy results of the TAnDEM study have demonstrated a significant improvement in PFS, ORR, and a
trend towards prolonged OS with the combined treatment strategy compared with hormonal treatment alone.
Although the results of the study clearly favor the combination, the low median PFS and ORR obtained in both
arms is worse than would have been achieved if the same population of patients had been treated with
chemotherapy and trastuzumab. Nonetheless, several additional clinical trials are ongoing and will evaluate the
combination of trastuzumab with fulvestrant and other AIs.
It is unclear whether the results observed with trastuzumab and anastrozole will also be observed with other
anti-HER2 agents and, in particular, with TKIs. TKIs might be better blockers of HER2 signaling than
monoclonal antibodies and they might also prevent signaling of HER1; it is possible TKIs could more
efficiently deprive cells of HER1 and HER2 signaling.[95] This question is being partially addressed in a phase
III clinical trial (EGF30008) of lapatinib and letrozole versus letrozole alone, which has recently completed
accrual (n = 1,280) of patients with tamoxifen-resistant advanced breast cancer. Although tumor expression of
HER1 or HER2 is not an eligibility criterion for this study, the sheer size of the study means that a considerable
number of patients with HER2 tumors have been included.
New Strategies in the Treatment of HR+/HER2+ Breast Cancer
Regardless of the outcomes of these trials, there is strong preclinical evidence in support of improved anti-
HER2 combinations with hormonal therapy. For example, preclinical data indicate that blocking HER2
signaling with a three-drug anti-HER2 (trastuzumab and pertuzumab) and EGFR (gefitinib) targeted therapy
combination is more effective than trastuzumab and tamoxifen or two-drug combinations in MCF7/HER2+
breast cancer xenografts.[95] In addition, treatment with endocrine therapy plus gefitinib, trastuzumab and
pertuzumab induces complete and durable tumor regressions.[95] Thus, triple-targeted therapy with ER-targeted
therapy such as tamoxifen or estrogen deprivation in MCF7/HER2+ tumors is highly efficacious, suggesting that
both ER and HER2 cooperate to drive tumor cell survival. It is also of importance to realize that even with
highly optimized 'triple' anti-HER2 therapy there is a need to proceed with hormonal blockade to achieve
optimum results. These findings are supported by an observation that one of the mechanisms by which tumors
acquire resistance to the EGFR and HER2 inhibitor lapatinib is via increased ER signaling.[96] Consequently, ER
becomes a key regulator of cell survival and antiapoptosis in codependence with HER2 in HR+/HER2+ breast
cancer cells.[96] For example, upfront administration of endocrine treatment in combination with lapatinib more-
effectively induces apoptosis than does inhibition of either pathway alone and also prevents the development of
anti-HER2 resistance.[96] Thus, total HER2 and HR blockade by a cocktail of agents may be required to
satisfactorily intervene in the HR/HER2 crosstalk, and this is an approach that deserves to be studied in the
clinic.
Another potential treatment strategy by which resistance to anti-ER–HER2 treatment might be overcome is via
inhibition of various downstream intracellular kinases that override control by upstream membrane receptors
such as HER2.[97,98,99] For example, breast-cancer cell lines with activated PI3K/Akt/mTOR signaling are
resistant to tamoxifen.[100,101] These tumors might be especially sensitive to mTOR inhibitors such as
temsirolimus (CCI-779)[102] and everolimus (RAD001).[103] Following this rationale, a randomized phase II study
compared oral temsirolimus and letrozole with letrozole alone in 104 patients with HER2-unknown metastatic
breast cancer.[104] Owing to the toxicity of the high-dose schedule, which resulted in dose delays and/or
reductions or discontinuations, the protocol was amended to low-dose schedules. After the amendment, early
data from 92 patients suggested that PFS could be longer for the combination arms than for the letrozole-alone
arm, and, therefore, a large phase III trial was initiated. This study, however, was terminated before accrual was
completed because of a lack of efficacy of the combination. The unexpected result raises the issue that phase I
studies evaluating the appropriate dose of signal-transduction inhibitors should aim to identify the biologically
effective dose by use of pharmacodynamic end points rather than focusing on the maximum tolerated dose.
Following this premise, the toxicity profile and the molecular pharmacodynamic findings from a phase I study
of RAD001 at a dose of 10 mg daily was used for further phase II–III development.[103] Interestingly, a lack of
efficacy of mTOR antagonists was suggested from pharmacodynamic analyses because these agents caused a
negative feedback activation of upstream signaling pathways, which induced Akt phosphorylation, protein
kinase activity, and downstream signaling.[105] Thus, upstream inhibition of mTOR with novel PI3K inhibitors in
combination with or without mTOR antagonists might be a treatment strategy worth exploring in HR+ breast
cancer. Studies investigating treatment regimens that combine signal transduction inhibitors with hormonal
treatment in HR+/HER2+ tumors have recently started, and over the next few years we will learn whether such
novel approaches will produce further significant gains in treatment efficacy for HR+ breast cancer.
Combined Anti-HER2 Targeted Therapy and Chemotherapy
A relevant question is whether the poor response to combined hormonal and anti-HER2 therapy in the
HR+/HER2+ patient population is better than could be achieved by treatment with trastuzumab alone or
trastuzumab combined with chemotherapy. There is no data from clinical trials comparing trastuzumab and
hormonal therapy with trastuzumab alone. Trastuzumab monotherapy is active and produces durable objective
responses in women with HER2+ breast cancer who have not previously received chemotherapy for their
metastatic disease.[106] In a large phase II clinical study,[107] 114 women were randomized to receive first-line
treatment with trastuzumab 4 mg/kg loading dose, followed by 2 mg/kg weekly, or a higher 8 mg/kg loading
dose, followed by 4 mg/kg weekly. The ORR was 34%, and the median TTP was 4.9 months in the subgroup of
tumors with HER2 gene amplification as documented by FISH analysis ( Table 2 ). These findings are not
dissimilar to the ones obtained in the TAnDEM trial.
The combination of trastuzumab and chemotherapy offered a significant survival advantage when compared
with chemotherapy alone for patients with HER2+ breast cancer, regardless of HR status.[38] In a pivotal phase
III trial, 469 patients with previously untreated, HER2+ metastatic breast cancer were randomized to receive
first-line chemotherapy (doxorubicin 60 mg/m2 or epirubicin 75 mg/m2 and cyclophosphamide 600 mg/m2 or
paclitaxel 175 mg/m2) either alone or in combination with the antibody. The primary end point of this study was
TTP. The addition of trastuzumab to chemotherapy was associated with a longer median TTP (7.4 months
versus 4.6 months; P <0.001), a higher ORR (50% versus 32%; P <0.001), an increase in median OS (25.1
months versus 20.3 months; P = 0.046), and a 20% reduction in the risk of death. In a similar randomized trial,
186 patients received docetaxel 100 mg/m2 every 3 weeks, with or without trastuzumab in the first-line
advanced-disease setting.[39] In all subgroups analyzed, including HR status, the combined treatment was
significantly superior to chemotherapy alone in terms of ORR (61% versus 34%; P = 0.0002), median OS (31.2
months versus 22.7 months; P = 0.0325), and median TTP (11.7 months versus 6.1 months; P = 0.0001). The
addition of trastuzumab did not substantially increase the toxicity profile of docetaxel. Finally, other phase II
trials have shown the efficacy and safety of trastuzumab in combination with other cytotoxic agents used in
daily practice in the management of breast cancer.[108,109]
In summary, although a considerable increase in toxicity is expected, the addition of chemotherapy to anti-
HER2 therapy results in ORRs in the range 38–61%, and TTP of 6.9–10.7 months.[38,39] These results are far
better than those obtained from upfront dual targeting with concurrent endocrine therapy and anti-HER2
therapy. Thus, in daily practice, the majority of patients with HR+/HER2+ advanced breast cancer should be
offered initial treatment with cytotoxic chemotherapy in combination with anti-HER2 targeted therapy.
Exceptions to this rule should include those patients who decline chemotherapy, those with comorbid conditions
that preclude the administration of chemotherapy and even perhaps those rare patients with slow-growing
tumors. Finally, patients who have been treated in the adjuvant setting with trastuzumab and have relapsed
within a relatively short period of time, should be enrolled in clinical trials evaluating new upfront anti-HER2
treatment strategies, such as lapatinib with or without trastuzumab.
Conclusions
HR-bearing breast tumors with HER2 overexpression and/or amplification represent an unresolved clinical
problem and a major cause of endocrine-treatment failure and mortality. Estrogen-deprivation strategies with
AIs have clearly shown superiority over tamoxifen in the adjuvant, neoadjuvant and advanced breast cancer
settings in postmenopausal patients. Early resistance to hormonal therapy, especially in the HER2+ patient
population, however, is a significant issue with these endocrine agents.
Considerable progress has been made in trying to elucidate the basis of resistance to endocrine therapy in
patients with tumors coexpressing HER2 and HR. There is increasing evidence that endocrine resistance is a
consequence of bidirectional crosstalk between the ER and the EGFR family signaling networks. As a result of
the increased crosstalk between HER2 and ER in HER2+ breast tumors, both pathways become more dependent
on each other.
In order to study the effects of a combined dual-targeting of HR and HER2 pathways, a prospective phase III
study (the TAnDEM trial) has compared the clinical benefit of trastuzumab and letrozole with that of letrozole
alone. Although the combined treatment provides significant improvement in HR+/HER2+ advanced breast
cancer, the overall benefit is modest and inferior to that seen with historical controls treated with anti-HER2
therapy plus chemotherapy. Although improved strategies to achieve a better blockade of these pathways need
to be tested in the clinic, it is unclear at this time whether a combination of hormonal therapy and trastuzumab is
equivalent to combined trastuzumab and chemotherapy in women with HR+/HER2+ tumors. On the basis of the
data available at this time, the combination of chemotherapy with anti-HER2 therapy should be the first-line
treatment option considered for patients with good performance status, visceral disease or rapidly progressing
HR+/HER2+ breast tumors (Figure 2). Patients with poor performance status, nonvisceral disease, or slow-
progressing tumors, who have not received previous treatment with endocrine treatment, could be considered
for upfront treatment with first-line hormone therapy in combination with anti-HER2 therapy. If AIs have
previously been administered, anti-HER2 monotherapy could be a valid alternative.

Figure 2.
Proposed therapeutic cascade in first-line HER2-positive postmenopausal advanced breast cancer. Patients with
poor performance status, nonvisceral disease, or slow-progressing tumors who have not received previous
treatment with aromatase inhibitors, should be considered for upfront treatment with first-line aromatase
inhibitors in combination with anti-HER2 therapy. If aromatase inhibitors have previously been administered,
anti-HER2 monotherapy could be considered. Combination chemotherapy with anti-HER2 therapy should be
the first-line treatment option considered in patients with a good performance status, visceral disease or rapidly
progressing HR+/HER2+ breast cancer.
Table 1. Relevant Trials of Endocrine Therapy for Hormone-receptor-positive Advanced Breast Cancer.

Table 2. Relevant Clinical Trials of anti-HER2-targeted Therapy for HER2-Positive Advanced Breast Cancer.
Sidebar: Review Criteria
The article is based primarily on a discussion of the TAnDEM trial results reported at the 31st European Society
for Medical Oncology Congress in 2006. Other data were obtained by searching the PubMed database. The
search terms used included "trastuzumab", "tamoxifen and resistance", "tamoxifen and HER2", "aromatase
inhibitors", "letrozole resistance", "anastrozole resistance", "estrogen receptor" and "HER2". In addition,
proceedings from conferences of the European Society of Medical Oncology, American Society of Clinical
Oncology, and the San Antonio Breast Cancer Symposium were searched for relevant abstracts.
Sidebar: Key Points
Aromatase inhibitors are the most effective endocrine agents for the treatment of postmenopausal patients with
breast tumors expressing hormonal receptors (HR+); however, not all HR-expressing tumors respond to
endocrine therapies and those who respond eventually become resistant
Several mechanisms for resistance to hormonal therapy have been proposed, including downregulation of HR
expression, HR mutations, altered expression of coregulators, and ligand-independent activation of estrogen
receptor and coactivators by overexpression and/or amplification of HER2
HR+/HER2+ breast tumors are too aggressive to benefit from single-agent hormonal therapy; however,
preclinical and recent clinical data indicate that such resistance might be overcome by inhibiting the HER2
pathway
Anti-ER/HER2 concurrent treatment provides significantly better outcomes in HR+/HER2+ advanced breast
cancer than hormone therapy alone, but clinical data indicate that it might achieve an inferior outcome
compared with anti-HER2 therapy plus chemotherapy
Combination chemotherapy with anti-HER2 therapy should be the first-line treatment option considered in
patients with good performance status, visceral disease or rapidly progressing HR+/HER2+ breast tumors
Whatever approach is chosen for the treatment of HER2+ breast cancer, it should be given upfront with anti-
HER2 therapy

Estrogen Receptor and HER2/neu Status Affect Epigenetic Differences of

Tumor-Related Genes in Primary Breast Tumors
Eiji Sunami; Masaru Shinozaki; Myung-Shin Sim; Sandy L. Nguyen; Anh-Thu Vu; Armando E.
Giuliano; Dave S. B. Hoon
Breast Cancer Res. 2008;10(3)
Abstract
Introduction: Estrogen receptor (ER)-positive breast cancers are considered prognostically more favorable than
ER-negative tumors, whereas human epidermal growth factor receptor (HER)2/neu-positive breast cancers are
associated with worse prognosis. The objective of the present study was to determine whether ER-positive and
ER-negative status relates to epigenetic changes in breast cancer-related genes. To evaluate epigenetic
differences in tumor-related genes relating to ER and HER2/neu status of primary tumors, we examined the
promoter methylation status of the promoter region CpG islands of eight major breast tumor-related genes
(RASSF1A, CCND2, GSPT1, TWIST, APC, NES1, RARβ2, and CDH1).
Methods: Paired ER-positive (n = 65) and ER-negative (n = 65) primary breast tumors (n = 130) matched for
prognostic factors were assessed. DNA was extracted from paraffin-embedded tumor tissue after
microdissection, and methylation-specific PCR and capillary-array electrophoresis analysis were performed.
Results: In early stages of tumor progression (T1 and N0), RASSF1A and CCND2 were significantly (P < 0.05)
more methylated in ER-positive than in ER-negative tumors. GSTP1 hypermethylation was more frequent in the
lymph node metastasis positive group than in the negative group. Double negative (ER-negative, HER2/neu-
negative) breast cancers had significantly lesser frequencies of RASSF1A, GSTP1, and APC methylation (P <
0.0001, P < 0.0001, and P = 0.0035, respectively). Both ER and HER2/neu status correlated independently with
these epigenetic alterations.
Conclusion: We demonstrated significant differences in tumor-related gene methylation patterns relevant to ER
and HER2/neu status of breast tumors. This may be of significance in the assessment of targeted therapy
resistance related to ER and HER2/neu status in breast cancer patients.
Introduction
Hypermethylation is an epigenetic change that blocks the promoter region of a gene and results in gene
silencing. In breast cancer, tumor-related genes may be silenced by hypermethylation; many hypermethylated
genes have been reported, and silencing of these genes plays important roles in carcinogenesis and tumor
progression.[1-3] Identification of epigenetic changes and their correlation with other clinical factors could lead to
improvements in cancer diagnosis and treatment.
In patients with breast cancer, estrogen receptor (ER) status is an important treatment and prognostic factor.
Breast cancer patients with ER-positive tumors generally have a more favorable prognosis than do those who
have ER-negative tumors. These breast cancer patients can be treated successfully with hormonal therapies such
as tamoxifen and aromatase inhibitors.[4-9] Epidemiological studies revealed that patients with ER-positive
tumors have risk profiles different from patients with ER-negative tumors. Parity and timing of births were
inversely associated with ER-positive tumors, but not with ER-negative tumors, and body mass index after
menopause was more strongly associated with ER-positive than with ER-negative tumors.[10] In addition, rates
of ER-positive breast cancer incidence have been shown to increase after age 50 to 54 years, whereas the rates
of ER-negative breast cancer incidence do not.[11]
Similarly, differences in the gene expression patterns of ER-positive and ER-negative tumors have been
documented in microarray expression studies, which identified profile differences in breast tumor subtypes.[12,13]
These findings suggest that ER status of breast cancer represents distinct phenotypes. However, few studies
have determined epigenetic changes in tumor-related genes in relation to ER status in matched-paired breast
cancers.
To investigate the epigenetic differences between ER-positive and ER-negative breast cancer, we assessed the
methylation frequency of several breast tumor-related genes that are known to undergo hypermethylated
changes in breast cancer, and that play important roles in tumorigenesis and cancer progression. The objective
of the study was to determine the association between ER status and epigenetic changes in these tumor-related
genes.
The genes assessed were as follows: RASSF1A (RAS association domain family 1A; location: 3p21.3;
GenBank: AF132675), CCND2 (cyclin D2; location: 12p13; GenBank: AF518005), GSTP1 (glutathione S-
transferase P1; location: 11q13; GenBank: U12472), TWIST (human basic helix-loop-helix DNA binding
protein; location: 7p21.2; GenBank: U80998), APC (adenomatous polyposis coli; location: 5q21-q22;
GenBank: M74088), NES1 (normal epithelial cell-specific 1 or kallikrein 10; location: 19q13.3-q13.4;
GenBank: AF024605), RARβ2 (retinoic acid receptor-β2; location: 3p24; GenBank: X07282), and CDH1 (E-
cadherin; GenBank: L08599). RASSF1A is a putative tumor-suppressor gene that is frequently inactivated
epigenetically rather than in a mutational event.[14] A direct correlation between promoter region methylation
and loss of expression has been shown in many tumor cell lines, including breast cancer.[15-18] RASSF1A can
exert a tumor-suppressing effect by blocking oncogene-mediated c-Jun amino-terminal kinase activation.[19] It
also associates with microtubules and contributes to the maintenance of genomic stability.[20] Loss of CCND2
expression caused by methylation is an early event in breast cancer tumorigenesis.[21] Methylation of CCND2
has been correlated with poor prognosis, implying that CCND2 has a tumor-suppressor function.[22] GSTP1 is
one of a family of enzymes that detoxifies hydrophobic electrophiles, and may be part of a protection system
from environmental or dietary carcinogens.[23] Our group has previously found that GSTP1 methylation
correlates with increased tumor size and increased likelihood of sentinel lymph node metastases.[24] TWIST
induces E-cadherin mediated cell-cell adhesion and induction of cell motility. Increased expression of TWIST
correlates with tumor invasion and metastasis.[25,26] APC gene germline mutations have been shown to be
associated with familial adenomatous polyposis. Hypermethylation of the APC promoter is also associated with
breast cancer, especially lobular breast cancer.[27-29] NES1 is a putative tumor suppressor gene found to be
downregulated in breast cancer.[30,31] RARβ2 is postulated to be a tumor suppressor gene. RARβ2 methylation
correlates with breast cancer metastasis.[32] It is through retinoic acid receptors that retinoids can prevent
 primary tumor progression.[33] CDH1 expression reduction is regarded as one of the main molecular events
involved in dysfunction of the cell-cell adhesion system, triggering cancer invasion and metastasis. Mahler-
Araujo and coworkers[34] reported a correlation between negative or reduced CDH1 expression and lack of ER
expression in tumors from 245 breast cancer patients.
This study was conducted to investigate epigenetic differences in specific tumor-related genes between ER-
positive and ER-negative breast cancers. We hypothesized that ER-positive breast tumors have different
epigenetic profiles of tumor-related genes during early stages of cancer progression. We examined the
methylation status of eight genes suspected of being involved in regulation of breast cancer, and investigated the
methylation status of those genes at different stages of tumor development. We compared the methylation status
of these genes between ER-positive and ER-negative breast tumors in early and advanced stages to investigate
whether epigenetic changes occur in early stages of primary tumor progression.
Human epidermal growth factor receptor (HER)2/neu is an important factor for treatment and prognosis.
HER2/neu over-expression occurs in 15% to 25% of breast tumors and is associated with poor prognosis and
resistance to hormonal therapy.[35-37] HER2/neu and ER expression have been reported to exhibit an inverse
correlation.[9,38,39] Furthermore, previous reports have demonstrated the effect of estrogen on downregulation of
HER2/neu production.[40] We investigated the epigenetic differences between HER2/neu-positive and
HER2/neu-negative breast tumors relative to ER status and further identified the epigenetic characteristics of
ER-negative, HER2/neu-negative (double-negative) breast tumors.

Original Article
Oncogene (2010) 29, 285–296; doi:10.1038/onc.2009.335; published online 26 October 2009

Capsaicin causes cell-cycle arrest and apoptosis in ER-positive and -negative breast cancer
cells by modulating the EGFR/HER-2 pathway
N H Thoennissen1,4, J O'Kelly1,4, D Lu1, G B Iwanski1, D T La1, S Abbassi1, A Leiter1, B Karlan2, R Mehta3 and H P Koeffler1
1
1. Division of Hematology/Oncology, Cedars-Sinai Medical Center, UCLA School of Medicine, Los Angeles, CA, USA
2
2. Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, UCLA School of Medicine, Los Angeles, CA, USA
3
3. Division of Carcinogenesis and Chemoprevention, IIT Research Institute, Chicago, IL, USA
Correspondence: Dr NH Thoennissen, Division of Hematology/Oncology, Cedars-Sinai Medical Center, UCLA School of Medicine, 8700 Beverly Blvd; AC 1069, Los Angeles,
CA 90048, USA. E-mail: Nils.Thoennissen@cshs.org
4
These authors contributed equally to this work.
Capsaicin (trans-8-methyl-N-vanillyl-6-nonenamide) is an ingredient of chili peppers with inhibitory effects against cancer cells of
different origin. We examined the activity of capsaicin on breast cancer cells in vitro and in vivo. The drug potently inhibited growth of
ER-positive (MCF-7, T47D, BT-474) and ER-negative (SKBR-3, MDA-MB231) breast cancer cell lines, which was associated with
G0/G1 cell-cycle arrest, increased levels of apoptosis and reduced protein expression of human epidermal growth factor receptor
(EGFR), HER-2, activated extracellular-regulated kinase (ERK) and cyclin D1. In contrast, cell-cycle regulator p27KIP1, caspase
activity as well as poly-ADP ribose polymerase (PARP) cleavage were increased. Notably, capsaicin blocked breast cancer cell
migration in vitro and decreased by 50% the size of MDA-MB231 breast cancer tumors growing orthotopically in immunodeficient
mice without noticeable drug side effects. in vivo activation of ERK was clearly decreased, as well as expression of HER-2 and cyclin
D1, whereas caspase activity and PARP cleavage products were increased in tumors of drug-treated mice. Besides, capsaicin potently
inhibited the development of pre-neoplastic breast lesions by up to 80% without evidence of toxicity. Our data indicate that capsaicin
is a novel modulator of the EGFR/HER-2 pathway in both ER-positive and -negative breast cancer cells with a potential role in the
treatment and prevention of human breast cancer.

Presurgical Test Predicts Breast Cancer Response to Erlotinib

NEW YORK (Reuters Health) Mar 13 - A short-term presurgical trial of erlotinib (Tarceva) in patients
with stage 1 to IIIA breast cancer may predict which patients will respond to erlotinib treatment after
tumor resection.
In a multicenter study report in the February 20th issue of the Journal of Clinical Oncology,
investigators found that estrogen receptor (ER)-positive cancers responded to this presurgical testing,
but other breast cancers failed to respond to erlotinib, an epidermal growth factor receptor (EGFR)
tyrosine kinase inhibitor.
This strategy of identifying which cancer patients are good candidates for a certain treatment may
speed a drug's approval process, the investigators add.
Dr. Marcia Guix of Vanderbilt University School of Medicine in Nashville, Tennessee, and colleagues
administered erlotinib, 150 mg orally for 6-14 consecutive days until the day before surgery, to 41
patients with stage I-IIIA invasive breast cancer. Erlotinib plasma levels and drug-induced changes in
tumor cell proliferation and apoptosis were assessed in pre- and post-surgical breast tissue.
The researchers found that "5 days of treatment with erlotinib were enough to induce a maximal
inhibition of cell proliferation and induction of apoptosis...The inhibition of proliferation occurred in
ER-positive but not in human epidermal growth factor receptor 2 (HER-2)-positive or triple-negative
cancers."
The primary adverse effects of erlotinib therapy were diarrhea and rash, which were not severe.
Dr. Guix and associates write that "this pre-surgical study supports the feasibility of testing novel
therapies during the pre-approval process to investigate a tumor profile of potential use in subsequent
clinical studies that address drug efficacy."
"We speculate that this approach may expedite the drug development process by potentially informing
the exclusion of non-responsive patients who will dilute the net signal of clinical activity of a drug or a
combination. In the case of erlotinib, these patients would be those with HER-2-positive and the triple-
negative cancers."
In an accompanying editorial, Dr. Tufia C. Haddad and Dr. Douglas Yee of the University of Minnesota
Cancer Center in Minneapolis note that one of the main strengths of this study is that it used patients --
not mice -- to test tumor response to a new drug.
"The idea that EGFR inhibitors should be tested in triple-negative breast cancer is supported by the
preclinical data, but not by this study," the editorialists comment. "The mice helped, but plans went
awry, and they could not substitute for a well-designed clinical trial."
The investigators enrolled "all-comers," Drs. Haddad and Yee note. "By not pre-selecting patients, they
provided important data necessary to design the next generation of erlotinib studies. Moreover, they
showed how a small neoadjuvant study with built-in tissue acquisition could provide strategies to
optimize erlotinib use in breast cancer."
J Clin Oncol 2008;26:830-832, 897-906.

Small Tumors Are Aggressive in HER2-Positive Breast Cancer

NEW YORK (Reuters Health) Dec 17 - Breast cancer tumors only a centimeter in diameter or less, without
node involvement, can still be aggressive and carry a poor prognosis in a subset of patients, a team comprised of
researchers from all three Mayo Clinics reported at the San Antonio Breast Cancer Symposium.
The team, led by Dr. Surabhi Amar of the Mayo Clinic in Jacksonville, Florida, identified 401 cases of breast
cancers less than 1 cm in diameter.
Of these, 350 were HER2-negative and hormone-receptor positive, with the patients' mean age being 67 years.
There were 27 tumors (6.7%) that were HER2-positive, and 24 cases (5.9%) of triple negative breast cancers
(i.e., negative for HER2 and for estrogen and progesterone receptors).
Histology findings were similar in the three groups, with ductal carcinoma the most common diagnosis. Grade
II and grade III disease were more common in women with HER2-positive breast cancer and those with triple
negative disease.
Adjuvant chemotherapy usage was 3.9% with hormone receptor-positive, HER2-negative disease, 28% with
HER2-positive disease, and 34.8% with triple negative disease.
Relapse rates were 12.5% with triple-negative disease, 7.4% with HER2-positive tumors, and 1.3% with HER2-
negative, hormone receptor-positive disease.
"The higher relapse rates in spite of more frequent use of adjuvant chemotherapy suggest that optimization of
adjuvant chemotherapy will be particularly important for these patients," Dr. Amar told Reuters Health.
"The important point to note is that most women will often not get repeat treatment after the initial round...But
even the smaller tumors can relapse," the researcher commented.

HER2-Positive Breast Cancer : Current and Future Treatment Strategies.

Engel RH, Kaklamani VG. Division of Hematology/Oncology, Northwestern University Feinberg School of
Medicine and the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois,
USA. Drugs. 2007;67(9):1329-41.
In the year 2006, breast cancer was estimated to affect >200 000 American women and cause nearly 56 000
deaths. Furthermore, breast cancer is the most common cancer diagnosed and second most common cause of
cancer-related deaths in women. The current treatment armamentarium for breast cancer includes chemotherapy,
endocrine therapy and biological therapy. Treatment has become more individualised based on characteristics of
the tumour including overexpression of the human epidermal growth factor receptor (HER)-2. Between 20 and
30% of all breast cancers overexpress HER2, which means 40 000-60 000 patients will have this type of
cancer.Previously, overexpression of HER2 was a negative prognostic and predictive risk factor for survival;
however, with the advent of trastuzumab, patients' prognosis is improving in all treatment settings. Much
controversy exists in the use of trastuzumab, including (i) the sequence of adjuvant trastuzumab (concurrent
with chemotherapy or sequential); (ii) the treatment duration (<1 year, 1 year or 2 years); and (iii) the treatment
choice upon disease progression (whether to continue or not with trastuzumab and add another cytotoxic agent).
Current trials are ongoing to help answer these questions.Furthermore, there has been interest in predicting
which HER2-positive patients would require anthracycline therapy, and which could avoid anthracycline
therapy and its toxicities. Novel therapeutics, such as lapatinib, an oral tyrosine kinase inhibitor, which blocks
both the epidermal growth factor receptor and HER2 receptor has recently been approved by the US FDA.
Whereas pertuzumab, a humanised monoclonal antibody, directed against heterodimerisation of HER2 and
HER3 has entered phase II and III clinical trials.

Breast Cancer Subtype Approximated by Estrogen Receptor, Progesterone Receptor, and

HER-2 Is Associated With Local and Distant Recurrence After Breast-Conserving Therapy.
Nguyen PL, Taghian AG, Katz MS, Niemierko A, Abi Raad RF, Boon WL, Bellon JR, Wong JS, Smith BL, Harris JR. Harvard
Radiation Oncology Program, Departments of Radiation Oncology and Surgery, Massachusetts General Hospital, Department of
Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, and Harvard Medical School, Boston, MA. J Clin
Oncol. 2008 Apr 14
PURPOSE: To determine whether breast cancer subtype is associated with outcome after breast-conserving
therapy (BCT) consisting of lumpectomy and radiation therapy. PATIENTS AND METHODS: We studied 793
consecutive patients with invasive breast cancer who received BCT from July 1998 to December 2001. Among
them, 97% had pathologically negative margins of resection, and 90% received adjuvant systemic therapy. No
patient received adjuvant trastuzumab. Receptor status was used to approximate subtype: estrogen receptor (ER)
or progesterone receptor (PR) positive and human epidermal growth factor receptor 2 negative = luminal A;
ER+ or PR+ and HER-2+ = luminal B; ER- and PR - and HER-2+ = HER-2; and ER- and PR - and HER-2- =
basal. Competing risks methodology was used to analyze time to local recurrence and distant metastases.
RESULTS: Median follow-up was 70 months. The overall 5-year cumulative incidence of local recurrence was
1.8% (95% CI, 1.0 to 3.1); 0.8% (0.3, 2.2) for luminal A, 1.5% (0.2, 10) for luminal B, 8.4% (2.2, 30) for HER-
2, and 7.1% (3.0, 16) for basal. On multivariable analysis (MVA) with luminal A as baseline, HER-2 (adjusted
hazard ratio [AHR] = 9.2; 95% CI, 1.6 to 51; P = .012) and basal (AHR = 7.1; 95% CI, 1.6 to 31; P = .009)
subtypes were associated with increased local recurrence. On MVA, luminal B (AHR = 2.9; 95% CI, 1.3 to 6.5;
P = .007) and basal (AHR = 2.3; 95% CI, 1.1 to 5.2; P = .035) were associated with increased distant
metastases. CONCLUSION: Overall, the 5-year local recurrence rate after BCT was low, but varied by subtype
as approximated using ER, PR, and HER-2 status. Local recurrence was particularly low for the luminal A
subtype, but was less than 10% at 5 years for all subtypes. Although further follow-up is needed, these results
may be useful in counseling patients about their anticipated outcome after BCT.
Vaccine Reduces Rates of Recurrence and Mortality in Women With HER2/Neu-Positive
Breast Cancer: Presented at AACR
SAN DIEGO -- April 14, 2008 -- A preventive HER2/neu peptide (E75) vaccine is showing great promise in the
prevention of breast cancer recurrence and reducing mortality when recurrences do occur in women with
HER2/neu-positive breast cancer, researchers reported here at the American Association for Cancer Research
(AACR) Annual Meeting 2008.
Breast cancer patients who received the E75 vaccine experienced a boost in their immunity, with a rise in T-
lymphocytes, and this translated into decreased breast cancer recurrence and a 50% reduction in mortality at 30
months, said Linda C. Benavides, MD, Resident in General Surgery, Brooke Army Medical Center, San
Antonio, Texas.
In particular, women with low-expressing HER2/neu tumours who were vaccinated had better immunological
and clinical responses, with decreased breast cancer recurrence and zero mortality. This result "surprised,
delighted, and excited" the researchers, Dr. Benavides said on April 14.
"The fact that HER2 low-expressors responded so favourably not only underscores the difference in mechanism
between the vaccine versus antibody therapy like trastuzumab, but it also offers the hope of additional adjuvant
therapy to the largest subset of breast cancer patients if proven in the upcoming phase 3 trial," she said in a press
briefing.
HER2/neu is a source of immunogenic peptides and is overexpressed in 30% of patients with early-stage breast
cancer. Dr. Benavides and her colleagues tested the vaccine, a 9-amino-acid protein, to determine its efficacy in
boosting immunity and in reducing recurrence and mortality rates in 163 node-negative and node-positive
patients demonstrating all levels of HER2/neu expression.
Of the 94 women that received the vaccine, 30 women were HER2/neu overexpressors and 64 were low-
expressors. HER2/neu overexpressors were determined to express more than 2.0 HER2/neu tumours on
fluorescent in situ hybridisation (FISH) and more than 3 HER2/neu tumours on immunohistochemistry (IHC).
HER2/neu low-expressors included patients with IHC results showing no tumours to 2 HER2/neu-positive
tumours.
The remaining 71 patients served as unvaccinated controls. Of these, 22 were overexpressors of HER2/neu and
49 were low-expressors.
The women were vaccinated once a month over 6 months, and were given boosters every 6 months.
All patients showed an immunological response to the vaccine, as measured by delayed-type hypersensitivity
reactions. However, vaccinated overexpressor patients showed a decreased number of E75-specific CD8+ T
cells compared with their low-expressor counterparts.
At a median follow-up of 30 months, disease recurrence rates were similar between vaccinated and
nonvaccinated overexpressors (18% and 14%, respectively; P = .7). However, mortality rates were better in the
vaccinated overexpressors than nonvaccinated overexpressors (25% vs 50%, P=NS), Dr. Benavides said.
Importantly, recurrence of breast cancer was substantially lower among the vaccinated patients with low
HER2/neu expression, who experienced an 11% recurrence rate compared with 18% for controls.
The mortality rate among low-expressors with recurrent disease was 0% among vaccinated patients versus 38%
among the control group (P = .08).
Dr. Benavides said that these findings are very encouraging for the more than 50% of breast cancer patients
whose tumours fall into the HER2/neu low-expressing category and who are not eligible for trastuzumab
treatment.
"It would be wonderful to be able to offer these patients adjuvant treatment, which is something they have not
had previously."

HER-2/neu Not Linked to Breast Cancer Indicators in Black Women

NEW YORK (Reuters Health) Dec 07 - NER-2/neu status is not associated with breast cancer prognostic factors in African American
women, unlike in Caucasian women, according to a report in the November 15th issue of Cancer.
"Our findings came as a surprise to the members of the research team," Dr. Azadeh T. Stark from Henry Ford Health System, Detroit,
Michigan told Reuters Health. "Therefore, we re-evaluated and re-analyzed our data several times to further confirm our findings."
Dr. Stark and colleagues investigated the prevalence of positive HER-2/neu breast carcinoma in a group of African-American and
Caucasian women diagnosed with invasive breast cancer and evaluated race-specific risk for positive HER-2/neu breast carcinoma in
light of the pathologic prognostic indicators used in clinical settings.
African-American women were diagnosed with advanced stages of carcinoma almost twice as often as Caucasian women were, the
authors report, and more African-American women were diagnosed with poorly differentiated nuclear grade.
Slightly more African-American women (32%) than Caucasian women (29%) were diagnosed with HER-2/neu-positive breast
carcinomas, the results indicate, but the difference was not statistically significant.
Among African-American women, neither age nor pathologic prognostic indicators were significant predictors for positive HER-2/neu
status, the researchers note. For Caucasian women, on the other hand, these variables were significantly associated with positive HER-
2/neu status.
Unlike for Caucasian women, the report indicates, the risk for positive HER-2/neu status was not significantly associated with TNM
stage, nuclear grade, or their interaction or other pathologic prognostic indicators in African-American women.
Thus the investigators conclude that "pathologic predictive indicators for HER-2/neu gene amplification and/or overexpression of its
protein may differ for African-American women."
The finding, Dr. Stark added may be "the beginning of a new era for breast cancer diagnosis and potentially, treatment for African-
American women."
Cancer 2005;104:2189-2196.

Clinical Considerations in Adjuvant Treatment of HER2-Positive Breast Cancer

Edward H. Romond, MD
Medscape Hematology-Oncology. 2006;9(2)
Introduction
Amplification of the HER2 gene and the associated overexpression of the HER2 protein have long been associated with an adverse
prognosis in breast cancer.[1] The clinical efficacy of the HER2-targeted monoclonal antibody trastuzumab in combination with
chemotherapy for treatment of HER2-positive metastatic breast cancer prompted the initiation of 4 large adjuvant trials with
complementary designs.
On the basis of positive results from these large clinical trials, use of trastuzumab in adjuvant treatment of patients with HER2-positive
breast cancer is becoming a standard of care. Although certain basic efficacy and safety questions have been addressed in these trials,
it is now necessary to examine several other key clinical issues. To optimize care and outcomes, for instance, clinicians should ensure
accurate HER2 testing and understand what is appropriate treatment for node-negative patients, as well as for patients with marginal
cardiac function. Additionally, practitioners are faced with decisions about the choice and timing of hormonal agents, as well as the
optimal duration of antibody treatment. These considerations will be discussed following a brief summary of efficacy and safety data.
Adjuvant Trastuzumab Trials: Efficacy Data
Initial results of 4 trials involving over 13,000 patients were all reported in 2005. The joint analysis of the North American trials, the
National Surgical Adjuvant Breast and Bowel Project (NSABP) B31 and North Central Cancer Treatment Group (NCCTG) N9831, [2]
showed a 52% relative reduction in disease-free survival (DFS) events when trastuzumab was started concurrently with a 3-month
course of paclitaxel following 4 cycles of standard doxorubicin/cyclophosphamide (AC) chemotherapy compared with the same
chemotherapy regimen minus trastuzumab. This translated to a 12% absolute improvement in DFS at 3 years in the group receiving
trastuzumab, with 87% of patients alive and free of cancer in the overall joint analysis, as well as in each of the trials when analyzed
separately (Figure).[2] In both trials, trastuzumab was given weekly for 1 year.
The Breast Cancer International Research Group (BCIRG) 006 trial[3] evaluated 1 year of trastuzumab starting concurrently with 3
months of docetaxel (T*) following 4 cycles of AC compared with the same chemotherapy without trastuzumab. These investigators
found a 51% relative risk reduction in DFS events at 3 years when trastuzumab was used, with 86% of patients alive and free of
cancer. A third arm of the protocol used a nonanthracycline regimen of 6 cycles of T* and carboplatin starting concurrently with a year
of trastuzumab (T*C*H) and yielded a 39% relative risk reduction in DFS events at 3 years compared with control, with 80% of
patients alive and free of cancer.
Finally, the Herceptin Adjuvant (HERA) trial[4,5] randomized patients with HER2-positive breast cancer to observation or either 1 or 2
years of trastuzumab following completion of all adjuvant chemotherapy ± radiation. The results of 1 year of trastuzumab vs control,
updated at the 2006 American Society of Clinical Oncology (ASCO) meeting,[5] showed a 36% reduction in DFS events at 3 years
from randomization, with 81% of patients who received trastuzumab alive and free of cancer. In all 4 trials, the relative benefit of
adding trastuzumab to chemotherapy was similar across all subgroups regardless of age, hormone receptor status, tumor size, or
number of positive nodes.
Adjuvant Trastuzumab Trials: Cardiac Safety
Because of the recognized cardiotoxicity associated with the combination of trastuzumab and chemotherapy, patients with significant
cardiac risk factors were excluded from the trials. In addition, 6.8% of patients in B31 and 3.9% of patients in N9831 randomized to
trastuzumab did not ultimately receive trastuzumab because of drops in left ventricular ejection fraction (LVEF) during AC
chemotherapy. It is important to note that these patients are included in the intent-to-treat efficacy analysis summarized above,
showing 87% DFS in the treatment arms.
By contrast, in the HERA trial, all patients enrolled and randomized to trastuzumab had a post-treatment LVEF of at least 55% and,
therefore, all received trastuzumab. The 4-year follow-up of cardiotoxicity on B31[6] shows that 3.9% (34 patients) in the AC →
paclitaxel/trastuzumab arm vs 0.8% (6 patients) in the control arm experienced a cardiac event defined as New York Heart Association
(NYHA) Class III or IV congestive heart failure (CHF), a difference of 3.1%. In N9831 at 3 years follow-up,[7] 3.5% (20 patients) in
the concurrent trastuzumab arm, and 0.3% (2 patients) in the control arm have experienced a cardiac event, a difference of 3.2%. In
the HERA trial,[5] only 0.6% (10 patients) receiving trastuzumab have experienced Class III or IV CHF (although if Class II is
included, this rises to 2.1%). In BCIRG 006,[3] 1.7% (17 patients) developed Class III or IV CHF when treated with AC →
T*/trastuzumab compared with 0.4% (4 patients) in the T*C*/trastuzumab arm and 0.3% (3 patients) in the control arm. The 4-year
follow-up of cardiotoxicity on B31[6] reported encouraging results regarding recovery of cardiac function following cessation of
trastuzumab therapy. Of 32 patients who experienced cardiac events and have been followed at least 6 months after diagnosis of CHF,
only 4 continue to experience cardiac symptoms and most have recovered a normal LVEF (although 19 continue to require cardiac
medications).
Refining Clinical Use of Trastuzumab in the Adjuvant Setting
On the basis of these efficacy and safety results, practitioners will now need to refine clinical use of trastuzumab in the adjuvant
setting, which means addressing several important issues, such as HER2 testing; treatment of node-negative patients; management of
patients with marginal cardiac function; choice and timing of hormonal therapy; and duration of trastuzumab treatment.
The Importance of Accurate HER2 Testing
Given the remarkable potential benefit of trastuzumab in the adjuvant setting, it is critical that false-negative assays be avoided as
much as possible. Similarly, because of the potential toxicity and cost of trastuzumab, it is equally important to avoid false-positive
results, which may expose patients to an intervention that would be unlikely to provide benefit and may possibly cause harm. It is
clear from quality-control studies conducted during the initial phase of both B31 and N9831 that immunohistochemical (IHC) and
fluorescent in situ hybridization (FISH) assays need to be carried out in highly experienced laboratories with detailed internal quality-
control procedures.[8,9] In B31, for example, central retesting of samples submitted as 3+ by IHC assay for the first 104 patients
enrolled showed a discordance of 24% by both IHC and FISH when the original testing was carried out in small-volume, less
experienced laboratories, whereas the reproducibility was 96% for assays originally done by large-volume, more experienced
laboratories. Following a protocol amendment requiring testing by IHC in an approved laboratory or by FISH, the reproducibility was
very high for the next 240 samples whether tested by IHC or by FISH.[10] It is important to recognize as well that assays performed by
FISH in less experienced laboratories are also fraught with an unacceptably high rate of nonreproducibility. The National
Comprehensive Care Network (NCCN) task force on HER2 testing recommends that all breast cancers be tested using IHC or FISH
by a highly competent laboratory and that tumors scored 2+ by IHC be further evaluated for gene amplification. It is likely that in the
near future, specific criteria for quality control in laboratories will be defined by the American College of Pathology in collaboration
with ASCO and NCCN. There are relatively few examples in pathology where a single observation leads to such an important
treatment decision.
Treatment of HER2-Positive, Node-Negative Patients
The joint analysis of the North American trials N9831 and B31 did not include sufficient node-negative patients to assess the benefit
of adding trastuzumab to chemotherapy in this cohort. By contrast, approximately one third of the patients enrolled in HERA and
BCIRG 006 had cancers that did not involve axillary nodes. In these studies, the relative DFS risk reductions shown on Forest plots
were similar for patients with node-negative and node-positive cancers. It is not surprising that patients with HER2-positive breast
cancers benefit from treatment with trastuzumab to the same relative degree, regardless of nodal status. The degree of absolute benefit
in node-negative disease, however, is not yet clearly defined, and this must be considered in light of potential short- and long-term
toxicities of treatment. It is important to remember that, despite encouraging early follow-up of patients experiencing cardiac
dysfunction, long-term data regarding this issue in the adjuvant setting are lacking. It is noteworthy that the Kaplan-Meier curves
(Figure) published in the online supplement of the joint B31/N9831 analysis show that the traditional clinical prognostic and
predictive markers of tumor size, hormone-receptor status, and degree of nodal involvement remain in place in the setting of HER2-
positive disease. In other words, although the relative risk reduction with the addition of trastuzumab may be approximately half, DFS
with hormone receptor-positive disease is better than with receptor-negative disease, with smaller cancers than with larger tumors, and
with fewer positive nodes than with more nodes. Thus, the smaller the tumor and the fewer the number of positive nodes, the smaller
the absolute incremental benefit of adding trastuzumab, especially in the setting of positive hormone receptors. If we assume that
HER2 biology is essentially the same in node-negative as in node-positive disease, then it is likely that patients with "small,"
especially hormone receptor-positive, node-negative cancers, may derive little absolute incremental benefit from the addition of
trastuzumab to chemotherapy ± hormone therapy. Where the line is drawn to define "small," however, is open to discussion in the
absence of definitive data and likely also will vary depending on different comorbidities from patient to patient. Over time, analysis of
outcomes for patients with smaller, node-negative cancers in the HERA and BCIRG 006 trials may provide the clearest risk/benefit
information regarding this question.
Patients With Marginal Cardiac Function
The evaluation of cardiac dysfunction in B31[6] identified 4 factors associated with a significantly higher risk of CHF: age, receiving
antihypertensive medications, a pretreatment baseline LVEF of 50%-54% (low normal), and a post-AC LVEF of 50%-54% by multi-
gated acquisition [MUGA] scan. What considerations apply then to the patient with a baseline LVEF below normal with mild global
hypokinesis on echocardiogram? For such a patient, the first question is whether to use anthracycline-based adjuvant chemotherapy.
Cardiac function in such patients may be considerably more vulnerable to significant drops in LVEF with4 cycles of AC, and some
patients will experience decrements large enough to preclude the advisability of giving subsequent trastuzumab, either alone or with a
taxane. Unfortunately for these patients, once a significant loss of cardiac function has occurred, the anthracycline cannot be taken
back. Given the fact that BCIRG 006 shows a 39% improvement in DFS at 3 years with T*C*/trastuzumab over anthracycline plus
taxane chemotherapy alone and with very little cardiac toxicity, my assessment is that over time, more patients with measurable mild
cardiac dysfunction will be served favorably by T*C*/trastuzumab rather than starting with anthracycline-based regimens. In these
patients, therefore, my preference is to give the non-anthracycline regimen because of the higher probability of being able to deliver a
full course of trastuzumab. It is prudent, moreover, that such patients be managed in collaboration with a cardiologist.
Choice and Timing of Hormonal Agents
In all of the large adjuvant trials, hormonal therapy was started concurrently with trastuzumab and during the early part of B31,
tamoxifen was started at the beginning of chemotherapy. With this schedule of hormonal therapy, DFS at 3 years in the trastuzumab-
treated group of the joint analysis is 87% and distant DFS is 90%. There are no data to suggest that delaying hormonal therapy until
after completion of trastuzumab would provide better outcomes. Also, although retrospective analyses of several clinical trials present
conflicting results regarding whether HER2 overexpression confers a degree of resistance to tamoxifen, we should not discount the
possibility suggested by laboratory models that blockade of the HER2 pathway may improve the sensitivity of HER2-positive breast
cancer to tamoxifen and that, therefore, the robust results seen in the adjuvant trials may in part be due to the concurrent
administration of trastuzumab and tamoxifen. Because of a lack of data to the contrary and the highly effective results seen in the
trials, I recommend that hormonal therapy for estrogen receptor-positive patients be initiated as in the trials, that is, after completion of
chemotherapy while trastuzumab is still being given.
What is strikingly consistent across all of the large adjuvant trials is that half of the patients are postmenopausal (median age 49 in all
4 trials) and half of the tumors are ER-positive, so that it would be appropriate to consider an aromatase inhibitor (AI) in about 25% of
the HER2-positive population. In all the adjuvant trials, the large majority of the hormone receptor-positive patients received
tamoxifen. Although the large AI trials all show a general superiority of the AIs over tamoxifen and although there is ongoing
discussion of the possibility that HER2 positivity may impair the blockade of the ER pathway by SERMs, it is an open question as to
whether these considerations hold true once the HER2 pathway is blocked by trastuzumab. Theoretically, one could argue for giving
tamoxifen during trastuzumab and switching to an AI afterwards, Mathematically, however, it is unlikely that this question could ever
be addressed in a clinical trial because of the small number of patients who are postmenopausal and have HER2-positive and ER-
positive disease (less than 5% of patients with invasive breast cancer), as well as because of the low event rate regardless of whether
patients receive tamoxifen or an AI following chemotherapy and trastuzumab. In the end, therefore, it is not possible to be dogmatic
about this question from an efficacy standpoint. Safety and side effect considerations are probably the appropriate grounds for choice
of a hormonal agent.
Duration of Trastuzumab Therapy
How long should trastuzumab be given? All the reported results of the large adjuvant trials involve administration of trastuzumab for 1
year. When the trials were designed, the efficacy of adding trastuzumab to adjuvant chemotherapy was obviously unknown and so it
was decided to give the antibody long enough not to miss the possibility of a significant benefit. The HERA trial is designed to
determine whether even longer administration of trastuzumab (2 years) may provide greater benefit. On the other hand, a small subset
of a Scandinavian trial (known as FinHer)[11] comparing two adjuvant chemotherapy regimens evaluated the addition of trastuzumab to
either of the chemotherapy arms in the 232 patients who had HER2-positive disease. [1] In this subset, half (116) of the HER2-positive
patients were given trastuzumab for just 9 weeks. Results showed a significant improvement in DFS for those who received the
antibody. While these results are obviously provocative, their applicability to clinical practice is limited by the small number of
patients who received trastuzumab. It is important to remember that P values do not reflect the magnitude of benefit but only the
likelihood that a difference is not due to chance. The magnitude of benefit is defined by the confidence interval. Because of the few
HER2-positive patients treated in the FinHer trial, the confidence interval indicates that adding the 9-week course of trastuzumab is
likely to provide a relative risk reduction in DFS events of at least 17% compared with chemotherapy alone. By contrast, the joint
analysis of B31/N9831, which included 3351 patients, rules out a risk reduction of anything less than 39% with the addition of
trastuzumab compared with AC → paclitaxel alone. Thus, the FinHer trial shows that even a short course of trastuzumab provides
some benefit but does not show that the benefit is comparable to a year of trastuzumab. At present, therefore, if a patient is to receive
adjuvant trastuzumab, it is in the patient's best interest to continue trastuzumab for a year as long as she maintains adequate cardiac
function. Larger trials are being launched to compare 1 year of trastuzumab with shorter durations to determine whether comparable
benefit can be achieved. Until these results are available, 1 year of trastuzumab should remain the standard of care.

Trastuzumab Effective in Some Breast Tumors With Undetectable HER-2

NEW YORK (Reuters Health) Sept 04 - Trastuzumab (Herceptin) plus cisplatin is effective against breast cancer cells with low or
undetectable HER-2 expression but with overexpression of the growth factor heregulin (HRG).
In a study conducted at Northwestern University in Chicago, Illinois, researchers report that activation of HER-2 by HRG in breast
cancers with low or undetectable HER-2 expression makes these tumors more resistant to cisplatin.
As reported in the August 10th Journal of Clinical Oncology, Dr. Ruth Lupu and colleagues engineered breast cancer cells with low
HER-2 to overexpress HRG, which made them "10-fold more resistant to the alkylating agent cisplatin." The researchers found that
co-exposure to trastuzumab completely reversed HRG-promoted resistance to chemo.
Trastuzumab is known to act synergistically with cisplatin and other agents such as docetaxel, paclitaxel and vinorelbine against HER-
2-positive breast cancers. The team concludes this therapeutic approach can also be "extremely efficient without HER-2
overexpression."
Dr. Lupu told Reuters Health that "this is a completely new avenue of use of Herceptin in metastatic breast cancer."
Assessment of HRG expression could identify a breast cancer population with HER-2-negative tumors that might benefit from
trastuzumab. "This approach makes about 30% more cases of breast cancer benefit from these chemotherapy agents," Dr. Lupu said.
J Clin Oncol 2006;24:3735-3746.

Clinical Tool Helps Quantify Benefit of Adjuvant Trastuzumab

September 15, 2006 –- A new model may help doctors estimate the trade-offs between efficacy and cardiac toxicity of trastuzumab
(Herceptin, Roche) in HER2-positive breast cancer. The tool, presented at the recent 42nd annual meeting of the American Society of
Clinical Oncology, is designed to help clinicians quantify benefit and predict long-term survival.
"The addition of trastuzumab in HER2-positive cancer is more effective than standard chemotherapy alone in most cases, including
elderly patients with node-negative disease and those with increased risk of cardiac toxicity," lead author Amit Gupta, MD, from the
University of Cincinnati, in Ohio, said at the presentation. "However, the incremental benefit decreases with advancing age and higher
risk of cardiac toxicity and in patients with lower risk of recurrence."
During their poster presentation, the researchers reported that 20% to 30% of all breast cancers are HER2 positive, a diagnosis
frequently linked to poor prognosis. Early results from 3 large randomized trials have shown that adjuvant trastuzumab, a monoclonal
antibody that targets the HER2 receptor, results in significant reduction in recurrence rates in high-risk HER2-positive breast cancer
patients. But the product has also been associated with significant cardiac toxicity, including congestive heart failure.
"We evaluated these trade-offs through a Markov state transition decision analytic model to simulate the survival benefits in a variety
of subpopulations of HER2-positive cancer patients," Dr. Gupta explained. "Outcomes were expressed in quality-adjusted life-years
and 10-year survival rates. We explored a number of prototypic scenarios that varied in age, risk of cancer recurrence, and cardiac
toxicity rates."
The investigators' base case was a 50-year-old patient with a 2-cm tumor, node positive, and estrogen or progesterone receptor
negative, with a 6% cumulative risk of cardiac toxicity. They conducted 1-way sensitivity analyses for trastuzumab on the base case
across a wide range of ages from 50 to 80. The researchers found that for efficacy, the hazard ratio was 0.48 to 0.95. For annual cancer
recurrence, the risk was 0.5% to 5%, and the risk for cardiac toxicity was 4% to 60%.
The addition of trastuzumab in HER2-positive cancer is more effective than standard chemotherapy alone in most patients, the
researchers report, but this benefit decreases with advancing age and higher risk of cardiac toxicity and in patients with lower risk of
recurrence.
"This model is a useful clinical tool to quantify risks and benefits of adjuvant trastuzumab and in predicting long-term survival in
different subpopulations of HER2-positive breast cancer patients," they conclude.
ASCO 42nd Annual Meeting: Abstract 6022. Presented June 6, 2006.

Update on the Adjuvant Treatment of HER-2-Positive Early-Stage Breast Cancer: An Expert

Interview With Dr. Eric P. Winer Medscape Hematology-Oncology. 2006;9(2)
Editor's Note:
Approximately 15% to 20% of all newly diagnosed invasive breast cancers are found to have gene amplification or receptor
overexpression of the human epidermal growth factor receptor (HER)-2. This subset of breast tumors, defined by HER-2 positivity, is
characterized by unique biological and clinical features. Trastuzumab, a humanized monoclonal antibody that targets the HER-2 gene
product, has a well-established role in the treatment of women with metastatic breast cancer. Given the success of trastuzumab in
metastatic disease, several large, randomized trials were initiated to evaluate the role of trastuzumab in early-stage breast cancer.
Since the release of data from the adjuvant trastuzumab trials – the combined NSABP B-31/NCCTG 9831 and HERA trials at the
American Society of Clinical Oncology (ASCO) meeting in May 2005 and BCIRG 006 at the San Antonio Breast Cancer Symposium
in December 2005 – the management algorithm for patients with HER-2-positive breast cancer has evolved. [1-3] All 3 analyses
demonstrated robust improvements in disease-free survival from the addition of either concurrent or sequential trastuzumab to
standard cytotoxic chemotherapy. Since May 2005, adjuvant trastuzumab has become an accepted and standard component of
adjuvant management for patients with HER-2-positive breast cancer. Many questions remain, however, and these are being
addressed by ongoing clinical trials.
At ASCO 2006, several abstracts provided new information on the adjuvant treatment of women with HER-2-positive disease. On
behalf of Medscape, Erica L. Mayer, MD, an Instructor in Medicine at Harvard Medical School and a Member of the Breast Oncology
Center at Dana-Farber Cancer Institute, Boston, Massachusetts, discussed updates from the 2006 meeting with Eric P. Winer, MD,
Associate Professor of Medicine at Harvard Medical School and the Director of the Breast Oncology Center at Dana-Farber Cancer
Institute. Dr. Winer is a leader in the field of breast medical oncology. He is also Co-Chairman of the Cancer and Leukemia Group B
(CALGB) breast cancer committee.
Medscape: In the past 12 months, we've seen clinicians become comfortable with the administration of adjuvant trastuzumab.
What do you think is the appropriate duration of adjuvant treatment with trastuzumab? Do you think that we should be
giving more or less treatment than the current 1-year, which was described in the adjuvant studies?
Dr. Winer: I don't think that we should be giving either more or less. On the basis of what we know from the 4 large, randomized
trials, all of which have shown benefits for trastuzumab with a 1-year duration of therapy, I think that outside of a clinical trial, we
should continue giving 1 year of adjuvant trastuzumab therapy. The recently published FinHER study[4] did demonstrate benefits with
a much shorter duration of therapy. However, this was a small study and without further confirmatory data; I would not offer that
approach.
Medscape: Although the criteria for use of adjuvant trastuzumab in high-risk HER-2-positive diseases are well defined, many
clinicians struggle with whether to give trastuzumab to lower risk patients, such as those with small hormone receptor-positive
tumors who may not require cytotoxic chemotherapy. What has been your approach to such patients, and how can we develop
"softer and safer regimens," as described by Dr. Martine Piccart at ASCO 2006?
Dr. Winer: This is a difficult issue, and I think that it's one with which many clinicians have struggled. It's unclear what to do for
patients who have relatively low-risk disease, such as subcentimeter node-negative tumors with either positive or negative hormone
receptors, or hormone receptor-positive node-negative tumors of 2 cm or less. The NSABP, Intergroup, and HERA trials did not
include any patients with tumors less than 1 cm, and the Intergroup trial only included patients with estrogen receptor-positive, node-
negative tumors if they were greater than 2 cm. The NSABP study included node-positive patients only. The concern with regard to
trastuzumab treatment is that rare, but serious side effects, such as cardiotoxicity, can be associated with it. Generally speaking, I have
been cautious about giving trastuzumab to this low-risk group, and I think that it requires an in-depth discussion with the patient. I
won't say that I absolutely haven't done it, but by no means do I believe that it's the standard of care at the moment. These are the
clinical settings for which we need data on kinder and gentler regimens, such trastuzumab monotherapy, trastuzumab in combination
with hormonal therapy, or trastuzumab in combination with single-agent non-anthracycline-based therapy, such as single-agent
paclitaxel. There is, of course, the non-anthracycline-containing regimen evaluated in BCIRG 006.[3] Although the docetaxel,
carboplatin, trastuzumab (TCH) regimen represents an alternative to anthracycline-containing regimens, TCH is also associated with
fairly significant toxicity and is not a regimen that I would tend to suggest for a low-risk patient population.
Medscape: There continues to be debate in regard to the superiority of either concurrent chemotherapy and trastuzumab, as
in NSABP B31 and Arm C of N9831, or sequential treatment, as in HERA and Arm B of N9831. Which method do you think is
preferable, and will data emerge to clarify this debate?
Dr. Winer: I don't think that we have a final answer to this question at the moment, and it may depend on the setting in which
trastuzumab is given and the specific type of chemotherapy with which it is given. I don't think that there's any question that the use of
sequential trastuzumab was beneficial within the context of the HERA study, and the benefits seen in HERA in terms of risk reduction
were equivalent to those seen in the other trials. Data from N9831 suggested that concurrent paclitaxel with trastuzumab is superior to
sequential treatment. It's important to note that the comparison was somewhat underpowered, and the difference between concurrent
and sequential therapy did not meet prespecified criteria for early stopping or reporting. It is possible that this is a chemotherapy-
specific effect, and when giving adjuvant doxorubicin, cyclophosphamide, and paclitaxel, trastuzumab must be given concurrently to
achieve substantial added benefit. I think that we're just going to have to continue to follow these studies and see what leads they
provide us in the years ahead. At present, however, if one is going to give a taxane, it is prudent to administer it concurrently with
trastuzumab.
Medscape: Can trastuzumab be given safely in the preoperative setting, and what are acceptable approaches to preoperative
management of HER-2-positive breast cancer?
Dr. Winer: Trastuzumab can safely be given in the preoperative setting, and there have been multiple single-arm, phase 2 trials and 1
small, randomized trial demonstrating the safety and efficacy of preoperative trastuzumab. [5-7] In my own view, outside of a clinical
trial, the only compelling reason to give preoperative trastuzumab is if a woman has a relatively large tumor and desires conversion
from mastectomy to breast-conserving surgery, or for locally advanced HER-2-positive disease. In these settings, I would use one of
the regimens that have demonstrated benefit in the adjuvant setting, or perhaps one of the preoperative regimens that has been
described in the context of phase 2 clinical trials.
Medscape: What is the best method to determine HER-2 positivity? Do you think that all tumor samples should undergo FISH
[Fluorescence In Situ Hybridization] testing?
Dr. Winer: This has been a hotly debated subject that is part of a bigger question: How can we improve our testing not only for HER-
2, but also for estrogen and progesterone receptors? Clearly, when many of our most important treatment decisions are based on these
tests, it's absolutely critical that the tests be as accurate as possible. For a patient with less than a 3+ result by IHC
[immunohistochemistry], FISH should be performed before one considers giving trastuzumab. I personally don't believe that a FISH
test is mandatory in patients with 3+ IHC scores from a reputable laboratory. FISH should be performed, however, if the clinician has
any reason to question the result of the IHC test. Ultimately, not everyone trusts the lab that they use, and if you don't trust your lab,
then you either need to find a different lab or rely on FISH, which tends to be performed in a central lab.
Medscape: Several abstracts at ASCO 2006 reported on the cardiotoxicity of adjuvant trastuzumab, including data from
NSABP B31 demonstrating that approximately 1 in 5 women are unable to complete 1 year of adjuvant trastuzumab due to
cardiotoxicity.[8] Can we predict who will experience cardiotoxicity? What about the safety of trastuzumab given with dose-
dense chemotherapy?
Dr. Winer: Cardiotoxicity is the most concerning adverse effect with trastuzumab therapy, and can limit the patient's ability to
complete a full year of trastuzumab. At this point, we have a hard time forecasting which patients will experience cardiotoxicity, and
there is debate about the validity of clinical predictors. In the NSABP analysis, older patients and those with a borderline ejection
fraction (EF) at baseline were more likely to develop cardiotoxicity. The age relationship has been observed in other studies as well,
although the data concerning baseline EF are somewhat more mixed. It's worth pointing out that given the fairly stringent eligibility
criteria for NSABP B31, few women with borderline heart function were enrolled. In daily practice, however, we may consider these
women for treatment, which could lead to an even greater incidence of cardiotoxicity. In terms of dose-dense therapy, our colleagues
at Memorial Sloan-Kettering Cancer Center, New York, NY, reported on a study[9] in which they looked at the use of dose-dense
doxorubicin and cyclophosphamide followed by concurrent paclitaxel and trastuzumab. In that phase 2 trial of approximately 70
patients, the regimen appears to be a safe approach; however, this is still a relatively limited experience compared with the wealth of
safety information from the larger trials.
Medscape: You've mentioned the use of non-anthracycline-containing adjuvant regimens. Do you think that concurrent use of
trastuzumab and anthracycline chemotherapy is a regimen that deserves further exploration?
Dr. Winer: I think that it deserves further exploration. Buzdar and colleagues[7] from MD Anderson Cancer Center, Houston, Texas,
evaluated preoperative paclitaxel followed by 5-FU [5-fluorouracil], epirubicin, and cyclophosphamide (FEC) chemotherapy with or
without concurrent trastuzumab in both a randomized and a single-arm extension protocol. A very high pathologic complete response
rate (60%) was reported in the combination therapy arm. The favorable response rate may be due to several factors, including patient
selection, preoperative anthracycline administration, or the prolonged duration of therapy (6 months), but it also may be related to the
concurrent exposure to both anthracycline and trastuzumab. I think that this finding needs to be explored further within the context of
clinical trials, which are currently under way. It is not a regimen that I would routinely use outside of a clinical trial until we have
more safety data.
Medscape: Provocative data were presented at both the San Antonio Breast Cancer Symposium 2005 and ASCO 2006 in
regard to identifying patient subgroups – such as those with c-Myc amplification – for whom trastuzumab may be particularly
beneficial. What can we learn from these markers, and can we expect this information to guide our clinical practice?
Dr. Winer: What we've learned from these analyses is that when we start looking at what is thought to be a relatively uniform group
of patients with HER-2-positive disease, it turns out that there is more heterogeneity than we initially thought. Subgroup analysis from
NSABP B-31 suggests that trastuzumab may be a particularly crucial drug in patients with coamplification of c-Myc and HER-2.[10]
Although trastuzumab was found to be beneficial in women with c-Myc nonamplified tumors, those with coamplified tumors had very
poor prognoses if they did not receive trastuzumab. However, in contrast, when trastuzumab was given, these patients had the best
prognoses among all women on the trial. If these findings are confirmed, we may want to consider different approaches in clinical
trials for c-Myc amplified vs and nonamplified tumors.
Medscape: Since the release of the adjuvant trastuzumab data in 2005, thousands of women have received this agent with
chemotherapy. Unfortunately, some may experience recurrent disease. Do you think that recurrent breast cancer after
adjuvant trastuzumab therapy is trastuzumab-resistant, or is there a role for further trastuzumab?
Dr. Winer: I suspect that one approach will not fit all patients in this setting; the decision to administer further treatment will depend
on the specific tumor type and the time lag until recurrence. For a woman who has received adjuvant trastuzumab and then develops
recurrent disease 3 years later, I would tend to think that there is a role for further trastuzumab: It would be one of the first treatments
that I would consider. On the other hand, in a woman who develops progressive cancer very shortly after stopping adjuvant
trastuzumab, I would be concerned that her disease is less likely to respond to trastuzumab. I personally don't have a definition for
trastuzumab resistance, and I suspect that there are many different ways for a tumor to become trastuzumab-resistant. Since
trastuzumab first became commercially available, the big unanswered question is whether there is any benefit to continuing it once a
tumor begins to progress on therapy. Despite the fact that we have been dealing with this problem for the past 8 years, we don't have
an answer yet.
Medscape: Exciting data were presented with regard to the role of lapatinib in the treatment of patients with advanced HER-
2-positive disease.[11,12] What are your thoughts about lapatinib in the adjuvant setting?
Dr. Winer: Given the data suggesting activity of lapatinib in the treatment of metastatic HER-2-positive breast cancer, it is quite
possible that lapatinib will have activity in the adjuvant setting as well, either given sequentially with trastuzumab, in place of
trastuzumab, or in combination with trastuzumab. It's possible that lapatinib may be approved by the FDA [US Food and Drug
Administration] and become commercially available in the next year or so; however, at this time, lapatinib has no role in the adjuvant
setting outside of a clinical trial. Trials evaluating the role of lapatinib in the adjuvant setting should open within the next year in both
North America and Europe.
Medscape: We have recently seen advancements in the treatment of HER-2-positive brain metastases. [13] Are there any new
methods at this time to detect or prevent the development of brain metastases for women with early-stage HER-2-positive
disease?
Dr. Winer: I think that it's important to recognize that brain metastases affect a very small proportion of patients who have early-stage
HER-2-positive breast cancer, and although it was one of the frequent sites of recurrence in the adjuvant trials, the vast majority of
women with early-stage HER-2-positive disease are not going to develop brain metastases. It is unclear whether early detection of
brain metastases is clinically important. There is reason to believe that finding brain metastases when a patient has a lower burden of
disease would lead to a better response to treatment, but the long-term impact of early detection on a woman's quality of life and
survival is unknown. I would not recommend that women with early-stage breast cancer have any routine brain imaging after the
completion of adjuvant therapy, and I know of no way to prevent brain metastases in the adjuvant setting at this time.
Medscape: A phase 1 trial[14] has reported activity with a combination of trastuzumab and bevacizumab. Bevacizumab is an
active agent in the metastatic setting. Do you think that this combination has potential in the adjuvant setting?
Dr. Winer: There is good reason to believe that concurrent trastuzumab and bevacizumab could be an effective combination for
several reasons, including preliminary results from the small phase 1 study, and encouraging preclinical data showing that VEGF
[vascular endothelial growth factor] is upregulated in a substantial proportion of patients with HER-2-positive disease. On the basis of
these data, concurrent trastuzumab and bevacizumab is potentially a very interesting regimen and will be investigated in the adjuvant
setting by the NSABP. Until we have the results of that trial, however, it is not a regimen that should be used in general practice.
Medscape: Just a few years ago, HER-2-positive breast cancer carried a poor prognosis, but now has become a much more
treatable disease. What future advances do you see for treatment of women with HER-2-positive breast cancer?
Dr. Winer: Over the next several years, we're going to see very substantial advances in the treatment of HER-2-positive breast cancer.
We've already seen great progress with the use of trastuzumab in both the metastatic and adjuvant settings, and this year, with the
development of lapatinib as an agent with activity in the metastatic setting after progression on trastuzumab. I anticipate that over the
next 5-10 years we're going to gain a much finer understanding of mechanisms of resistance to trastuzumab and will identify new
molecular targets to consider as we develop clinical trials. In the years ahead, recurrence rates after a diagnosis of early-stage HER-2-
positive disease will fall dramatically. At the same time, we will continue to extend the lives of those women living with HER-2-
positive metastatic disease.

New Guidelines Recommend Determining HER2 Status for All Invasive Breast Cancer
December 18, 2006 — The American Society of Clinical Oncology (ASCO) and the College of American
Pathologists (CAP) guidelines recommend that human epidermal growth factor receptor 2 (HER2) status be
determined for all invasive breast cancer, according to a report published in the December 11 Early Release
issue of the Journal of Clinical Oncology.
"The human epidermal growth factor receptor 2 gene ERBB2 (commonly referred to as HER2) is amplified in
approximately 18% to 20% of breast cancers," write Antonio C. Wolff, MD, from ASCO in Alexandria,
Virginia, and colleagues. "HER2 positivity is associated with worse prognosis (higher rate of recurrence and
mortality) in patients with newly diagnosed breast cancer who do not receive any adjuvant systemic therapy.
Thus, HER2 status might be incorporated into a clinical decision, along with other prognostic factors, regarding
whether to give any adjuvant systemic therapy."
Other considerations are that HER2 positivity is predictive of resistance to endocrine therapies and that there is
relatively less benefit from nonanthracycline, nontaxane-containing chemotherapy regimens but better response
to anthracycline therapy and paclitaxel. Agents that target HER2, such as the humanized monoclonal antibody
trastuzumab (Herceptin, Genetech), are effective in both the metastatic and adjuvant settings and as a single
agent.
To study these issues and develop recommendations for optimal HER2 testing performance, ASCO and CAP
convened an expert panel to systematically review the literature. The guidelines were reviewed by selected
experts and approved by the board of directors of both organizations.
"HER2 testing should be routinely performed in patients with a new diagnosis of invasive breast cancer," the
authors write. "However, the best method to assess HER2 status, in regards both to the type of assay used and
the optimal method to perform each assay, remains controversial. For most of the prospective randomized
adjuvant trials of trastuzumab, testing algorithms for HER2 were somewhat arbitrarily developed."
Available evidence suggests that about 20% of current HER2 testing is inaccurate. Data obtained with carefully
validated testing do not clearly demonstrate the superiority of either immunohistochemistry (IHC) or in situ
hybridization (ISH) as a predictor of benefit from anti-HER2 therapy.
The panel recommends determining HER2 status for all invasive breast cancer, using a testing algorithm that
relies on accurate, reproducible assay performance, including newly available types of brightfield ISH.
Elements to reliably reduce assay variability include proper attention to specimen handling, assay exclusion,
and reporting criteria.
The guidelines recommend an algorithm defining positive, equivocal, and negative values for both HER2
protein expression and gene amplification. A positive HER2 result is an IHC staining of 3+ (uniform, intense
membrane staining of more than 30% of invasive tumor cells), a fluorescent in situ hybridization (FISH) result
of more than 6 HER2 gene copies per nucleus, or a FISH ratio (HER2 gene signals to chromosome 17 signals)
of more than 2.2. In contrast, a negative result is an IHC staining of 0 or 1+, a FISH result of less than 4.0
HER2 gene copies per nucleus, or a FISH ratio of less than 1.8.
In the case of equivocal results, additional action is necessary for final determination. To perform HER2 testing,
laboratories should demonstrate 95% concordance with another validated test for positive and negative assay
values.
The guidelines strongly recommend validating laboratory assays or modifications, using standardized operating
procedures, and complying with new testing criteria. These criteria should be monitored using stringent
laboratory accreditation standards, proficiency testing, and competency assessment.
The panel further recommends that HER2 testing be done in a CAP-accredited laboratory or in a laboratory
meeting the accreditation and proficiency testing requirements specified in the guidelines.
Cited in the guidelines are summary recommendations from the 2003 National Institute of Standards and
Technology (NIST) Consensus Workshop on reference material for HER2 testing:
 NIST-certifiable standard should be available breast-cell lines (3) with variable receptor and gene
expression to bracket the range of receptor quantity
 Grown in optimal form
 Characterized by NIST as to HER2
o Receptor content (scatchard plots)
o Physical protein characteristics
o Gene copy number
o RNA expression levels
 Second standard will be made commercially (must be used in all HER2 laboratory testing by
vendors/commercial labs/researchers)
 Fixative for HER2 testing and for reference standard must be required to be 10% buffered formalin
 Must be included with each slide (or run) and used in all interlab and interassay comparisons.
"Despite attempts within the international pathology community to improve the status of HER2 testing in
routine practice, testing inaccuracy remains a major issue with both IHC and FISH," the authors conclude. "The
use of laboratory assays as the sole determinant for therapy selection poses a significant challenge to
pathologists performing and interpreting the results and to oncologists who must rely on them for clinical
decisions."
Some of the authors have disclosed financial relationships with Clarient, Roche, Abbott, Genentech,
GlaxoSmithKline, European Collection of Cell Cultures, Immunicon, Pfizer, Novartis, M2 Communications,
Serinomics, Ventana, Abbott/Vysis, and/or Nanoprobes.
J Clin Oncol. Published online December 11, 2006.

FDA OKs Herceptin for Early Breast Cancer

LOS ANGELES (Reuters) Nov 17 - The U.S. Food and Drug Administration has expanded the use of
Genentech Inc.'s breast cancer drug Herceptin to include women with early stage cancer who have undergone
surgery, the biotechnology company said on Thursday.
Herceptin has been on the market since 1998 as a treatment for the 25% to 30% of breast cancer patients who
have HER-2-positive tumors and whose cancer has spread beyond the breast.
Since the announcement in 2005 of positive trial results for Herceptin in combination with chemotherapy in
earlier-stage cancer, physicians have already been using the drug in these patients.
The studies have shown that 87% of women treated with Herceptin and chemo were disease-free after three-
and-a-half years, compared with 71% of women treated with chemo alone, the company said.
"This is the largest improvement in outcome for any group of women with breast cancer in 25 years," Dr.
Edward Romond, professor of hematology/oncology at the University of Kentucky, said in a statement.
The most serious side effect of Herceptin is congestive heart failure, which investigators found occurs 3 to 4%
more often in patients treated with Herceptin than in those treated only with chemotherapy.
The FDA was initially expected to decide on the new indication for Herceptin in August but the review was
extended after the agency requested additional information.

Extended Approval of Herceptin Welcomed by US Experts, but UK Physicians Remain

Concerned About Cost
November 24, 2006 — Breast-cancer experts in the United States have welcomed the recent extension in the
labeling for trastuzumab (Herceptin, Genentech/Roche), which now allows use of the drug in early-stage
disease. The new indication is for HER-2-positive node-positive breast cancer following surgery, and
trastuzumab is used together with doxorubicin, cyclophosphamide, and paclitaxel.
The news "highlights a truly significant advance in the management of breast cancer," said Edith Perez, MD,
director of the Mayo Clinic's Breast Clinic in Jacksonville, Florida. Dr. Perez was involved in 1 of the 2 phase 3
clinical trials submitted for Food and Drug Administration approval that showed that the addition of
trastuzumab reduced the risk of breast cancer recurrence by 52% (Romond EH et al. N Engl J Med.
2005;353:1673-1684). Commenting in a statement issued by the Mayo Clinic, Dr. Perez said the results have
already led to changes in clinical practice.
"The results of the joint analysis show that, for women with early-stage HER2-positive breast cancer, the
addition of Herceptin to chemotherapy reduces the relative risk of breast-cancer recurrence by approximately
half, which translates into fewer women dying from one of the most aggressive types of breast cancer,". "This is
the largest improvement in outcome for any group of women with breast cancer in 25 years,".
However, in the United Kingdom, where trastuzumab use in early-stage breast cancer has recently been
recommended by the National Institute of Clinical Excellence, a group of oncologists has voiced concern over
the high cost of the drug. The drug costs 4 times as much as other adjuvant treatments, says Tom Roques, MD,
consultant clinical oncologist at Norfolk and Norwich University Hospital NHS. Writing with colleagues in the
November 24 issue of BMJ, he points out that these other drugs have been proven to be clinically effective and
have a far greater cost-effectiveness than is currently expected for trastuzumab. The limited annual budget at
their hospital would allow 75 patients to be treated with trastuzumab or 355 to be treated with adjuvant
treatment (16 of whom would be cured), and it would fall on them to make decisions about who would receive
what treatment and then to explain these decisions to patients.
"These untreated patients will be people we know," they write. "We will be the ones to tell them they are not
getting treatment that has been proven to be effective and that costs relatively little because it is not the
'treatment of the moment.' "
BMJ. 2006;333;1118-1120.

Evaluation of Her-2/neu Status in Carcinomas With Amplified Chromosome 17

Centromere Locus Megan L. Troxell, MD, PhD; Charles D. Bangs; Helen J. Lawce; Ilana B. Galperin, MS; Daniel Baiyee,
MD, PhD; Robert B. West, MD, PhD; Susan B. Olson, PhD; Athena M. Cherry, PhD Am J Clin Pathol. 2006;126(5):709-716.
©2006 American Society for Clinical Pathology
Abstract
Accurate assessment of Her-2/neu (erb-b2) status in breast carcinoma is essential for therapy planning. Clinical
assays are targeted at protein overexpression (immunohistochemical analysis) or gene amplification
(fluorescence in situ hybridization [FISH]). Cases with aberrant FISH signal patterns are problematic and may
lead to underreporting of Her-2/neu amplification.
We performed FISH with additional chromosome 17 probes, SMS (Smith-Magenis syndrome critical region)
and RARA (retinoic acid receptor), on 7 cases with unusual Her-2/CEP17 (chromosome 17 centromere control
probe) results to assess whether different measurements of chromosome 17 copy number might clarify the Her-
2/neu amplicon status. Although the Her-2/CEP17 ratio scores were within normal range (<2.0), the Her-2/SMS
or Her-2/RARA ratio revealed amplification of Her-2/neu in 5 of 7 cases. Immunohistochemical analysis
demonstrated Her-2/neu protein overexpression in the same 5 cases only.
We describe novel application of SMS/RARA FISH probes for assessing cases with complex Her-2/CEP17
FISH patterns. Such additional data, correlated with immunohistochemical analysis, may help guide therapy in
patients with breast carcinoma.
Introduction
Research in tumor diagnosis and treatment has led to the discovery of numerous prognostic and predictive
markers for breast carcinoma. Current patient management relies on a number of ancillary studies, including
estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu (erb-b2) protein overexpression and/or gene
amplification status. It has been known for many years that the 20% to 30% of breast carcinomas
overexpressing Her-2/neu have a poor prognosis compared with those with normal levels and may respond
differently to cytotoxic chemotherapy.[1-4] These tumors often are high grade, with a high proliferation rate and a
propensity for lymph node involvement.[3,4] Recently, these tumors have been found to have distinct molecular
profiles.[5-9] The Her-2/neu (erb-b2) oncogene encodes a 185-kd tyrosine kinase receptor of the epidermal
growth factor receptor family, although a unique ligand has not been identified.[3] In the majority of cases, Her-
2/neu protein overexpression correlates well with amplification of the Her-2/neu locus on the chromosome 17
long arm.[2-4]
With the Food and Drug Administration (FDA) approval of trastuzumab (Herceptin) in 1998, targeted therapy
has become available for Her-2/neu-overexpressing tumors. This humanized monoclonal antibody initially was
used to treat patients with Her-2/neu+ metastatic disease, with a response rate of 20% to 35%.[10-12] However,
recent data from US and European studies have identified a significant benefit of first-line trastuzumab therapy,
in conjunction with surgery and cytotoxic chemotherapy.[13,14] Thus, the correct identification of Her-2/neu+
breast carcinomas is an important component of the pathologic evaluation of breast carcinoma specimens.
Her-2/neu studies originally were performed with biochemical assays requiring fresh frozen tissue samples[3,4];
subsequently, immunohistochemical methods to detect Her-2/neu overexpression at the cell membrane,
performed on archived, formalin-fixed, paraffin-embedded tissue samples, have been implemented in many
pathology laboratories.[3,4] Fluorescence in situ hybridization (FISH) assays to evaluate gene amplification also
allow paraffin slide-based assessment of Her-2/neu and correlation with morphologic features. There are 2
FDA-approved immunohistochemical assays (HercepTest, DAKO, Carpinteria, CA, and PATHWAY, Ventana,
Tucson, AZ) and 2 FDA-approved FISH assays (INFORM, Ventana, and PathVysion, Abbott-Vysis, Des
Plaines, IL). Many laboratories use immunohistochemical analysis as a primary assay, with "reflex" FISH
testing of a specific subset of immunohistochemical results (eg, 2+, or 1+, 2+), and other laboratories use FISH
primarily.[15,16] Of note, novel methods, including those with immunohistochemical analysis and in situ
hybridization developed on the same tissue section, are under investigation and validation.[17]
As experience with assay methods has accumulated, cases with aberrant immunohistochemical or in situ
hybridization patterns have been described. These include cases with heterogeneous tumor populations revealed
by FISH and cases with chromosome 17 aneusomy. A number of small studies have addressed chromosome 17
polysomy;[2,18-23] however, rare cases with apparent amplification of the chromosome 17 control FISH probe at
the 17 centromere (CEP17), present in the Abbott-Vysis reagent, also have been identified.[24] In this situation,
the calculated Her-2/CEP17 ratio is low, and this ratio may not reflect real Her-2/neu status, denying patients
targeted therapy. We tested FISH probes to the chromosome 17 loci SMS (Smith-Magenis syndrome) and RARA
(retinoic acid receptor) as surrogate chromosome 17 controls in 7 cases with a high copy number of CEP17, in
correlation with Her-2/neu immunohistochemical analysis.
Discussion
Robust methods, rigorous quality control, and careful interpretation are required to perform assays to address
prognosis and to appropriately predict those patients who will benefit from targeted therapies. This holds true
for trastuzumab therapy in breast carcinoma because the treatment is costly and is cardiotoxic in a subset of
patients.[12-14] Considerable controversy exists regarding the most appropriate testing algorithm for assessment of
Her-2/neu status, given the availability of immunohistochemical and FISH assays. Recent data yield an
approximately 95% concordance between these assays when performed in experienced reference laboratories,
on par with interlaboratory immunohistochemical or interlaboratory FISH concordance.[25-28] Current standards
indicate that cases scored as 2+ by Her-2/neu immunohistochemical analysis should have a reflex confirmatory
FISH assay performed; of those, only FISH+ patients are eligible for trastuzumab therapy.[15,16] Some
laboratories perform FISH primarily, and it is unclear how often confirmatory immunohistochemical analysis is
performed to resolve cases with atypical FISH patterns.
We identified CEP17 amplification in a series of consecutive Her-2/neu FISH assays. We further investigated
the nature of the chromosome 17 amplicon with FISH probes to additional loci (SMS 17p11.2, RARA 17q21.2)
and with Her-2/neu immunohistochemical analysis. The use of alternative chromosome 17 probes, SMS and
RARA, allows an Her-2/chromosome 17 ratio to be derived, providing an alternative FISH ratio score in cases
with a complex CEP17 pattern. Whether cases with amplified CEP17 and amplified Her-2/neu constitute some
of the immunohistochemically 3+ positive but FISH negative cases in the literature that may respond to
trastuzumab therapy is unclear.[11,29,30]
Based on results of all 3 assays, CEP17-amplified cases fell into 2 groups. Of 7 study cases, 2 had an unusually
low Her-2/CEP17 ratio because of a CEP17 count greater than 125. Thus, the amplified portion of chromosome
17 did not involve the Her-2/neu locus, although the SMS/RARA probes showed that 1 case had a large
amplicon involving CEP17 and SMS. These probes also suggested chromosome 17 polysomy in case 2. Cases
in this first group were negative for Her-2/neu protein overexpression.
Five cases had apparent amplification of Her-2/neu and CEP17 on initial FISH testing, yielding a ratio of 1.0.
This ratio is within normal limits (<2.0); simply reporting the Her-2/CEP17 ratio would not indicate Her-2/neu
amplification and may deny targeted therapy. However, all of these cases demonstrated overexpression of Her-
2/neu by immunohistochemical analysis. SMS/RARA probes revealed chromosome 17 copy number, and we
found that the Her-2/RARA or Her-2/SMS ratio was a better indication of the Her-2/chromosome 17 ratio and
was consistent with Her-2/neu amplification in each case. Deletion of the SMS or RARA target loci may account
for a shifted Her-2/SMS or Her-2/RARA ratio. However, the cases reported herein had markedly elevated Her-
2/neu signal counts, and most had nearly normal SMS or RARA numbers per nucleus (2 per nucleus). Case 7
may have monosomy 17 or deletion of 1 copy of SMS, in addition to a large amplicon including CEP17, Her-
2/neu, and RARA. Further details of the chromosomal content of amplicons are not revealed by these FISH
studies (eg, the possibility of complex rearrangements involving those segments). Nevertheless, large amplicons
also result in amplification and, perhaps, overexpression of other oncoproteins on chromosome 17. For
example, the target sequence of the RARA probe includes the GRB7 locus. MLN64/CAB1, PPARBP,
topoisomerase IIa, BRCA1, and other nearby genes may be affected in such cases.[6,8,31]
The use of alternative chromosome 17 control probes in Her-2/neu FISH analysis recently was described by
Gliem et al[24] in abstract form, and our data confirm and extend their findings. They reported 1.23% of 2,855
cases with amplified CEP17 (D17Z1) signals and further tested these cases with a different combination of
FISH probes, including Her-2/neu and D17S122 (17p12). They found that 90% of tested cases had an amplified
Her-2/D17S122 ratio, and no cases showed amplification of D17S122. However, immunohistochemical
correlation was not provided.
Previous reports have described chromosome 17 aneusomy, with dual-color FISH (with chromosome 17
centromere control probe) generally favored over single-color FISH in light of polysomy.[2,18-23,28,32,33] Some of
these studies also provide brief data alluding to CEP17 amplification.[18,20-22,28,33] Watters et al[18] found aneusomy
17 in 116 (54.2%) of 214 cases and described a maximum CEP17 count of 10.49, without further
characterization. Bose et al[22] described 24 (32.4%) of 74 cases with aneusomy 17, with 1 case (1%) showing 7
to 10 CEP17 signals per cell. Press et al[28] described 2 (0.08%) of 2,502 cases with Her-2/CEP17 ratios of less
than 2.0 but high numbers of Her-2/neu signals per cell, with aggregated Her-2/neu signals, likely representing
amplification; however, data on CEP17 were not provided. Wang et al[20] found 97 (51.3%) of 189 cases in their
selected cohort aneusomic for chromosome 17, including 10 cases with CEP17 of more than 3.76 per cell. They
found concordance between immunohistochemical results and Her-2/CEP17 ratios was maintained, and they
concluded there was little influence of chromosome 17 copy number on Her-2/neu expression.[20] In contrast,
Ma et al[33] reported 377 (42.2%) of 893 polysomic for chromosome 17, with 65 cases (7.3%) of "high
polysomy" (>3.75 signals per cell). They found a trend toward increased protein expression with polysomy.
Likewise, Varshney et al[21] reported 71 (10.3%) of 687 cases with polysomy 17, with 19 cases (2.8%) with high
polysomy, defined as CEP17 of more than 4 per cell. It is interesting that cases in the high polysomy cohort
with an Her-2/CEP17 ratio less than 2 were identified with negative immunohistochemical results (3 cases) or
with positive immunohistochemical results (3+, 6 cases). Although further details are not provided, it is likely
that these cases may be similar to cases in our study. We speculate that their cases without protein
overexpression may have only CEP17 amplification without Her-2/neu amplification, and their cases with Her-
2/neu protein overexpression may have large amplicons encompassing CEP17 and Her-2/neu. Likewise,
Hofmann et al[29] describe 3 (1.0%) of 302 patients with FISH-, immunohistochemically 3+ positive tumors who
responded to trastuzumab therapy and noted that two specimens showed CEP17 of more than 9 per nucleus.
We recommend reporting raw FISH data, including number of cells counted, CEP17 signals, Her-2/neu signals,
and the calculated Her-2/CEP17 ratio for routine cases. In cases with aberrant signal patterns such those
reported herein, we recommend describing the pattern in a detailed comment. Further evaluating such cases
with additional FISH probes targeted at other chromosome 17 loci may be helpful to allow the ratio of Her-
2/neu to chromosome 17 copy number to be calculated correctly. Our data also indicate that confirmatory
(reflex) immunohistochemical analysis in cases with a complex FISH pattern may add important, clinically
relevant information.

Reverting Estrogen-Receptor-Negative Phenotype in HER-2-Overexpressing Advanced

Breast Cancer Patients Exposed to Trastuzumab Plus Chemotherapy
Elisabetta Munzone; Giuseppe Curigliano; Andrea Rocca; Giuseppina Bonizzi; Giuseppe Renne; Aron
Goldhirsch; Franco Nolè
Breast Cancer Res. 2006;8(1) ©2006 BioMed Central, Ltd. Posted 01/30/2006
Abstract
Introduction:The amounts of estrogen receptor (ER) and progesterone receptor (PgR) in a primary tumor are
predictive of the response to endocrine therapies of breast cancer. Several patients with ER-positive primary
tumors relapse after adjuvant endocrine therapy with no ER expression in the recurrent tissue; much fewer with
a recurrent disease after an ER-negative primary tumor may become endocrine responsive. These sequences of
events indicate that a phenotype based on ER expression may not be a permanent feature of breast cancer.
Methods:Ten patients with advanced breast cancer whose tumors overexpressed HER-2, but not ER or PgR,
were treated with weekly trastuzumab at standard doses with or without chemotherapy.
Results:Three out of 10 patients showed overexpression of ERs first appearing after 9, 12 and 37 weeks,
respectively, from the initiation of trastuzumab. Two of these patients were subsequently treated with endocrine
therapy alone: one of them received letrozole for 3 years without evidence of progression.
Conclusion:Therapeutic targets enabling the appearance of an endocrine responsive disease may increase
treatment options for patients with breast cancer. Furthermore, these clinical data suggest that an ER-negative
phenotype is a multi-step process with a reversible repression modality, and that some ER-negative tumors may
either revert to an ER-positive phenotype, allowing an endocrine treatment to be effective.
Introduction
Biological features of endocrine responsiveness, namely the overexpression of estrogen receptor (ER) and/or
progesterone receptor (PgR), are important predictive and prognostic markers in breast cancers.[1] About 50%
of patients with ER-positive primary tumors that relapse after adjuvant tamoxifen therapy have recurrent tumors
in which ER expression is lost.[2] Progression to an ER-negative phenotype typically involves the constitutive
overexpression of growth-promoting genes that are normally regulated by estrogens, thereby leading to a loss of
estrogen dependence, resistance to anti-estrogens, and a more aggressive phenotype overall.
The re-expression of ER in tumors in which ER has been lost or is not expressed could therefore indicate
sensitivity to endocrine therapy. ER-negative tumors frequently overexpress growth factor receptors such as
epidermal growth factor receptor (EGFR) or c-erbB2,[3,4] as do many ER-negative breast cancer cell lines,
suggesting that upregulated growth factor signaling might provide an alternative growth stimulus. The
overexpression of EGFR and c-erbB2 is also an important prognostic indicator of breast cancer, independently
of their inverse correlation with ER expression.[5,6] This increased expression and/or activation of growth
factor receptors correlates with increased mitogen-activated protein kinase (MAPK) activity, both in tumors and
in cell lines.[7-9] Using cell lines that overexpress constitutively active forms of Raf-1, MAPK/ERK kinase
(MEK)-1, or c-erbB-2 and ligand-activatable EGFR, some authors have shown that the resultant hyperactivation
of MAPK (ERK1/2) activity through these signaling pathways leads to the downregulation of ERα. This
downregulation is not a consequence of ligand-independent ERα activation and is reversible in vitro.
Abrogation of ERK (extracellular signal-regulated kinase) activity with the use of either pharmacologic
inhibitors or dominant-negative ERK constructs reverses the downregulation of ERα and restores its activity.
[10] These data suggest that upregulated growth factor signaling via MAPK is directly linked to the loss of ER
expression and generation of the ER-negative phenotype and that, at some stage in the progression pathway, the
ER-negative phenotype may be not permanent.
As a consequence, therapeutic targets enabling the restoration of ER expression may provide beneficial
treatment strategies for breast cancer patients.
Both gefitinib (Iressa®), which inhibits the kinase activity of EGFR, and trastuzumab (Herceptin™), a
monoclonal antibody against c-erbB2, have been shown to reduce MAPK activity.[11]
These data support the hypothesis that a patient with advanced breast cancer with ER-negative tumors and c-
erbB2 overexpressed could revert from an ER-negative phenotype to ER-positive after treatment with
trastuzumab.
Discussion
This is the first report of an ER-negative phenotype changing to ER positive after a trastuzumab-containing
therapy in patients with advanced breast cancer. Interestingly, previous reports evaluating the use of
trastuzumab in the preoperative setting in patients with locally advanced breast cancer do not address this
particular issue.[12,13]
The patient sample was limited, but this could be an important anecdoctal and hypothesis-generating report that
should be confirmed in larger trials.
Another potential limit was that the reassessment was performed at a variable time point after the start of
therapy, and the timing was not predefined. Our three patients had a reversion of ER to a positive phenotype
after 9, 12 and 37 weeks from the start of treatment with trastuzumab. For this reason we do not have data on
which to base a hypothesis about the optimal timing for performing the reassessment.
A recent report by Arpino et al. proposed that a lack of PgR expression could be a reflection of active signaling
in the HER family and, as a consequence, the response to trastuzumab might be different in the PgR-positive
and PgR-negative subsets.[14] Interestingly, two of our patients after ER reversion to a positive phenotype
remained PgR negative; both had a partial response to trastuzumab, whereas the only patient who also had a
PgR reversion was resistant to trastuzumab.
Other studies that address ER loss reversibility in breast cancer cell lines involve treatments with demethylating
agents such as 5-azacytidine.[15,16] About 25% of ER-negative breast tumors were found to contain methylated
ER.[17] However, several ER-positive tumors also showed similar degrees of methylation.[18] Methylation, by
modifying the DNA structure assisting in the recruitment of histone deacetylases, ensures that the gene is in an
inactive conformation. If methylation occurs as a step subsequent to another mechanism of ER repression, one
would predict that some ER-negative breast tumors at an earlier point in a progression pathway do not express
ER because one of these other mechanisms is still operative. In such tumors, it might then be possible to reverse
this phenotype and restore antiestrogen sensitivity, perhaps by using a demethylating agent.
An interesting recently reported transcription factor that might be linked to hormone-independent breast cancer,
as well as elevated growth factor signaling, is NF-κB. Its activity is elevated in hormone-independent breast
cancer, and it is implicated in enhanced cell survival and chemoresistance in cancer.[19] Holloway et al. have
shown recently that an elevation in NF-κB activity is attributable to enhanced growth factor signaling through
ERK1/2; inhibiting this NF-κB activity, either pharmacologically or through the expression of a constitutively
active IκB, partly restores ER activity and expression in these cells. These findings suggest a role for
cytoplasmic substrates of MAPK in ER downregulation in breast cancer and further support a role for MAPK-
induced NF-κB activity in this downregulation.[20]
Conclusion
We conclude that our clinical data – although limited in the patient sample – support previous assessments in
vitro, suggesting that an ER-negative phenotype may be a multi-step process with a reversible repression
modality, and that some ER-negative tumors might revert to the ER-positive phenotype allowing an endocrine-
based treatment.
Although further studies are essential to show that inhibitors of mitogenic signaling can restore ER expression
and/or function in breast tumors, coupling molecules such as signal transduction inhibitors, monoclonal
antibodies, demethylating agents or NF-κB inhibitors with antiestrogens could result in therapies that are better
tolerated and active for the treatment of ER-negative breast cancer. In addition, once the MAPK substrate or
substrates responsible for ER downregulation are identified, they could provide an additional drug target.
The table shows the evaluation of patients' characteristics at baseline with the site of disease at which the
biological characteristics were evaluated, and after treatment with trastuzumab with the site of disease at which
the biological characteristics were reassessed. ER, estrogen receptor; first assessment, site of disease where ER,
PgR and HER2 were evaluated at baseline; HT, hormonal treatment; PgR, progesterone receptor; second
assessment, site of disease where ER, PgR and HER2 were reassessed; time A, time elapsed between first
assessment and treatment start (weeks); time B, time elapsed between trastuzumab start and second assessment
(weeks). PD, progressive disease. SD, stable disease. PR, partial response.
aPaclitaxel was introduced after progression to trastuzumab alone.

Trastuzumab in the Adjuvant Setting: An Expert Interview With

Dr. Martine J. Piccart
Medscape Hematology-Oncology. 2006;9(1) ©2006 Medscape
Editor's Note:
Results reported at the 28th San Antonio Breast Cancer Symposium (SABCS) upheld previous findings regarding the
benefits of trastuzumab in the adjuvant treatment of breast cancer. Interim results of the BCIRG 006, [1] presented by
Dennis Slamon, MD, PhD, indicated that trastuzumab administered concurrently with docetaxel-containing
chemotherapy extended disease-free survival compared with chemotherapy alone over a follow-up period of 23
months. These results build on data from another adjuvant trial, the NSABP/NCCTG joint analysis, [2] presented at
the 2005 American Society of Clinical Oncology annual meeting. That analysis indicated a significant survival
advantage for patients receiving doxorubicin/cyclophosphamide followed by paclitaxel/trastuzumab therapy vs the
same chemotherapy without trastuzumab. In addition, the HERA trial data, [3] published recently in The New England
Journal of Medicine indicated that 1 year of trastuzumab compared with observation following chemotherapy
resulted in a 46% reduction in risk of disease recurrence. Taken together, the results from these complementary
adjuvant clinical trials indicate that trastuzumab provides a significant benefit when used in conjunction with
various types of chemotherapy. However, several questions regarding the use of trastuzumab remain. Medscape
spoke with the lead author of the HERA trial, Martine Piccart, MD, PhD, with the Medical Oncology Clinic Jules
Bordet Institute Centre des Tumeurs de l'Universite Libre de Bruxelles, in Brussels, Belgium, to discuss the latest
data and some of the practical issues regarding the use of trastuzumab in the adjuvant treatment of patients with
breast cancer.
Medscape: What are the key implications of the HERA trial findings?
Dr. Piccart: The latest findings of the HERA trial [3] tell us that 1 year of trastuzumab administered after completion
of locoregional treatment and chemotherapy reduces the risk of relapse of early breast cancer by about 50%. What is
striking is the highly significant reduction in risk of distant metastases. We were therefore clearly very impressed by
these findings and were not expecting an effect of this magnitude.
The question to be answered by further follow-up is whether the treatment effect will remain as strong or will
weaken over time. Of note, we have calculated that even if the benefit from this treatment did not extend beyond 1
1/2 years, the trial would most likely still be positive 4 years from now. So the chance that this will suddenly become
a negative trial is less than 20%.
Medscape: Does the choice of chemotherapy influence the extent of benefit with trastuzumab?
Dr. Piccart: The effect of adding trastuzumab is real and very strong and also, as the HERA findings indicate,
clearly independent of the chemotherapy regimen used. The HERA trial was carried out worldwide, and reaching an
agreement on which chemotherapy regimen to use was impossible. Thus, we elected to allow a range of
chemotherapy regimens. This means that the findings from this trial are widely applicable. That being said, many
believe that an anthracycline-based regimen will be particularly effective in patients with HER2-positive breast
cancer, and, indeed, most patients in the HERA trial received anthracyclines.
I was also very impressed by data presented by Dr. Slamon [1] at SABCS indicating that patients with HER2 and
topoisomerase-2 coamplification seemed to benefit most from the use of anthracyclines given prior to docetaxel +
trastuzumab. Conversely, if this coamplification is not present, it may be that all that is needed is a nonanthracycline
therapy given with trastuzumab.
Medscape: Can you speak to the issue of using trastuzumab with chemotherapy concurrently vs sequentially?
Dr. Piccart: By giving trastuzumab sequentially, one might lose the potential synergy that occurs between
trastuzumab and chemotherapy. On the other hand, administering both agents concurrently might increase the risk of
cardiac toxicity over the long term compared with sequential use -- although we cannot state this with any degree of
certainty due to the short follow-up that currently exists for these trials. The planned follow-up for the HERA trial is
10 years after the last patient is randomized.
Medscape: What are some of the emerging markers that show promise in predicting response to
trastuzumab?
Dr. Piccart: Although we see a profound overall treatment effect with trastuzumab, we know that some patients who
receive trastuzumab do not benefit from it. Trastuzumab is an expensive drug; therefore, the translational studies that
we perform in the next few years will be critical for defining which patients should receive the drug. We will
probably find a subset of HER2-positive patients that should not be treated with trastuzumab and would therefore not
need to be exposed to potential cardiac toxicity. In addition to Dr. Slamon's work regarding HER2 and
topoisomerase-2 coamplification, another important work, by Dr. Paik's team, [4] found that patients with HER2 and
cMyc coamplification derived a profound benefit from trastuzumab. So more studies of this nature are needed to
properly identify patients who are likely to benefit from trastuzumab.
In the subset analyses we have performed with patients from the HERA trial, we could not find a group of patients
who failed to benefit on the basis of patient and basic tumor characteristics. We are currently trying to recover the
tumor blocks of patients in the HERA trials -- it was unfortunate that there was no mechanism to systematically
collect these blocks when the trial was initiated. We still have to obtain about 2000 blocks, and the in-depth analysis
of these will form the basis for the translational research study.
Medscape: Given the recent results from several trials, can you comment on what may be the optimal
treatment duration for trastuzumab?
Dr. Piccart: This is a critical question. The HERA trial has another investigational arm evaluating 2 years of
trastuzumab. Clearly the 1- vs 2-year comparison is going to be very important in helping to determine optimal
treatment duration. If 2 years of trastuzumab are better than 1 year, it will indicate that duration of treatment, at least
with sequential single-agent trastuzumab, is important. But it is still unclear whether or not trastuzumab should be
given together with chemotherapy, and if given concurrently, there might be a profound synergism that allows a
much shorter duration of treatment. The Finnish group presented data [5] at SABCS from a provocative study in which
they gave only 9 weeks of trastuzumab in combination with either docetaxel or vinorelbine, followed by 3 cycles of
anthracycline-based therapy. A huge treatment effect was observed. This was a small study, and therefore not
definitive, but the results are highly intriguing.
I think that in the HERA trial, if 2 years turn out to be better than 1 year, then we will probably not be tempted to
evaluate a shorter duration of therapy. However, if 2 years are no better than 1 year, then we should start evaluating
trastuzumab in clinical trials of shorter duration.
Medscape: Do you have any concluding thoughts?
Dr. Piccart: Given that we have 4 trials of trastuzumab in the adjuvant setting using different approaches, the
question I am most often asked is "what is the best strategy?" We are fortunate that these trials have a
complementary design and that we have evaluated several ways in which to give trastuzumab. With the limited
knowledge we have now, I think that we must perform a careful evaluation of risks and benefits in individual
patients. So, for example, for a woman in her 60s with obvious cardiac risk factors and HER2-overexpresing, ER-
positive breast cancer, and a small number of positive nodes, I would be very confident in using the approach used in
the HERA trial. By contrast, for a young woman without cardiac risk factors, but with an aggressive tumor, I might
not want to wait until chemotherapy is completed to use trastuzumab. I would select one of the chemotherapy
regimens evaluated in the other trials, for example 4 cycles of doxorubicin/cyclophosphamide followed by
paclitaxel/trastuzumab. However, if this young woman were to express concern about the possibility of cardiac
toxicity, I might use the carboplatin-docetaxel approach with concomitant trastuzumab, because the regimen had
negligible cardiac toxicity but was highly effective.
It is a real benefit that we were able to conduct these trials so rapidly, that they have complementary designs, and that
they are all coming to maturity at about the same time. It means that we have more options for our patients than if
only one study had been carried out.
There is still a lot we could do for these women though. Since other anti-HER2 approaches are becoming available,
it is clear that we are going to build on these results with trastuzumab; we may combine targeted approaches, such as
with a combination of anti-HER2 and antiangiogenic agents. However, these strategies are expensive, so it will also
become increasingly important to be able to identify the subsets of patients that will benefit the most. But we are
truly living in exciting times.

HER-2/neu Not Linked to Breast Cancer Indicators in Black Women

NEW YORK (Reuters Health) Dec 07 - NER-2/neu status is not associated with breast cancer prognostic factors in African American
women, unlike in Caucasian women, according to a report in the November 15th issue of Cancer.
"Our findings came as a surprise to the members of the research team," Dr. Azadeh T. Stark from Henry Ford Health System, Detroit,
Michigan told Reuters Health. "Therefore, we re-evaluated and re-analyzed our data several times to further confirm our findings."
Dr. Stark and colleagues investigated the prevalence of positive HER-2/neu breast carcinoma in a group of African-American and
Caucasian women diagnosed with invasive breast cancer and evaluated race-specific risk for positive HER-2/neu breast carcinoma in
light of the pathologic prognostic indicators used in clinical settings.
African-American women were diagnosed with advanced stages of carcinoma almost twice as often as Caucasian women were, the
authors report, and more African-American women were diagnosed with poorly differentiated nuclear grade.
Slightly more African-American women (32%) than Caucasian women (29%) were diagnosed with HER-2/neu-positive breast
carcinomas, the results indicate, but the difference was not statistically significant.
Among African-American women, neither age nor pathologic prognostic indicators were significant predictors for positive HER-2/neu
status, the researchers note. For Caucasian women, on the other hand, these variables were significantly associated with positive HER-
2/neu status.
Unlike for Caucasian women, the report indicates, the risk for positive HER-2/neu status was not significantly associated with TNM
stage, nuclear grade, or their interaction or other pathologic prognostic indicators in African-American women.
Thus the investigators conclude that "pathologic predictive indicators for HER-2/neu gene amplification and/or overexpression of its
protein may differ for African-American women."
The finding, Dr. Stark added may be "the beginning of a new era for breast cancer diagnosis and potentially, treatment for African-
American women."
Cancer 2005;104:2189-2196.

HER2/neu Vaccine May Curb Breast Cancer Recurrence

NEW YORK (Reuters Health) Nov 22 - A vaccine based on a peptide from the HER2/neu protein prompts a specific immune response
and may prevent clinical recurrences in certain disease-free patients who have been treated for node-positive breast cancer (NPBC),
according to researchers.
"While our results are preliminary," lead investigator Dr. George E. Peoples told Reuters Health, "we are encouraged that this type of
trial, evaluating cancer prevention as opposed to cancer treatment, will ultimately reveal the power, and appropriate future use, of
cancer vaccines."
In the October 20th issue the Journal of Clinical Oncology, Dr. Peoples of Walter Reed Army Medical Center, Washington, DC and
colleagues note that E75 is an immunogenic peptide from the HER2/neu protein that is highly expressed in many breast cancers. "Our
clinical trials are investigating E75 mixed with GM-CSF as a simple vaccine strategy," the researchers explain.
The team used the vaccine in 24 HLA-A2+ patients with NPBC, while a further 29 HLA-A2- NPBC patients acted as controls.
Vaccinated patients showed clonal expansion of E75-specific CD8+ T cells, which lysed HER2/neu-expressing tumor cells.
At 22 months' median follow-up, the only two deaths that had occurred were in the control group. Disease-free survival was 85.7% in
the vaccinated group and 59.8% in controls. The recurrence rate was 8% in the vaccinated group and 21% in controls.
Dr. Peoples pointed out that the "reduction in recurrences in our vaccinated breast cancer patients is similar to the recent reports using
Herceptin - trastuzumab - a monoclonal antibody, that targets the same HER2/neu protein as our vaccine."
He added: "Preclinical data suggest that the two may be synergistic, and, therefore, the combination of Herceptin and our vaccine may
be even more effective in preventing recurrences in high risk breast cancer patients."
In an accompanying editorial, Drs. Lupe G. Salazar and Mary L. Disis of the University of Washington, Seattle, call the study data
"provocative" and note that it remains to be determined which patients might benefit most from vaccination.
J Clin Oncol 2005;23:7536-7545.

Volume 353:1673-1684 October 20, 2005 Number 16

Trastuzumab plus Adjuvant Chemotherapy for Operable HER2-
Positive Breast Cancer
Edward H. Romond, M.D., Edith A. Perez, M.D., John Bryant, Ph.D., Vera J. Suman, Ph.D., Charles E. Geyer, Jr., M.D., Nancy E. Davidson, M.D.,
Elizabeth Tan-Chiu, M.D., Silvana Martino, D.O., Soonmyung Paik, M.D., Peter A. Kaufman, M.D., Sandra M. Swain, M.D., Thomas M. Pisansky,
M.D., Louis Fehrenbacher, M.D., Leila A. Kutteh, M.D., Victor G. Vogel, M.D., Daniel W. Visscher, M.D., Greg Yothers, Ph.D., Robert B. Jenkins,
M.D., Ph.D., Ann M. Brown, Sc.D., Shaker R. Dakhil, M.D., Eleftherios P. Mamounas, M.D., M.P.H., Wilma L. Lingle, Ph.D., Pamela M. Klein,
M.D., James N. Ingle, M.D., and Norman Wolmark, M.D.
ABSTRACT
Background We present the combined results of two trials that compared adjuvant chemotherapy with or without
concurrent trastuzumab in women with surgically removed HER2-positive breast cancer.
Methods The National Surgical Adjuvant Breast and Bowel Project trial B-31 compared doxorubicin and
cyclophosphamide followed by paclitaxel every 3 weeks (group 1) with the same regimen plus 52 weeks of
trastuzumab beginning with the first dose of paclitaxel (group 2). The North Central Cancer Treatment Group
trial N9831 compared three regimens: doxorubicin and cyclophosphamide followed by weekly paclitaxel (group
A), the same regimen followed by 52 weeks of trastuzumab after paclitaxel (group B), and the same regimen
plus 52 weeks of trastuzumab initiated concomitantly with paclitaxel (group C). The studies were amended to
include a joint analysis comparing groups 1 and A (the control group) with groups 2 and C (the trastuzumab
group). Group B was excluded because trastuzumab was not given concurrently with paclitaxel.
Results By March 15, 2005, 394 events (recurrent, second primary cancer, or death before recurrence) had been
reported, triggering the first scheduled interim analysis. Of these, 133 were in the trastuzumab group and 261 in
the control group (hazard ratio, 0.48; P<0.0001). This result crossed the early stopping boundary. The absolute
difference in disease-free survival between the trastuzumab group and the control group was 12 percent at three
years. Trastuzumab therapy was associated with a 33 percent reduction in the risk of death (P=0.015). The three-
year cumulative incidence of class III or IV congestive heart failure or death from cardiac causes in the
trastuzumab group was 4.1 percent in trial B-31 and 2.9 percent in trial N9831.
Conclusions Trastuzumab combined with paclitaxel after doxorubicin and cyclophosphamide improves
outcomes among women with surgically removed HER2-positive breast cancer. (ClinicalTrials.gov numbers,
NCT00004067 [ClinicalTrials.gov] and NCT00005970 [ClinicalTrials.gov] .)

Data Support Herceptin With Hormonal Therapy

ZURICH, May 29 (Reuters) May 29 - Roche unveiled new data on Monday showing that its cancer drug Herceptin increased the time
some breast-cancer patients live without the cancer progressing when used in combination with hormonal therapy.
Swiss pharmaceutical group Roche said the late-stage, or Phase III, trial results were for patients whose advanced breast cancer was
hormone receptor-positive, as well as HER2-positive, a particularly aggressive form of the disease.
Hormone receptor-positive breast cancer affects two-thirds of patients with breast cancer and is typically considered lower-risk due to
successful treatment with hormonal therapies, the company said.
However, up to a quarter of these breast cancers are also HER2-positive, an aggressive form of the disease that requires immediate
attention because the tumours are fast-growing and there is a higher likelihood of relapse.
The study evaluated the blockbuster drug Herceptin plus hormone therapy Arimidex versus Arimidex alone as first-line therapy or
second-line hormonal therapy in postmenopausal women with advanced, HER2-positive and hormone receptor-positive breast cancer.
"Patients who received Herceptin had a statistically significant improvement in progression-free survival," Roche said in a statement.
Herceptin is currently only licensed in the European Union as a treatment for metastatic cancer - a late-stage condition where tumours
have spread around the body. European experts have backed the early use of the drug. A new approval would extend its use to a large
number of mainly younger patients.
The injectable medicine is suitable for 20 to 30 percent of women with a form of breast cancer whose tumours generate a protein
called HER2, making them particularly fast-growing.
Herceptin is Roche's third-biggest product, with sales last year of 2.15 billion Swiss francs ($1.72 billion), up 48 percent on 2004 in
local currency terms.
Analysts at bank ZKB in Zurich said sales in 2006 for the drug were estimated at 2.850 billion francs. "The new usage for Herceptin is
positive," they said in a daily note to investors.
Roche shares were down 0.26 percent at 188.50 francs at 0736 GMT, in line with the Dow Jones index of European drug peers
<.SX7P>.
Herceptin is marketed in the United States by Genentech , in Japan by Chugai and internationally by Roche.

Outcome of HER-2-Positive Breast Cancer Tied to Hormone Receptor Status

NEW YORK (Reuters Health) Dec 17 - HER-2-positive, hormone receptor-negative breast cancer patients have
a high risk of failure after chemotherapy, and the most common site of cancer recurrence after treatment failure
is the brain, Mayo Clinic researchers reported at the San Antonio Breast Cancer Symposium.
Breast cancers that are estrogen-receptor and progesterone-receptor negative are associated with the worst
outcomes, and require aggressive treatment right from the time of diagnosis, Dr. Laura Vallow of the Mayo
Clinic in Rochester, Minnesota, told Reuters Health.
Her group reviewed records of 120 women with brain metastases after an initial diagnosis of breast cancer
treated at their institution between June 1996 and November 2006. Of these women, data on HER-2 and
hormone receptor status were available for 83 women.
Of the 83 women, 39 or 47% were HER-2-positive. Nearly all (96%) had received radiation therapy at the time
brain metastases were diagnosed. The brain was the first site of treatment failure in 15 of the 39 women, or
38%, with 11 being hormone receptor-negative and 4 being hormone-positive.
HER-2-positive women with hormone receptor-positive disease had a median time from diagnosis to brain
metastasis of 45 months compared with 14.5 months for HER-2-positive women with hormone-receptor
negative disease.
Time to death from diagnosis of brain metastasis was 10 months for HER-2-positive, hormone receptor-positive
patients compared with 3 months for HER-2-positive, hormone-receptor-negative disease.
"This isn't the whole population," Dr. Vallow pointed out in comments to Reuters Health. "This is just women
with brain metastases, and this is a retrospective look. These numbers look pretty terrible, but the most recent
data show that disease-free survival has increased 12% and the risk of death has decreased 33% in our 2005
data."
Furthermore, "With Herceptin available now, we have a drug that can really make a difference," Dr. Vallow
stressed.
Anthracyclines of No Benefit in HER2-Negative Breast Cancer
December 27, 2007 — Anthracyclines have no effect on patients with breast cancer that is HER2-negative, and
so these patients could be spared unnecessary toxic effects from this class of agents, concludes a new meta-
analysis. The benefits of these agents seem to be confined to women who have HER2 overexpressed or
amplified breast tumors, the authors conclude in the January 2 issue of the Journal of the National Cancer
Institute.
The meta-analysis considered data from 8 published clinical trials and evaluated 5354 patients for whom HER2
information was available. For women with HER2-positive disease (n = 1536 patients), anthracyclines were
superior to non–anthracycline-based regimens in disease-free survival and overall survival, the researchers
report. The pooled hazard ratio (HR) for the risk for relapse was 0.71 (P < .001), and the HR for the risk for
death from any cause was 0.73 (P < .001).
However, for women with HER2-negative disease (n = 3818 patients), anthracyclines did not improve either
disease-free or overall survival. In this case, the pooled HRs for the risk for relapse was 1.00 (P = .75) and for
risk for death, 1.03 (P = .60).
"We believe that, based on the available evidence, the use of anthracyclines in the adjuvant treatment of HER2-
negative patients is no longer justified," lead researcher Alessandra Gennari, MD, PhD, from the National
Cancer Research Institute in Genoa, Italy, told Medscape Oncology.
Although anthracycline-containing regimens still represent the standard of care in early breast cancer, there has
been some "pulling away" from this class of drugs in the last year or so, Dr. Gennari commented. Results from
this meta-analysis, first reported at the San Antonio Breast Cancer Symposium last year, have contributed to this
trend, she said, but so have recent results from 2 large US studies, which have shown that regimens not
containing anthracyclines are less toxic and are just as effective, if not more so.
One of these studies, the Breast Cancer International Research Group 006, was conducted in women with
HER2-positive disease, but the other trial, from the US Oncology Group, was conducted in women with breast
cancer not selected by HER2 status, notes an accompanying editorial. The editorial suggests that taking into
consideration only HER2 status is too simple an approach. Editorialist Soonmyung Paik, MD, and colleagues
from the National Surgical Adjuvant Breast and Bowel Project at Allegheny General Hospital in Pittsburgh,
Pennsylvania, predict that in the future, "optimization of adjuvant chemotherapy for patients diagnosed with
breast cancer will depend on defining the baseline prognosis and chemosensitivity of each subclass of breast
cancer beyond those crudely defined by HER2 status alone."
In this rapidly evolving field, the just-published meta-analysis "may already have only historical importance,"
the editorial comments. However, Dr. Gennari takes issue with this comment. From a research perspective, it
may be correct because current studies are already focusing on newer questions, she concedes.
"However, from a clinical perspective, anthracycline-containing regimens still represent the standard of care in
early breast cancer. Our results summarize the existing data and provide the evidence that is needed to modify
treatment guidelines in this setting, with future consequences for tens of thousands of patients worldwide," she
told Medscape Oncology. "As a consequence, the clinical importance of our results is not at all historical."
The Italian Association for Cancer Research and the University of Genoa, Italy, funded this study.
J Natl Cancer Inst. 2008;100:2-4, 14-20.

Outcome of HER-2-Positive Breast Cancer Tied to

Hormone Receptor Status
NEW YORK (Reuters Health) Dec 17 - HER-2-positive, hormone receptor-negative breast cancer
patients have a high risk of failure after chemotherapy, and the most common site of cancer recurrence
after treatment failure is the brain, Mayo Clinic researchers reported at the San Antonio Breast Cancer
Symposium.
Breast cancers that are estrogen-receptor and progesterone-receptor negative are associated with the
worst outcomes, and require aggressive treatment right from the time of diagnosis, Dr. Laura Vallow of
the Mayo Clinic in Rochester, Minnesota, told Reuters Health.
Her group reviewed records of 120 women with brain metastases after an initial diagnosis of breast
cancer treated at their institution between June 1996 and November 2006. Of these women, data on
HER-2 and hormone receptor status were available for 83 women.
Of the 83 women, 39 or 47% were HER-2-positive. Nearly all (96%) had received radiation therapy at
the time brain metastases were diagnosed. The brain was the first site of treatment failure in 15 of the
39 women, or 38%, with 11 being hormone receptor-negative and 4 being hormone-positive.
HER-2-positive women with hormone receptor-positive disease had a median time from diagnosis to
brain metastasis of 45 months compared with 14.5 months for HER-2-positive women with hormone-
receptor negative disease.
Time to death from diagnosis of brain metastasis was 10 months for HER-2-positive, hormone
receptor-positive patients compared with 3 months for HER-2-positive, hormone-receptor-negative
disease.
"This isn't the whole population," Dr. Vallow pointed out in comments to Reuters Health. "This is just
women with brain metastases, and this is a retrospective look. These numbers look pretty terrible, but
the most recent data show that disease-free survival has increased 12% and the risk of death has
decreased 33% in our 2005 data."
Furthermore, "With Herceptin available now, we have a drug that can really make a difference," Dr.
Vallow stressed.

Novel Peptide Vaccine Reduces Mortality in Women With HER2-

Overexpression Breast Cancer
April 15, 2008 (San Diego, California) — A novel peptide vaccine was able to reduce the mortality rate
in women with HER2/neu overexpressing breast cancer by about half, researchers report here at the
American Association for Cancer Research (AACR) 2008 Annual Meeting.
"The numbers in this study are small but the concept is good," commented William N. Hait, MD, PhD,
president of the AACR and senior vice president of Worldwide Hematology and Oncology Research
and Development at Johnson & Johnson. "It's a good first step and we are cautiously optimistic."
HER2/neu is a source of immunologic peptides and approximately 30% of early-stage breast cancers
have an amplified HER2/neu gene or overexpression of its protein product. There has been a great deal
of interest in the HER2 gene, explained lead author Linda C. Benavides, MD, a general surgical
resident at Brooke Army Medical Center in San Antonio, Texas. "Historically, we have focused on
patients because they are candidates for Herceptin. Our vaccine showed a response in patients who
expressed HER2/neu at all levels, including low expressers for whom no therapy is available."
"Most vaccine trials have been performed in the metastatic setting," she told journalists, "But our
results show that the vaccine is safe in women with minimum symptoms. It decreased mortality and
morbidity."
What was most surprising in this study was that patients with low-HER2/neu-expressing tumors
responded so well to the vaccine. In fact, Dr. Benavides pointed out, the patients with low-expressing
(0 to 2+ on immunohistochemistry [IHC]) HER2/neu tumors had a better response to the vaccine than
women with higher-expressing tumors. They experienced not only a better immune response, but a
better clinical one as well, as demonstrated by a decreased rate of breast cancer recurrence and 0%
mortality after E75 peptide vaccination.
The researchers had previously conducted clinical trials with the HER2/neu E75 peptide vaccine in
both node-positive and node-negative breast cancer patients who demonstrated a variety of levels of
HER2/neu expression. In this study, they performed a subset analysis review that was based on the
level of HER2/neu expression in the 163 patients who were enrolled in their E75 vaccine trial.
All patients were typed for human leukocyte antigen (HLA). Women who were HLA-A2+/A3+
received the vaccine; women who were HLA-A2–/A3– served as the control group. Overexpression
was defined as fluorescence in situ hybridization (FISH) greater than 2.0 and IHC 3+ HER2/neu
tumors; low expression was defined as IHC ranging from 0 to 2+.
Of the 92 vaccinated patients, 29 (34%) were defined as HER2 overexpressors and 56 (66%) were
defined as low-expressors. The control group (n = 71) included 22 (33%) overexpressors and 44 (67%)
low-expressors. The HER2/neu overexpressors were similar in regard to prognostic and treatment
factors, although a statistically larger number of vaccinated women who overexpressed HER2 were
also hormone-receptor negative and node negative (P = 0.007).
At a median follow-up of 30 months, the rates of disease recurrence were similar between HER2/neu
overexpressors in both the vaccine and control groups (18.2% vs 13.8%). However, the researchers
noted that the mortality rate was 50% lower among the vaccinated patients who had a disease
recurrence (25% vs 50%).
The researchers also noted that recurrence rates were substantially reduced in vaccinated patients with
low HER2/neu expression. They experienced a 10.7% recurrence rate, compared with the 18.2% seen
in the control group. This subgroup showed not only a better immunologic response, but also a better
mortality rate (0%).
"This may represent a new form of HER2-directed therapy, because the low expressors do not qualify
for trastuzumab," Dr. Benavides said. "The vaccine has been registered for a phase 3 trial, which will
focus on low-expressing women."
The first phase 3 trial in low-expressing women is slated to begin in the fall. Based on the data
presented at AACR, the phase 3 trial has been restructured and is the first to focus on low-expressing
women, explained Dr. Benavides.
American Association for Cancer Research (AACR) 2008 Annual Meeting: Abstract 2545. Presented
April 14, 2008.

Previous Volume 353:1652-1654 October 20, 2005 Number 16 Next

The Distinctive Nature of HER2-Positive Breast Cancers

Harold J. Burstein, M.D., Ph.D.
Breast cancer is not a single disease but a group of several important tumor subtypes, each with a different natural history and each
requiring a different treatment. Overexpression of HER2 (which derives its name from human epidermal growth factor receptor 2)
defines one of these unique subtypes. The HER2/neu gene is a member of a family of genes encoding transmembrane receptors for
growth factors, including the epidermal growth factor receptor (EGFR), HER2, HER3, and HER4. The intracellular domain of HER2
has tyrosine kinase activity that regulates important aspects of the physiology, growth, and differentiation of cells.1,2 Extracellular
domains of the HER2 protein interact with HER family members, allowing HER2 to serve as a coreceptor and to facilitate signal
transduction as part of a heterodimer complex that forms after ligand binding. There is no known ligand for HER2 itself, however,
suggesting that the primary role of HER2 is to modulate signals after ligand binding to other HER-family receptors.
Amplification of the HER2/neu oncogene and related genetic elements in the amplicon on chromosome 17 causes a marked increase
(up to 100 times the usual level) in the expression of HER2 on the surface of breast-tumor cells. The mechanism of the selective
amplification of HER2/neu is unknown. Overexpression of HER2 can transform cultured cells into a malignant phenotype and
accelerate tumorigenesis. Overexpression of HER2 appears to encourage the formation of receptor homodimers and heterodimers
involving HER2, with different signaling properties than seen normally.
HER2 became clinically relevant with the demonstration that HER2-positive breast cancers have a worse prognosis than HER2-
negative tumors.3 Between 15 and 20 percent of invasive breast cancers are HER2-positive; amplification of the gene and the resultant
overexpression of HER2 occur during the in situ stage of tumor development. After HER2/neu amplification has occurred, the HER2
phenotype is thought to be fixed for the duration of the natural history of the invasive tumor. For this reason, testing for HER2 can be
performed on either the primary tumor or a metastatic tumor deposit, generally with similar results.
HER2-positive breast cancers have a distinctive molecular signature, including extensive changes in the patterns of gene expression
that distinguish these cancers from other types of breast cancer.4 They also have distinctive clinical features. Population-based studies
and retrospective analyses have shown that overexpression of HER2 is an adverse prognostic factor that is associated with poorly
differentiated, high-grade tumors, high rates of cell proliferation and lymph-node involvement, and a relative resistance to certain types
of chemotherapy. Anthracycline-based adjuvant chemotherapy is particularly beneficial in HER2-positive tumors. Roughly half of
HER2-positive breast cancers also express the steroid hormone receptors for estrogen, progesterone, or both. However, in these
tumors, the levels of steroid hormone receptors are typically lower than in HER2-negative, hormone-receptor–positive tumors, and for
this reason, in part, HER2-positive breast cancer is relatively resistant to tamoxifen. All these factors contribute to the greater risk of
recurrence among women with HER2-positive breast cancer than in those with HER2-negative breast cancer. HER2/neu gene
amplification is rare outside breast cancer. Tumors other than breast cancer with some degree of HER2 positivity typically express far
less HER2 than breast cancers, without evidence of gene amplification.
Trastuzumab, a humanized monoclonal antibody against HER2 created by inserting portions of the antigen-binding site of a mouse
monoclonal antibody against HER2 into a human monoclonal antibody, was developed after it had been recognized that HER2
overexpression served as both a marker of aggressive disease and a target for treatment. Because laboratory and clinical studies
indicated that the inhibition of cell growth by trastuzumab is limited to HER2-positive cancers, testing tumors for expression of HER2
became integral to the selection of patients for clinical trials of the efficacy of trastuzumab. Because of the success of these trials,
HER2 testing became routine in the care of patients with breast cancer, although controversy remains as to the best method of testing.
The studies reported in this issue of the Journal by Piccart-Gebhart and colleagues (pages 1659–1672) and Romond and colleagues
(pages 1673–1684) are the culmination of a decade-long adventure in clinical investigation. They show that trastuzumab can
dramatically improve outcomes among women with HER2-positive breast cancer. The clinical observations are clear, but the scientific
basis for the effects of trastuzumab is uncertain. Laboratory studies and limited data from clinical trials suggest myriad possible
mechanisms of action of trastuzumab (see diagram). After binding to the HER2 protein, trastuzumab contributes to apoptosis, causes
down-regulation of surface HER2 expression, alters downstream signaling and regulatory pathways in the cell cycle, suppresses the
production of the angiogenic factor vascular endothelial growth factor (VEGF), and potentiates the effects of chemotherapy. There may
also be an extracellular effect, possibly in mediating antibody-dependent immune recognition.
Interactions between Trastuzumab and Tumor Cells.
HER2 serves as a coreceptor with related members of the HER family of tyrosine kinase–associated growth
factors. Acquired amplification of the HER2/neu gene on chromosome 17 in HER2-positive breast cancer
leads to marked overexpression of HER2 on the cell surface, which alters normal signaling function.
Trastuzumab is a humanized monoclonal antibody that binds to HER2 and inhibits tumor-cell growth
through a variety of intracellular, and possibly extracellular, mechanisms.

Trastuzumab appears to have no clinical benefit in HER2-negative breast cancers, in which normal levels of HER2 protein are
expressed. This finding suggests that a critical density or threshold of HER2 expression or gene amplification is necessary for
trastuzumab to act. Similarly, trastuzumab lacks substantial activity against other non-breast tumors, even if they express moderately
elevated HER2 levels. It seems likely that the clinical use of trastuzumab will be narrowly confined to the unique subtype of HER2-
positive breast cancer.
A better understanding of the biologic actions of trastuzumab is critical to improving treatments that target HER2. For instance, trials
of adjuvant treatment have not determined whether the potentiation of the effect of chemotherapy by trastuzumab warrants concurrent
chemotherapy and trastuzumab administration, or whether sequential treatments would be adequate. Similarly, the optimal duration of
therapy may depend on how, precisely, trastuzumab works. As yet, there is no defined threshold of HER2 gene amplification that
predicts which HER2-positive tumors will respond to treatment. It seems probable that the greater the degree of gene amplification, the
greater the potential benefit, but this possibility has not been tested clinically.
Resistance to trastuzumab is now a problem, but we do not understand its mechanism. Strategies to overcome resistance include
interference with the coreceptor role of HER2 by blocking interactions with other HER-family receptors or the modulation of related
signaling or apoptotic pathways. In vitro models suggest important crosstalk between HER2-driven signal paths and both VEGF-
receptor and estrogen-receptor pathways. Clinical trials that use both anti-HER2 and anti-estrogen therapies or an anti-VEGF antibody
are under way and may prove fruitful.
The history of HER2 and trastuzumab treatment is a triumphal narrative of translational research. An oncogene, originally discovered
in a rat model of chemically induced carcinogenesis, was found to have a sequence that resembled that of a normal cellular gene. The
HER2/neu gene, when overexpressed, transforms normal cells into cancer cells. Next, overexpression of the gene was found in human
breast cancers, where it was shown to contribute to a poor prognosis. A novel antibody therapy that targets the overabundant HER2
protein was developed, and this antibody now redefines the natural history of the disease and establishes a new standard of treatment
for breast cancer. It is a dramatic story that epitomizes the often cited cliché of "bedside to bench to bedside" research.
Like all good stories, this one has a profound lesson: not all breast cancers are the same. Hormone receptors, HER2, and increasingly,
genomic profiles distinguish at least four major classes of breast cancer: HER2-positive tumors; HER2-negative, hormone-receptor–
positive tumors, which can be divided into two classes, favorable and unfavorable, on the basis of genomic and pathobiologic features;
and basal-like tumors that express neither HER2 nor hormone receptors. The growing appreciation of the biologic diversity of breast
cancer is forcing treatment into patterns that reflect the underlying biologic features of the tumor, and it challenges us to redefine
principles of therapy for each distinctive class of breast cancer.
 Previous Volume 353:1659-1672 October 20, 2005 Number 16 Next

Trastuzumab after Adjuvant Chemotherapy in HER2-Positive Breast

Cancer
Martine J. Piccart-Gebhart, M.D., Ph.D., Marion Procter, M.Sci., Brian Leyland-Jones, M.D., Ph.D., Aron Goldhirsch, M.D., Michael
Untch, M.D., Ian Smith, M.D., Luca Gianni, M.D., Jose Baselga, M.D., Richard Bell, M.D., Christian Jackisch, M.D., David
Cameron, M.D., Mitch Dowsett, Ph.D., Carlos H. Barrios, M.D., Günther Steger, M.D., Chiun-Shen Huang, M.D., Ph.D., M.P.H.,
Michael Andersson, M.D., Dr.Med.Sci., Moshe Inbar, M.D., Mikhail Lichinitser, M.D., István Láng, M.D., Ulrike Nitz, M.D., Hiroji
Iwata, M.D., Christoph Thomssen, M.D., Caroline Lohrisch, M.D., Thomas M. Suter, M.D., Josef Rüschoff, M.D., Tamás Süt , M.D.,
Ph.D., Victoria Greatorex, M.Sc., Carol Ward, M.Sc., Carolyn Straehle, Ph.D., Eleanor McFadden, M.A., M. Stella Dolci, Richard D.
Gelber, Ph.D., for the Herceptin Adjuvant (HERA) Trial Study Team
ABSTRACT
Background Trastuzumab, a recombinant monoclonal antibody against HER2, has clinical activity in advanced breast cancer that
overexpresses HER2. We investigated its efficacy and safety after excision of early-stage breast cancer and completion of
chemotherapy.
Methods This international, multicenter, randomized trial compared one or two years of trastuzumab given every three weeks with
observation in patients with HER2-positive and either node-negative or node-positive breast cancer who had completed locoregional
therapy and at least four cycles of neoadjuvant or adjuvant chemotherapy.
Results Data were available for 1694 women randomly assigned to two years of treatment with trastuzumab, 1694 women assigned to
one year of trastuzumab, and 1693 women assigned to observation. We report here the results only of treatment with trastuzumab for
one year or observation. At the first planned interim analysis (median follow-up of one year), 347 events (recurrence of breast cancer,
contralateral breast cancer, second nonbreast malignant disease, or death) were observed: 127 events in the trastuzumab group and 220
in the observation group. The unadjusted hazard ratio for an event in the trastuzumab group, as compared with the observation group,
was 0.54 (95 percent confidence interval, 0.43 to 0.67; P<0.0001 by the log-rank test, crossing the interim analysis boundary),
representing an absolute benefit in terms of disease-free survival at two years of 8.4 percentage points. Overall survival in the two
groups was not significantly different (29 deaths with trastuzumab vs. 37 with observation). Severe cardiotoxicity developed in 0.5
percent of the women who were treated with trastuzumab.
Conclusions One year of treatment with trastuzumab after adjuvant chemotherapy significantly improves disease-free survival among
women with HER2-positive breast cancer. (ClinicalTrials.gov number, NCT00045032 [ClinicalTrials.gov] .)

Her2/neu (hereafter referred to as HER2) belongs to a family of four transmembrane receptor tyrosine kinases that mediate the growth,
differentiation, and survival of cells.1,2 Overexpression of the HER2 protein, amplification of the HER2 gene, or both occur in
approximately 15 to 25 percent of breast cancers, and are associated with aggressive behavior in the tumor.3,4
Trastuzumab (Herceptin, Roche), a humanized monoclonal antibody against the extracellular domain of HER2, has been shown to
benefit patients with HER2-positive metastatic breast cancer when administered weekly or every three weeks, alone5,6 or in
combination with chemotherapy.7,8 Trastuzumab is not associated with the adverse events that typically occur with chemotherapy, such
as alopecia, myelosuppression, and severe nausea and vomiting.9 With the exception of hypersensitivity, which has been seen mainly
and occasionally with the first infusion, cardiotoxicity (principally congestive heart failure) is the most important adverse effect of
trastuzumab. Cardiotoxicity has been reported in 1.4 percent of women who received the drug as a single agent for metastatic
disease.5,6 The adverse effect of the interaction between trastuzumab and anthracyclines on the heart7 and the lesser adverse effect of
the interaction between trastuzumab and taxanes7,8 are concerns in the design and conduct of studies of adjuvant therapy, given the
established activity and central role of anthracyclines and taxanes in the treatment of breast cancer. For this reason, investigations of
trastuzumab in the adjuvant setting require careful cardiac monitoring and stopping rules specified for cardiotoxicity.
Our group investigated whether the administration of trastuzumab was effective as adjuvant treatment for HER2-positive breast cancer
if used after completion of the primary treatment (e.g., surgery, radiotherapy, and chemotherapy given preoperatively [neoadjuvant],
postoperatively [adjuvant], or both). The administration of trastuzumab after chemotherapy permits the application of our findings to
the wide variety of chemotherapy regimens used throughout the world.10 In our trial, one group of women received trastuzumab for one
year and another group received the drug for two years. We included these two groups for three reasons: a major peak in the rate of
relapse occurs 18 to 24 months after surgery,11 effective treatment of HER2-positive breast cancer may require prolonged attenuation of
HER2 activity,12 and tamoxifen, which is an effective targeted therapy for breast cancer, is most beneficial when given for longer than
one year.13 We report a comparison of the results obtained with observation or with one year of trastuzumab after primary treatment of
breast cancer.
Discussion
This study shows that trastuzumab can benefit women with HER2-positive breast cancer when given after completion of adjuvant
chemotherapy. As compared with observation after primary therapy (including surgery with or without radiotherapy and neoadjuvant
or adjuvant chemotherapy), trastuzumab given after primary therapy reduced the rate of recurrence, particularly distant recurrence, by
approximately 50 percent. This degree of benefit in early breast cancer is the largest to be reported since the introduction of tamoxifen
in hormone-receptor–positive disease. This trial is the culmination of a collaboration between basic research scientists and clinical
investigators over the past two decades. 1,2,3,4,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33
The interpretation of our results must take into account the very short follow-up period — a median of 12 months and a maximum of
36 months. However, the pattern of early, and largely distant, relapse found among patients with HER2-positive breast cancer, and the
clinically and statistically significant reduction in the risk of relapse achieved with trastuzumab, justified release of the results of the
interim efficacy analysis.
We acknowledge that we have only an incomplete picture of the risks associated with trastuzumab. The risk of cardiotoxicity is
currently low in our trial, but this could change with longer follow-up. Another concern is that longer follow-up may show that
trastuzumab is not effective in reducing the incidence of disease recurrence in the central nervous system. Brain metastases developed
in approximately one third of the women receiving trastuzumab as treatment for advanced breast cancer, despite control of systemic
disease.34 It is not clear whether such central nervous system metastases reflect aggressive disease or poor penetration of trastuzumab
into the brain.
Will the benefit of adjuvant trastuzumab accrue to all women who have HER2-positive breast cancer who are treated outside clinical
trials? Women with small ( 1 cm in diameter), node-negative invasive tumors were not eligible for this trial. Although at a median of
one year of follow-up, trastuzumab improved the disease-free survival in all subgroups (Figure 3), further follow-up may show that the
magnitudes of absolute benefit differ across subgroups. For example, almost 60 percent of the disease-free–survival events observed so
far occurred in the hormone-receptor–negative cohort (48 percent of the patients), but we cannot rule out the possibility that in the
future disease-free–survival events may occur disproportionately more often among patients in the subgroup with hormone-receptor–
positive tumors. By design, women with cardiac risk factors and an LVEF of less than 55 percent after completion of chemotherapy
with or without radiotherapy were excluded from the study, and our data are not applicable to the treatment of such women.
In our study, HER2 overexpression or HER2 amplification had to be confirmed by a central laboratory before randomization, thereby
reducing the risk of false positive results. It is our view that adjuvant trastuzumab should be considered only if the HER2-positive
status of the tumor has been determined by a high-volume laboratory with quality-control procedures.35
The results of the HERA trial should be widely applicable to women with HER2-positive breast cancer for the following reasons:
different types of neoadjuvant or adjuvant chemotherapy were allowed before the initiation of trastuzumab; the schedule of
administration of one dose every three weeks, which was shown in the metastatic setting to have efficacy, side effects, and
pharmacokinetics similar to those of the weekly schedule,6 was used; and patients with node-negative disease were included. It appears
that trastuzumab is effective regardless of the type of chemotherapeutic regimens received before treatment with trastuzumab and the
extent of nodal involvement.
We do not know if introducing trastuzumab early in the course of adjuvant systemic therapy, concomitantly with chemotherapy, could
further improve the outcome. The question of timing is likely to remain unanswered, because early administration of trastuzumab, as
studied in ongoing trials,36,37 requires the drug to be used concurrently with specific chemotherapy regimens that are hypothesized to
enhance the effectiveness of trastuzumab.30,32
The results of this trial indicate that one year of adjuvant trastuzumab should be considered a standard option on completion of
locoregional therapy and neoadjuvant or adjuvant chemotherapy for women who fulfill the study eligibility criteria used in the HERA
trial.

Previous Volume 345:995-998 September 27, 2001 Number 13 Next

Trastuzumab and Breast Cancer

To the Editor: Slamon et al. (March 15 issue)1 show that the addition of trastuzumab, a monoclonal antibody against the human
epidermal growth factor receptor HER2 (also known as HER2/neu), to chemotherapy in women with metastatic breast cancer that
overexpresses HER2 is associated with significantly better responses and longer survival than chemotherapy alone. However,
cardiotoxicity is the most serious complication of trastuzumab, especially when it is administered in combination with
anthracyclines.1,2,3
We hypothesized that cardiotoxicity and antitumor efficacy may be related to specific uptake of trastuzumab in the myocardium and
tumor, respectively. Twenty patients with metastatic breast cancer that expressed HER2 received a tracer dose of radiolabeled
trastuzumab (111In-DTPA-trastuzumab4) to determine whether pretreatment external scintigraphy may allow for such predictions.
Planar and tomographic scans were performed after injection of the tracer dose, which was coadministered at a loading dose of 4 mg
per kilogram of body weight. Subsequently, all patients were treated with trastuzumab either as monotherapy (4 women) or combined
with epirubicin and cyclophosphamide (11 women) or paclitaxel chemotherapy (5 women).1
Seven of the 20 patients had scintigraphic evidence of myocardial uptake (Figure 1); in 6 of them New York Heart Association class II
to IV cardiotoxicity subsequently developed (1 was treated with trastuzumab alone, 4 with trastuzumab plus epirubicin and
cyclophosphamide, and 1 with trastuzumab plus paclitaxel); the seventh woman with myocardial uptake had episodes of cardiac
arrhythmia during the administration of trastuzumab. In contrast, in the 13 patients without myocardial uptake, no adverse cardiac
effects occurred. All 11 patients with intense scintigraphic evidence of tumor uptake had objective responses (10 had partial
remissions and 1 had a complete remission; 1 was treated with trastuzumab alone, 7 with trastuzumab plus anthracycline and
cyclophosphamide, and 3 with trastuzumab plus paclitaxel), in contrast to only 1 of the 9 women without trastuzumab uptake by the
tumor.
 Figure 1. A Single-Photon-Emission Computed Tomographic Image Showing a Sagittal Slice through the Lower
Chest and Upper Abdominal Region of a Woman with Metastatic Breast Cancer and a Large Hepatic Metastasis in
the Left Lobe of the Liver.
Strong uptake is seen in the liver metastasis, which has almost replaced the left hepatic lobe (arrow), as well as in
the horseshoe-shaped myocardial wall (arrowheads) located above. A denotes anterior, and P posterior.

These data suggest that pretreatment scanning with a tracer dose of radiolabeled trastuzumab can predict the cardiotoxicity and
therapeutic efficacy of trastuzumab. Although the pathophysiological basis of the observed cardiotoxicity remains unclear, the
targeting of trastuzumab to the myocardium of women in whom adverse cardiac effects eventually develop suggests the expression of
HER2 or a related cross-reactive antigen in the heart as the underlying mechanism.

Thomas M. Behr, M.D.

Martin Béhé, Ph.D.
Philipps University
D-35043 Marburg, Germany
tmbehr@mailer.uni-marburg.de

Bernhard Wörmann, M.D.

Georg-August University
D-37075 Göttingen, Germany
References
1. Slamon DJ, Leyland-Jones B, Shak S, et al. Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic
breast cancer that overexpresses HER2. N Engl J Med 2001;344:783-792.[Abstract/Full Text]
2. Eisenhauer EA. From the molecule to the clinic -- inhibiting HER2 to treat breast cancer. N Engl J Med 2001;344:841-842.
[Full Text]
3. Cobleigh MA, Vogel CL, Tripathy D, et al. Multinational study of the efficacy and safety of humanized anti-HER2
monoclonal antibody in women who have HER2-overexpressing metastatic breast cancer that has progressed after chemotherapy for
metastatic disease. J Clin Oncol 1999;17:2639-2648.[Abstract/Full Text]
4. Angerstein C, Behr TM, Behe M, Becker W. Kit formulation for In-111-labeled trastuzumab (Herceptin) for
immunoscintigraphy of metastatic breast cancer expressing the HER2/neu receptor. Eur J Nucl Med 2000;27:916-916.abstract

To the Editor: Slamon and associates show that trastuzumab treatment combined with conventional first-line chemotherapy can be
beneficial for patients with metastatic breast cancer that overexpresses HER2 but can cause cardiotoxicity in up to 27 percent of
patients. We report on a 60-year-old woman with metastatic breast cancer (with more than moderate staining for HER2 [a score of 3+])
who had received prior treatment with 350 mg of anthracyclines per square meter of body-surface area. The left ventricular ejection
fraction was normal at base line (65 percent; normal range, greater than 55 percent) but decreased to 55 percent after 10 weeks of
treatment with 2 mg of trastuzumab per kilogram and 90 mg of paclitaxel per square meter. Two weeks later, the patient had symptoms
and signs of heart failure without elevation of cardiac enzymes (creatine kinase MB isoenzyme and troponin). Cardiac catheterization
showed a left ventricular ejection fraction of 32 percent and elevated filling pressures but no coronary artery disease. Biopsies of left
ventricular tissue revealed messenger RNA encoding HER2 and HER4 (Figure 1). Trastuzumab therapy was stopped, and the left
ventricular ejection fraction rose to 70 percent at 6 weeks and 72 percent at 18 weeks.
Figure 1. Messenger RNA Encoding HER2 and HER4 Detected by Quantitative Real-Time Polymerase-
Chain-Reaction Analysis from Total RNA of the Left Ventricular Tissue Obtained from Five Endomyocardial
Biopsies.1

Our report demonstrates the presence of HER2 in human cardiac tissue; trastuzumab may therefore have a direct cardiotoxic effect
mediated by the cardiac HER2 receptor. Neuregulins (also called heregulins) and their cognate receptors, HER2 (also called ErbB2)
and HER4 (also called ErbB4), but not HER3, have been found in ventricular myocytes in neonatal and adult rats.2 In cultured rat
myocytes, neuregulin promoted survival and inhibited apoptosis. The tissue from our patient was therefore probed for HER2 and
HER4. However, since in our patient contractile dysfunction was reversible within a few weeks and cardiac enzymes remained within
 the normal range, it is unlikely that trastuzumab induced major structural damage to the heart (i.e., apoptosis or necrosis). Further
research is warranted to confirm this probable reversible mechanism of trastuzumab-induced cardiac dysfunction.

Florian Strasser, M.D.

Daniel C. Betticher, M.D.
Thomas M. Suter, M.D.
University Hospital Bern
3010 Bern, Switzerland
References
1. Gibson UE, Heid CA, Williams PM. A novel method for real time quantitative RT-PCR. Genome Res 1996;6:995-1001.
[Abstract]
2. Zhao YY, Sawyer DR, Baliga RR, et al. Neuregulins promote survival and growth of cardiac myocytes: persistence of ErbB2
and ErbB4 expression in neonatal and adult ventricular myocytes. J Biol Chem 1998;273:10261-10269.[Abstract/Full Text]

To the Editor: Slamon et al. documented a high level of cardiotoxicity in patients to whom trastuzumab was administered together
with anthracycline and cyclophosphamide chemotherapy, as compared with the other treatment groups. However, the authors leave
unanswered the key question of whether the onset of cardiac dysfunction is related to the duration of trastuzumab treatment. No
information is provided about the cumulative dose of trastuzumab and its relation with the subsequent development of cardiotoxicity in
the group that received trastuzumab plus anthracycline and cyclophosphamide. The data on the cumulative dose of trastuzumab and
cardiotoxicity from this trial may provide clues on how best to meet the difficult challenge of how to combine trastuzumab with
chemotherapeutic agents to maximize its potential benefit while minimizing its cardiotoxicity.

Carlo Palmieri, M.B., B.S.

Thomas Powles, M.B., B.S.
David Vigushin, M.B., B.Ch., Ph.D.
Imperial College School of Medicine
London W12 0NN, United Kingdom

To the Editor: In November 1998, a 52-year-old man presented with ulcerated cancer of the left breast in the central subareolar region.
He had no family history of breast cancer. He received three preoperative courses of epirubicin (90 mg per square meter) and
cyclophosphamide (600 mg per square meter) at three-week intervals. After the tumor had shrunk, radical mastectomy with axillary
lymphadenectomy was performed. Pathological evaluation (according to the criteria of the International Union against Cancer and the
American Joint Committee on Cancer1 and the modified criteria of Bloom and Richardson2) revealed an invasive ductal breast cancer
(pT4b, N2, M0, G3) that expressed estrogen and progesterone receptors (Figure 1A). After surgery, another five cycles of epirubicin
and cyclophosphamide were given, followed by irradiation of the left side of the chest wall. Finally, the patient received 20 mg of
tamoxifen daily.
Figure 1. Breast Cancer in a 52-Year-Old Man.
The histologic appearance of the primary tumor revealed an invasive ductal breast cancer (hematoxylin and
eosin, x40) (Panel A), and overexpression of HER2 (indicated by a score of 3+) was observed on
immunohistochemical staining (Panel B). Amplification of the HER2 gene was detected by fluorescence in
situ hybridization. Up to 20 intranuclear signals were observed individually and in clusters (arrow in Panel
C). A computed tomographic scan revealed an intrapulmonary metastasis in the lower left lobe of the lung
(arrow in Panel D). Four months after the initiation of treatment with trastuzumab and paclitaxel, the lung
metastasis was no longer detectable (Panel E).

In October 2000, a recurrence in the area of the mastectomy scar was removed by wide local excision. Histopathological evaluation
confirmed a metastasis of the primary breast cancer. At the same time, computed tomography revealed an intrapulmonary metastasis
(1.5 cm in diameter) in the left lower lobe (Figure 1D) and multiple metastases in the thoracic spine.
Immunostaining with an antibody against HER2 (A0485, Dako, Hamburg, Germany) demonstrated intense staining in the primary
tumor and the metastasis (Figure 1B). Fluorescence in situ hybridization (HER2-neu Gene Detection System, Ventana, Frankfurt,
Germany) showed up to 20-fold amplification of the HER2 gene (Figure 1C).
In women with breast cancer that overexpresses HER2, trastuzumab treatment extends remission periods and increases the response
rate when given in combination with paclitaxel. After the patient provided written informed consent, we administered 12 courses of
paclitaxel (90 mg per square meter) and trastuzumab (4 mg per kilogram during the first week and 2 mg per kilogram thereafter) at
weekly intervals. The bone metastases were treated with 90 mg of pamidronate every four weeks. Four months later, the lung
metastasis was undetectable (Figure 1E). A magnetic resonance imaging scan revealed no changes in the metastases to the thoracic
spine. As of July 2001 (nine months after the initiation of trastuzumab therapy), the patient is in partial clinical remission and good
clinical condition while continuing to receive trastuzumab.
The prognostic significance of HER2 protein expression in male breast cancer is controversial, and there is insufficient information
concerning amplification of the HER2 gene in these tumors.3,4 Our findings indicate that genomic amplification of the HER2 oncogene
may have a role in the development of male breast cancer and that the monoclonal antibody trastuzumab offers a reasonable treatment
option.

Christian Rudlowski, M.D.

Werner Rath, M.D.
University Hospital Aachen
D-52074 Aachen, Germany
rudlowski@t-online.de

Albert J. Becker, M.D.

Otmar D. Wiestler, M.D.
Reinhard Buttner, M.D.
University of Bonn Medical Center
D-53113 Bonn, Germany

Previous Volume 353:1673-1684 October 20, 2005 Number 16 Next

Trastuzumab plus Adjuvant Chemotherapy for Operable HER2-

Positive Breast Cancer
Edward H. Romond, M.D., Edith A. Perez, M.D., John Bryant, Ph.D., Vera J. Suman, Ph.D., Charles E. Geyer, Jr., M.D., Nancy E.
Davidson, M.D., Elizabeth Tan-Chiu, M.D., Silvana Martino, D.O., Soonmyung Paik, M.D., Peter A. Kaufman, M.D., Sandra M.
Swain, M.D., Thomas M. Pisansky, M.D., Louis Fehrenbacher, M.D., Leila A. Kutteh, M.D., Victor G. Vogel, M.D., Daniel W. Visscher,
M.D., Greg Yothers, Ph.D., Robert B. Jenkins, M.D., Ph.D., Ann M. Brown, Sc.D., Shaker R. Dakhil, M.D., Eleftherios P. Mamounas,
M.D., M.P.H., Wilma L. Lingle, Ph.D., Pamela M. Klein, M.D., James N. Ingle, M.D., and Norman Wolmark, M.D.
ABSTRACT
Background We present the combined results of two trials that compared adjuvant chemotherapy with or without concurrent
trastuzumab in women with surgically removed HER2-positive breast cancer.
Methods The National Surgical Adjuvant Breast and Bowel Project trial B-31 compared doxorubicin and cyclophosphamide followed
by paclitaxel every 3 weeks (group 1) with the same regimen plus 52 weeks of trastuzumab beginning with the first dose of paclitaxel
(group 2). The North Central Cancer Treatment Group trial N9831 compared three regimens: doxorubicin and cyclophosphamide
followed by weekly paclitaxel (group A), the same regimen followed by 52 weeks of trastuzumab after paclitaxel (group B), and the
same regimen plus 52 weeks of trastuzumab initiated concomitantly with paclitaxel (group C). The studies were amended to include a
joint analysis comparing groups 1 and A (the control group) with groups 2 and C (the trastuzumab group). Group B was excluded
because trastuzumab was not given concurrently with paclitaxel.
Results By March 15, 2005, 394 events (recurrent, second primary cancer, or death before recurrence) had been reported, triggering the
first scheduled interim analysis. Of these, 133 were in the trastuzumab group and 261 in the control group (hazard ratio, 0.48;
P<0.0001). This result crossed the early stopping boundary. The absolute difference in disease-free survival between the trastuzumab
group and the control group was 12 percent at three years. Trastuzumab therapy was associated with a 33 percent reduction in the risk
of death (P=0.015). The three-year cumulative incidence of class III or IV congestive heart failure or death from cardiac causes in the
trastuzumab group was 4.1 percent in trial B-31 and 2.9 percent in trial N9831.
Conclusions Trastuzumab combined with paclitaxel after doxorubicin and cyclophosphamide improves outcomes among women with
surgically removed HER2-positive breast cancer. (ClinicalTrials.gov numbers, NCT00004067 [ClinicalTrials.gov] and NCT00005970
[ClinicalTrials.gov] .)

Trastuzumab, a monoclonal antibody targeting the extracellular domain of the HER2 protein, was approved in 1998 as a first-line
treatment in combination with paclitaxel for HER2-positive metastatic breast cancer.1 The benefit of this approach in patients with
metastatic disease and the poor prognosis of HER2-positive breast cancer2,3 motivated the National Cancer Institute (NCI) to sponsor
two trials of adjuvant treatment with trastuzumab, led by the National Surgical Adjuvant Breast and Bowel Project (NSABP) and the
North Central Cancer Treatment Group (NCCTG).
NSABP trial B-31, which began accrual in February 2000, compares four cycles of doxorubicin and cyclophosphamide followed by
paclitaxel (group 1) with the same chemotherapy plus 52 weeks of trastuzumab beginning on day 1 of paclitaxel therapy (group 2).
NCCTG trial N9831 began enrollment in May 2000 and compares three regimens: four cycles of doxorubicin and cyclophosphamide
followed by weekly paclitaxel for 12 weeks (group A), four cycles of doxorubicin and cyclophosphamide followed by 52 weeks of
trastuzumab after the completion of paclitaxel therapy (group B), and four cycles of doxorubicin and cyclophosphamide followed by
52 weeks of trastuzumab beginning on day 1 of paclitaxel therapy (group C).
The control groups of the trials, as well as group 2 in trial B-31 and group C in trial N9831, differed in terms of the scheduling of
paclitaxel treatment and some aspects of hormonal therapy and radiotherapy but were otherwise identical. For this reason, the NCI and
the Food and Drug Administration approved a joint-analysis plan developed by the NSABP and NCCTG to combine data from group 1
and group A (referred to as the control group) for comparison with group 2 and group C (referred to as the trastuzumab group). Group
B of trial N9831 was excluded because the protocol required trastuzumab to be administered after the completion of chemotherapy.
The plan required a first interim analysis after the occurrence of 355 events. Before the data were locked, 2043 patients (of a planned
total of 2700) were enrolled in trial B-31 and 1633 patients (of a total of 2000 for the comparison of group A with group C) were
enrolled in trial N9831. In April 2005, the independent data-monitoring committees of each trial recommended closing enrollment and
releasing the results.
Discussion
The addition of trastuzumab to paclitaxel after a regimen of doxorubicin and cyclophosphamide reduced the rates of recurrence by half
among women with HER2-positive breast cancer. The absolute decreases in distant recurrence were 8.8 percentage points after three
years and 15.9 percentage points after four years, although the latter value had a wide confidence interval (11.1 to 20.8 percentage
points). The reduction was similar among women with hormone-receptor–negative tumors and women with hormone-receptor–
positive tumors. No subgroups that did not appear to benefit from trastuzumab therapy were identified. Since only 191 women with
node-negative breast cancer were included in these studies and only 3 had had an event at the time of the analysis, we cannot comment
on the effect of trastuzumab in this subgroup.
The addition of trastuzumab reduced the mortality rate by one third (P=0.015). Among eligible patients who continued treatment after
doxorubicin and cyclophosphamide and who were HER2-positive on central testing, the relative reduction in the mortality rate
associated with trastuzumab was 39 percent (P=0.01). Although relatively little follow-up information is available beyond three years,
current data rule out a risk of distant recurrence among trastuzumab-treated women of greater than 27 per 1000 women per year, in
contrast to a risk of 90 per 1000 women per year in the control group (see Figure 4 in the Supplementary Appendix). Since the risk of
distant recurrence should remain appreciable in the control group for some time, a substantial additional survival benefit related to
trastuzumab can be anticipated.
The effect of trastuzumab was substantial in both trials (see Figure 1 in the Supplementary Appendix), a finding that is noteworthy
given differences in the paclitaxel schedule and the timing of hormonal therapy. The benefit of trastuzumab was evident at local or
regional and distant sites. Although isolated brain metastases were more common first events in the trastuzumab group than in the
control group, the imbalance can be attributed to the occurrence of earlier failures at other distant sites in the control group.
Data from trial B-31 suggested that trastuzumab reduced the incidence of nonbreast second primary cancers, an unanticipated effect
requiring independent verification. There was no obvious pattern of site or histologic type (Table 4).
The primary concern regarding the safety of trastuzumab is the increased risk of cardiac dysfunction associated with past or concurrent
anthracycline treatment.12,13 In both studies, the cumulative three-year incidence of congestive heart failure increased by about 3
percentage points with the addition of trastuzumab. Most episodes occurred during trastuzumab treatment, but additional follow-up
will be needed to define the long-term cardiotoxicity of trastuzumab. Clearly, appropriate selection and careful cardiac monitoring of
patients are essential. Trastuzumab did not increase the overall frequency or severity of noncardiac adverse effects associated with the
chemotherapy regimens, but we did see rare cases of interstitial pneumonitis in patients receiving trastuzumab during or shortly after
the paclitaxel phase of treatment. Two cases were fatal.
Trial N9831 was also designed to address the efficacy of trastuzumab initiated concurrently with paclitaxel as opposed to sequentially
(group C vs. group B), but this comparison requires substantially longer follow-up than was needed for the assessment of concurrent
trastuzumab therapy in the joint analysis. However, after reviewing the results of the first joint interim efficacy analysis, the data-
monitoring committee overseeing trial N9831 requested an unplanned comparison of groups B and C and subsequently recommended
disclosure of the results. Though early, the comparison suggested delayed administration of trastuzumab may be less effective than
concurrent administration.15 Recent data from the Herceptin Adjuvant (HERA) Trial showed that treatment with trastuzumab begun
after the completion of chemotherapy substantially reduced the rate of recurrence relative to the rate associated with chemotherapy
alone.16 Since only 26 percent of patients received taxanes in the HERA trial, comparison of those results with ours may be
problematic. Therefore, further follow-up of groups B and C in trial N9831 is necessary for an adequate evaluation of the efficacy of
concurrent as compared with sequential administration of trastuzumab.

Adjuvant docetaxel or vinorelbine with or without trastuzumab for breast cancer

Joensuu H, Kellokumpu-Lehtinen PL, Bono P, Alanko T, Kataja V, Asola R, Utriainen T, Kokko R, Hemminki A, Tarkkanen M, Turpeenniemi-
Hujanen T, Jyrkkio S, Flander M, Helle L, Ingalsuo S, Johansson K, Jaaskelainen AS, Pajunen M, Rauhala M, Kaleva-Kerola J, Salminen T,
Leinonen M, Elomaa I, Isola J; FinHer Study Investigators. N Engl J Med. 2006 Feb 23;354(8):809-20. Department of Oncology, Helsinki
University Central Hospital, Helsinki, Finland. Comment in: N Engl J Med. 2006 Feb 23;354(8):789-90.
BACKGROUND: We compared docetaxel with vinorelbine for the adjuvant treatment of early breast cancer. Women with tumors that
overexpressed HER2/neu were also assigned to receive concomitant treatment with trastuzumab or no such treatment. METHODS:
We randomly assigned 1010 women with axillary-node-positive or high-risk node-negative cancer to receive three cycles of docetaxel
or vinorelbine, followed by (in both groups) three cycles of fluorouracil, epirubicin, and cyclophosphamide. The 232 women whose
tumors had an amplified HER2/neu gene were further assigned to receive or not to receive nine weekly trastuzumab infusions. The
primary end point was recurrence-free survival. RESULTS: Recurrence-free survival at three years was better with docetaxel than
with vinorelbine (91 percent vs. 86 percent; hazard ratio for recurrence or death, 0.58; 95 percent confidence interval, 0.40 to 0.85;
P=0.005), but overall survival did not differ between the groups (P=0.15). Within the subgroup of patients who had HER2/neu-
positive cancer, those who received trastuzumab had better three-year recurrence-free survival than those who did not receive the
antibody (89 percent vs. 78 percent; hazard ratio for recurrence or death, 0.42; 95 percent confidence interval, 0.21 to 0.83; P=0.01).
Docetaxel was associated with more adverse effects than was vinorelbine. Trastuzumab was not associated with decreased left
ventricular ejection fraction or cardiac failure. CONCLUSIONS: Adjuvant treatment with docetaxel, as compared with vinorelbine,
improves recurrence-free survival in women with early breast cancer. A short course of trastuzumab administered concomitantly with
docetaxel or vinorelbine is effective in women with breast cancer who have an amplified HER2/neu gene. (International Standard
Randomised Controlled Trial number, ISRCTN76560285.). Copyright 2006 Massachusetts Medical Society.

Viewpoint: The Use of Trastuzumab in Breast Cancer in the

Adjuvant Setting
Nancy U. Lin, MD
Medscape Hematology-Oncology. 2006;9(1) ©2006 Medscape
Introduction
HER2 is overexpressed in approximately 25% of human breast cancers and is associated with diminished disease-free
survival and overall survival.[1] Trastuzumab, which targets HER2, has been shown to improve outcomes in women with
HER2-positive, advanced breast cancer.[2] These positive findings have led to interest in its use in the adjuvant setting. The
results of 3 major studies that demonstrated its efficacy in the adjuvant setting were recently published.
Of major concern, however, is the risk trastuzumab may pose to the heart, as its use was associated with an increase in
cardiac dysfunction in the pivotal advanced therapy trial. [2] As a result, cardiac assessments were required before study
entry, after doxorubicin and cyclophosphamide (AC), and at 6, 9, and 18 months within the context of the adjuvant
trastuzumab study, NSABP B-31, led by the National Surgical Adjuvant Breast and Bowel Project. An independent data
monitoring committee reviewed the data after the first 1000 patients before allowing accrual to the second stage, and at
each scheduled interim analysis, if the absolute difference in cardiac events between arms was statistically greater than
4%, the study would be closed to further accrual.
A discussion of the results of the adjuvant therapy trials and the cardiac risk trial follows.
Trastuzumab After Adjuvant Chemotherapy in HER2-Positive Breast Cancer
Piccart-Gebhart, Procter M, Leyland-Jones B, et al
N Engl J Med. 2005;353:1659-1672
Summary
The Herceptin Adjuvant (HERA) trial is a phase 3, randomized trial in which 5081 women with HER2-positive early-
stage breast cancer received a minimum of 4 cycles of chemotherapy and adjuvant radiation as indicated, followed by
observation alone, 1 year of trastuzumab, or 2 years of trastuzumab. Women were eligible if they had node-positive
disease, or node-negative disease with tumor size greater than 1 cm. The results of the observation vs 1-year trastuzumab
comparison were released after an interim efficacy analysis demonstrated improvements in disease-free survival that
crossed the prespecified O'Brien-Fleming boundary. Evaluation of the 1-year vs 2-year comparison is ongoing, and results
are not yet available.
The addition of trastuzumab significantly improved disease-free survival (127 events vs 220 events, unadjusted hazard
ratio 0.54, log-rank P < .001), corresponding to an absolute benefit of 8.4% at 2 years. There were numerically fewer
deaths in the trastuzumab arm compared with observation alone (29 vs 37), but the difference did not reach statistical
significance. The rate of symptomatic congestive heart failure (CHF), though higher in the trastuzumab arm, was still
quite low (1.73% vs 0.06%, P < .001).
Comment
This study was thoughtfully designed and demonstrates a clear benefit for the addition of trastuzumab to standard
chemotherapy in women with node-positive or high-risk node-negative, HER2-positive breast cancer. In the context of 3
North American trials also demonstrating remarkably similar benefits, there is solid evidence to consider trastuzumab in
women who would have met the eligibility requirements for the trial. This trial differs from most of the North American
trials in that trastuzumab was not given concurrently with chemotherapy, yet a substantial benefit was still seen, and the
cardiac toxicity was lower than observed with concurrent chemotherapy/trastuzumab. Still other unanswered questions
include the optimal duration of trastuzumab therapy, the optimal chemotherapy backbone, and the potential long-term
cardiac effects of trastuzumab.
Abstract

Trastuzumab Plus Adjuvant Chemotherapy for Operable HER2-Positive Breast Cancer

Romond EH, Perez EA, Bryant J, et al
N Engl J Med. 2005;353:1673-1684
Summary
In this article, the authors present data from a combined analysis of 2 of the trials evaluating trastuzumab in the adjuvant
setting: the NSABP trial B-31 and the North Central Cancer Treatment Group trial N9831. Only patients with HER2-
positive breast cancer were eligible for either study. NSABP B-31 included only women with node-positive breast cancer;
N9831 also included women with high-risk node-negative breast cancer (tumor size > 2 cm if hormone receptor-positive,
or > 1 cm if hormone receptor-negative), though this represented only a small fraction of the total patient population. In
NSABP B-31, patients were randomized to receive either standard chemotherapy (AC for 4 cycles, followed by paclitaxel
for 4 cycles, given every 3 weeks), or standard chemotherapy plus weekly trastuzumab. Trastuzumab was begun
concurrently with paclitaxel. Patients in N9831 were randomly assigned to 1 of 3 arms: (1) AC for 4 cycles, every 3
weeks, followed by 12 weekly doses of paclitaxel, (2) the same chemotherapy followed by weekly trastuzumab, or (3) the
same chemotherapy plus trastuzumab begun concurrently with paclitaxel. The primary end point was disease-free
survival. The joint analysis included 1679 women in the combined control group and 1672 women in the combined
trastuzumab group. Patients in N9831 who were assigned to Arm 2 were excluded from the joint analysis.
At a median follow-up of 2 years, there was a highly statistically significant reduction in disease-free survival events in
women assigned to the trastuzumab arm (133 events vs 261 events, hazard ratio 0.48, P < .0001), corresponding to an
estimated absolute improvement of 11.8% (95% confidence interval 8.1% to 15.4%) at 3 years. There were also
numerically fewer deaths in the trastuzumab arm compared with the control group (62 deaths vs 92 deaths, hazard ratio
0.67, P = .015). The incidence of New York Heart Association class III or IV CHF or death from cardiac causes was
higher in the trastuzumab group compared with the control group (4.1% vs 0.8%).
Comment
The combined analysis supports the conclusion that trastuzumab significantly improves disease-free survival and distant
disease-free survival in women with node-positive, HER2-positive breast cancer. That an overall survival difference is
beginning to emerge after short follow up is remarkable and suggests that adjuvant trastuzumab is not merely delaying the
appearance of recurrences. Further follow up is needed to confirm this impression. Finally, because only 3 total events had
occurred in node-negative women at the time of study analysis, further follow-up is required before making conclusions
about the role of trastuzumab, given with anthracycline- and taxane-based chemotherapy, in women with negative lymph
nodes at the time of diagnosis.
Abstract

Assessment of Cardiac Dysfunction in a Randomized Trial Comparing Doxorubicin and Cyclophosphamide

Followed by Paclitaxel, With or Without Trastuzumab as Adjuvant Therapy in Node-Positive, Human
Epidermal Growth Factor Receptor 2-Overexpressing Breast Cancer: NSABP B-31
Tan-Chiu E, Yothers G, Romond E, et al
J Clin Oncol. 2005;23:7811-7819
Summary
A total of 1664 patients (81% of the total NSABP B-31 trial cohort) were included in the analysis of cardiac toxicity, with
a median follow up of 27 months from the first day of cycle 5 of therapy (ie, after completion of AC). The 3-year
cumulative incidence of cardiac events among evaluable patients was 4.1% (95% confidence interval 2.9% to 5.8%) in
trastuzumab-treated patients, compared with 0.8% (95% confidence interval 0.3% to 1.9%) in the control group. Most
cardiac events occurred during the period of trastuzumab treatment; however, 3 of 31 cases of CHF occurred more than 1
year after initiation of trastuzumab. Among 27 patients followed for at least 6 months after a diagnosis of CHF, 26 are
currently asymptomatic, but 18 of those patients are still receiving cardiac medications. The investigators also examined
the proportion of patients who were not able to complete the planned 1-year course of trastuzumab. In 19% (n=133) of
evaluable patients, trastuzumab was permanently discontinued for cardiac reasons, primarily as a result of asymptomatic
declines in left ventricular ejection fraction (LVEF).
In a multivariate analysis, age and post-AC LVEF were statistically significant predictors of trastuzumab-associated
cardiac toxicity. For example, in women younger than age 50 years, with post-AC LVEF ≥ 65%, the 3-year cumulative
incidence of CHF was only 1.1% (95% confidence interval 0.2% to 8.0%). In contrast, for a woman age 65 years or older,
with a post-AC LVEF of 50% to 54%, the incidence was 20% (95% confidence interval 11.1% to 35.9%). Of note, there
was no effect of trastuzumab on the rate of CHF seen in women with left-sided lesions who were treated with adjuvant
radiotherapy, compared with women with right-sided lesions.
Comment
These data will be useful to clinicians in assessing the risk-benefit trade-offs associated with trastuzumab-based therapy in
women with early-stage, HER2-positive breast cancer. For the older woman with low-normal ejection fraction after AC
chemotherapy, the data suggest a relatively high risk of cardiac toxicity, albeit with wide confidence intervals. Such a
patient may be better served with sequential trastuzumab, as was utilized in the HERA trial, or to consideration of
chemotherapy alone, depending on the level of baseline risk. Further follow-up of the N9831 study will be of interest, in
order to elucidate the risk-benefit trade-offs associated with sequential or concurrent trastuzumab. In addition, mature
results of the Breast Cancer International Research Group Study 006, which included a nonanthracycline-containing arm,
will be of great interest as clinicians and patients seek to maximize the ratio of benefit to risk.

Advances in Treatment of HER2-Positive Early Breast Cancer: An Expert Interview With Dr. Debu Tripathy
Editor's Note:
There has been a great deal of excitement in the last 18 months about the results achieved with trastuzumab in the
adjuvant treatment of patients with HER2-overexpressing breast tumors. The interim results of the Breast Cancer
International Research Group (BCIRG) 006 study[1] that were reported at the 2005 annual San Antonio Breast Cancer
Symposium by Dr. Dennis Slamon proved to be both intriguing and somewhat controversial. To better understand those
results within the broader context of clinical findings by other trial groups, Medscape spoke with Debu Tripathy, MD,
Professor of Internal Medicine, University of Texas Southwestern Medical Center, and Director of the Komen/UT
Southwestern Breast Cancer Research Program, Dallas, Texas, who provided his perspective.
Medscape: What key questions was BCIRG 006 designed to answer, and do you think the interim results thus far
reported have answered some of those questions?
Dr. Tripathy: This was the last of the 4 major trials[2-4] to be reported, but this study was unique. First, this study used a
different taxane as part of the chemotherapy regimen. The control arm of doxorubicin and cyclophosphamide followed by
docetaxel was compared with the 2 trastuzumab-containing arms, one of which was doxorubicin and cyclophosphamide
followed by docetaxel with trastuzumab. The other novelty in this trial was that it tested a completely nonanthracycline
arm, which contained docetaxel, carboplatin, and trastuzumab, also known as the TCH arm. This third arm was designed
to avoid cardiotoxicity by not including an anthracycline, and to combine drugs that had shown the greatest amount of
synergy in preclinical models. In the end, both of the trastuzumab-containing arms demonstrated an improvement in
outcome compared with the control arm.
Medscape: Based on previous trial results, these interim data showing a benefit with trastuzumab were not
surprising. Were there any findings that suggested a new focus for the ongoing trial going forward?
Dr. Tripathy: The cardiac toxicity rate seemed to be lower in the TCH arm, which confirmed one of the reasons this trial
was designed -- to minimize cardiac toxicity. In fact, the number of patients with clinical congestive heart failure in the
TCH arm was similar to that in the control arm, which didn't include trastuzumab at all. Conversely, the incidence of
congestive heart failure was higher in the anthracycline-containing arm. The number of cardiac events in the TCH arm
was fewer than in the anthracycline-containing arm, although there wasn't enough statistical power to conclude that one
arm was clearly less cardiotoxic. I think we're going to need to wait for longer follow up before we come to any definitive
conclusions.
In addition, some interesting subanalyses were done in the study. One was actually based on other genes that are
amplified. To be eligible for the trial, all patients were required to have amplification of the HER2/neu gene by
fluorescence in situ hybridization (FISH) testing. It turns out that many other genes in the vicinity of HER2s are also
amplified in this situation. One of those genes is topoisomerase 2-alpha (also known as "topo 2"), which is the target of
doxorubicin. It has been known for some time that if a tumor cell amplifies and overexpresses topo 2, it will be more
sensitive to doxorubicin. In a subanalysis, these investigators noted that about 35% of the patients had tumors that
amplified topo 2 along with HER2; and in that group of patients, there was clearly an advantage to the AC followed by
docetaxel plus trastuzumab arm. However, in the majority of patients whose tumors did not amplify topo 2, it appeared
that the TCH arm and the AC-docetaxel-trastuzumab arms were equally effective. What this suggests is that we might be
able to get away with the less cardiotoxic TCH regimen in patients whose tumors do not amplify topo 2. This new insight
was based on a fairly large number of patients. The subanalysis is continuing, and I don't think it's quite ready for prime
time. I wouldn't make treatment decisions based on topo 2 amplification yet, but I think it's intriguing and may help us
customize therapy in the future as topo 2 is measured in the other trastuzumab trials.
Medscape: By avoiding cardiotoxic regimens for patients in whom such treatment may not be necessary or may not
be effective?
Dr. Tripathy: Absolutely. This is a big area in the field right now: trying to identify who is and who is not at risk for
cardiotoxicity. We will certainly be applying trastuzumab in most high-risk patients -- those with positive nodes and other
poor prognostic factors -- unless they really have clinically significant heart disease. The struggle is going to be in
deciding what is an acceptable minimal risk of congestive heart failure due to treatment with trastuzumab for someone
with node-negative breast cancer, grade 2, for instance, in which the risks and the benefits might be closely balanced. The
use of additional predictors of benefits vs toxicities would allow better patient selection.
Medscape: Just to clarify: we're only talking about patients whose tumors overexpress or amplify HER2?
Dr. Tripathy: Yes, that's the one thing we're sure about with respect to trastuzumab: the patient's tumor needs to
overexpress HER2, either at the immunohistochemical level (level 3+) or by FISH. Some people believe FISH is more
accurate, but I think there's still controversy in that area.
At this point, any patient with an invasive breast cancer should have HER2/neu determination. We certainly need to know
about HER2 status in the metastatic setting because trastuzumab is now part of the standard treatment. It is also becoming
part of the standard treatment in the adjuvant setting. I suppose you could omit HER2 analysis in someone with a very
low-risk tumor -- where even if the result was positive, you wouldn't treat differently. Nevertheless, I think HER2/neu
status should be determined in all patients because the clinical situation may change -- the patient may have a recurrence,
for example -- and it may not be as easy to obtain a tumor sample for testing the second time around.
Medscape: How clinically significant are the differences between treatment arms in the BCIRG 006, in terms of the
cardiac effects?
Dr. Tripathy: There are 2 ways to look at this question. Dennis Slamon and colleagues showed very clearly that if you
take the average of all the patients' ejection fractions, it does drop. However, for most people, the decrease in ejection
fraction is only about 2 or 3 percentage points, which is not clinically significant. The real area of concern is for patients
in whom the drop is clinically significant. These patients require cardiac medications. The most detailed analysis of this
issue was done in the NSABP studies.[5] Although many cases improve and are eventually reversed, a substantial number
of patients remain on cardiac medications and 2% to 4% of patients develop clinical congestive heart failure.
However, I disagree with the notion that all patients experience a drop in cardiac ejection fraction, and that these decreases
are persistent. We know that there are asymptomatic ejection fraction decreases in about 10% to 20% of patients, but we
don't know the natural history of this yet. So far, it does not appear to be a problem. However, we need to be alert to long-
term follow-up and must explain to patients that some of this is unknown, and that even if they are feeling well, they may
be more susceptible to cardiac problems as they get older. At the same time, we know that the risk of recurrence with
breast cancer is also a substantial concern, and that it is clearly reduced with trastuzumab. We will need to assess the risk-
benefit ratio for each case, which is difficult at this point because we don't have long-term data yet.
Medscape: Another area that has not been resolved but that is being studied is the question of how long to treat. It
seems that some researchers have given trastuzumab for as few as 9 weeks and some are studying 2 years. What
are your thoughts?
Dr. Tripathy: I think we have to go with the data. Right now, the bulk of the data have been derived from studies with 1
year of therapy. Granted, 1 year of adjuvant therapy was arbitrarily based on the fact that we had 1 year of safety data.
However, those are the data that we have now. There was one small study from Finland [4] presented at the SABCS in
which a more abbreviated course of treatment -- 9 weeks -- was given concomitantly with chemotherapy. It included a
group of about 200 patients with HER2-positive tumors -- which represents one fifteenth of the size of the larger
trastuzumab studies. Even though that study showed a reduction by about one half in the number of the events, the
confidence interval was very wide. It's important to recognize that even though the abbreviated treatment seemed to be
effective, the level of certainty is much smaller.
What that study does tell us, though, is that it is within the realm of possibility to derive the same benefit, and perhaps
fewer cardiac toxicities, with more abbreviated therapy. At some point, it's going to be important to test shorter durations.
To be honest with you, it's going to be harder to do it in the United States because people are fixated on the idea that more
is better. In view of the cost of this therapy, in countries where the resources to treat with trastuzumab for a year are not
available, they may consider doing studies of shorter treatment durations. I think that's an important, unanswered question.
By the same token, you can extend the question in the other direction -- the HERA study [2] included a 2-year arm. They
have not reported on that arm yet, but again, we may actually discover that there is a whole range of benefit with
trastuzumab: from very brief, at 9 weeks of treatment, all the way up to 2 years.
Medscape: Were there any other reports at the San Antonio meeting that you found particularly important in the
area of adjuvant treatment for patients with HER2-positive tumors?
Dr. Tripathy: There was one other interesting paper by the NSABP group[6] that addresses the issue of selecting patients
who are likely to derive optimal benefit from trastuzumab. This was an analysis based on a series of genes that the
NSABP found in previous chemotherapy studies to be associated with improved outcome. They looked at the genomic
tumor DNA from many patients, trying to identify specific genes whose amplification might predict response. Using a
multivariate analysis, they honed in on a few genes, one of which was c-myc. Subsequently, they discovered a
subpopulation of patients with coamplification of both genes, HER2 and c-myc, who achieved a much greater than 50%
reduction of disease recurrence -- closer to a 75% to 80% reduction. So this marker, at least in this study, appears to
predict patients who obtain a really superior benefit from trastuzumab. By applying these kinds of markers, we might be
able to identify patients with low-risk breast cancer who should receive treatment because their benefit can be expected to
be profound.
Medscape: Is there anything else that you'd like to say?
Dr. Tripathy: The only other point I'd like to make is that some people have criticized the BCIRG, as well as the NSABP
and HERA, for releasing the trastuzumab data too early. [7] I think it's important to understand that these studies were huge.
There is no doubt that trastuzumab is going to benefit patients. These studies were so large that early reporting was based
on a predefined number of events, which was met. What might change over time is the magnitude of the benefit. It may be
that the benefits we are seeing now apply to the high-risk, earlier recurrences. In fact, the HERA study reported that 60%
of the recurrences were in the estrogen receptor (ER)-negative subgroup, which represented only 48% of all patients
enrolled. Historically, patients with ER-negative tumors tend to experience recurrence of disease more quickly. It may be
that recurrences in patients with ER-positive tumors might not be affected as much and that over time, instead of a 50%
relative reduction, the benefit may stabilize at a lower level. But I certainly don't think this is going to revert to being a
negative study, given the extraordinarily small P value. This was certainly not a premature release of data: the statistics
are robust.

Role of Trastuzumab in Adjuvant Therapy for Locally Invasive Breast Cancer

Katie L. Kabe; Jill M. Kolesar Am J Health-Syst Pharm. 2006;63(6):527-533.
Abstract
Purpose: The role of trastuzumab in adjuvant therapy for locally invasive breast cancer is discussed.
Summary: Trastuzumab is a humanized monoclonal antibody that binds to the extracellular domain of human epidermal growth
factor receptor-2 (HER2). Currently, trastuzumab is indicated for use in HER2-positive patients with metastatic breast cancer. Because
trastuzumab specifically targets a receptor that is overexpressed in tumor cells, it is less likely to cause the cytotoxic adverse effects of
traditional chemotherapy. Cardiotoxicity has been a major concern, however. Several trials were started to evaluate trastuzumab in the
adjuvant setting in patients diagnosed with early-stage breast cancer. The interim results of these trials have shown a promising effect
of adjuvant therapy with trastuzumab in improving overall survival, disease-free survival, relapse-free survival, and distant-disease-
free survival.
Conclusion: The use of trastuzumab as adjuvant therapy in patients with HER2-positive breast cancer can lead to increased survival.
The appropriateness of trastuzumab therapy should be considered based on HER2 status, cost, and risk of toxicity.
Introduction
Cancer is one of the most common causes of death in the United States, causing almost one fourth of all deaths. [1] Breast cancer is the
most commonly diagnosed cancer among women, with 211,240 new cases projected for 2005 in the United States, accounting for 32%
of cancer diagnoses in women. Breast cancer is estimated to have been responsible for 40,140 deaths in 2005. While the rate for breast
cancer has increased over the past 20 years, the death rate has been declining. Treatment and outcomes are influenced by the stage of
cancer, which is determined by the size and number of tumors involved, lymph node involvement, and presence of metastases. The
prognosis is favorable if the breast cancer is operable, with an overall survival (OS) of approximately 70% five years after diagnosis. [2]
The chance of recurrence within five years is 30-35% if the cancer is node negative and 50-60% if node positive. Node-negative breast
cancer may be termed high risk if it is estrogen-receptor (ER) negative, progestin-receptor (PR) negative, contains a tumor that is
greater than 2 cm in diameter, or contains a tumor that is pathologically grade 2 or 3.[3]
When breast cancer is operable, adjuvant chemotherapy is given after surgery or irradiation to decrease the chance of recurrence by
killing cancer cells that may have migrated elsewhere in the body. Multiple chemotherapy regimens have been used for adjuvant
treatment of breast cancer. Cyclophosphamide, methotrexate, and fluorouracil were traditionally used together for six months.
Anthracyclines, such as doxorubicin and epirubicin, have been shown to increase survival and decrease recurrence and are now
considered standard components of a regimen.[2] Various combinations may also include taxanes, such as paclitaxel and docetaxel, to
increase survival.[4] In addition, due to the large number of women with breast cancer associated with up-regulated ERs, hormonal
therapies are often used to negate estrogen-stimulated unregulated growth in the breast.
Trastuzumab Overview
Trastuzumab (Herceptin, Genentech, Inc.) is a humanized monoclonal antibody that binds to the extracellular domain of human
epidermal growth factor receptor-2 (HER2).[5] HER2 is a protooncogene that can cause cellular differentiation and proliferation
through tyrosine kinase activity and is overexpressed in about 20-25% of breast cancer tumor cells. Patients with HER2-positive
breast cancer generally have a more aggressive disease and a poorer prognosis. Blocking HER2-stimulated growth of cancer cells is
the general mechanism of action of trastuzumab; however, the complete mechanism of antitumor activity has not been fully
characterized. Trastuzumab may cause down-regulation of the HER2-receptor and decreased signal transduction. [6] Also, it may cause
antibody-dependent, cell-mediated cytotoxicity.[6,7] Trastuzumab has been shown to decrease angiogenesis through action at the
vascular endothelial growth factor receptor in vitro.[8]
Currently, trastuzumab is indicated for use in HER2-positive patients with metastatic breast cancer. [7] It has additive efficacy when
used with paclitaxel, vinblastine, methotrexate, doxorubicin, or epirubicin. [9,10] Vinorelbine, thiotepa, cisplatin, carboplatin, docetaxel,
cyclophosphamide, and etoposide have a synergistic effect with trastuzumab. Trastuzumab is antagonized by concurrent use with
fluorouracil.[10] Although very effective, the use of trastuzumab concurrently with doxorubin is not recommended due to cardiotoxicity.
Liposomal doxorubicin and epirubicin are possible alternatives to doxorubicin that may cause less damage to the heart and are being
investigated for use in combination with trastuzumab.[11,12]
Because trastuzumab specifically targets a receptor that is overexpressed in tumor cells, it is less likely to cause the cytotoxic adverse
effects of traditional chemotherapy. When the drug is first infused, about 25-40% of patients will experience a mild infusion reaction
characterized by fever and chills.[7,13] This is dose related and can be minimized with diphenhydramine and acetaminophen. A very
small percentage of people, about 0.3%, will experience a serious reaction, including bronchospasm, hypotension, and dyspnea. [7]
Minor adverse effects, including pain, asthenia, headache, nausea, diarrhea, constipation, rash, flu-like symptoms, anxiety, insomnia,
and rhinitis, were reported in over 10% of patients in one trial using trastuzumab as monotherapy for unresponsive metastatic breast
cancer.[14] Cytopenias were rare with trastuzumab alone.
Cardiotoxicity has been a major concern with trastuzumab and requires additional screening for cardiac dysfunction. Many patients in
this population are already at risk due to previous anthracycline therapy and age.[5] When used as monotherapy, trastuzumab has a 1-
7% frequency of inducing cardiac dysfunction, specifically congestive heart failure (CHF) and decreased left ventricular ejection
fraction (LVEF).[5,7] The rate of cardiac dysfunction is about 4-13% when trastuzumab is used with taxanes and rises to 19-27% when
used with doxorubicin and cyclophosphamide.[5] The mechanism of this phenomenon is not known, but possibly HER2-receptors
located in cardiac tissue play a role in differentiation and survival.[5] To decrease the likelihood of adverse cardiac events, trastuzumab
is contraindicated in patients with decreased cardiac function and should be discontinued if patients develop symptoms of decline in
cardiac function.
Different guidelines have been proposed regarding how to monitor cardiac function and when to withhold or discontinue therapy.
Multiple gated acquisition is often used to identify drops in LVEF, while echocardiography may be useful in ruling out alternative
causes of decreased LVEF. For metastatic breast cancer patients, weekly monitoring of heart rate and body weight has been proposed,
with appropriate follow-up if either value increases drastically. This guideline suggests stopping therapy if the patient is asymptomatic
and LVEF falls at least 20 percentage points to less than 40% or LVEF is less than 30%. If the patient had symptomatic cardiac
dysfunction, it has been proposed that trastuzumab be withheld if the LVEF falls at least 10 percentage points to less than 50%. [15]
Two trials presented in this article used the following guidelines: cardiac function should be monitored routinely in patients on
trastuzumab, and the drug should be withheld if there is a 15% decrease in LVEF or at least a 10% decrease in LVEF and LVEF falls
at least 1% below the lower limit of normal (LLN). When the drug is withheld, LVEF can be reassessed in four weeks. Trastuzumab
should be permanently discontinued if it needs to be withheld for two consecutive doses or three total doses. These trials and many
similar trials monitored cardiac function every three months.[16]
Trastuzumab as Adjuvant Therapy
Once trastuzumab had proven successful in improving survival outcomes in metastatic breast cancer, several trials were started to
evaluate trastuzumab in the adjuvant setting. Four large-scale, randomized, multi-center, Phase III trials are currently evaluating the
safety and efficacy of trastuzumab for use as adjuvant therapy in breast cancer. [16-18] A combined interim analysis of two of the trials,
the North Central Cancer Treatment Group Intergroup trial (N9831) and the National Surgical Adjuvant Breast and Bowel Project trial
(B-31), was recently published.[16] The results from the Herceptin Adjuvant (HERA) trial were also recently reported. [17] The fourth
trial, Breast Cancer International Research Group (BCIRG) trial 006, is still under way. [18] A combined analysis of N9831 and B-31
was possible because both the design and patient selection of those two trials were very similar. [16] All patients entering the trials were
required to be immunohistocompatibility 3+ or fluorescence in situ hybrid positive; to have invasive breast cancer; to have had a prior
lumpectomy, mastectomy, or lymph node dissection; and to have normal LVEF and normal hematologic, hepatic, and renal functions.
Exclusion criteria for both trials consisted of previous anthracycline or taxane therapy, a history of significant peripheral neuropathy, a
history of cardiac disease, or locally advanced or distant disease. The patients recruited for B-31 were exclusively node positive.
N9831 included node-positive and high-risk node-negative patients. Node-negative women were considered high risk if they were ER
negative with a tumor at least 1 cm in diameter or ER positive with a tumor at least 2 cm in diameter. [16] Characteristics of the patients
in both trials are listed in Table 1 .
The designs for N9831 and B-31 are shown in Figures 1 and 2, respectively. While B-31 compared trastuzumab with no trastuzumab,
N9831 was designed with an additional group receiving trastuzumab after the paclitaxel regimen was completed to compare
concurrently administered trastuzumab with sequentially administered trastuzumab. [16] For the combined interim analysis, only
patients from groups A and C were included from N9831, because B-31 did not have a group comparable to group B. Both trials
withheld trastuzumab if a patient had symptoms of cardiac dysfunction. As mentioned previously, trastuzumab was withheld in
asymptomatic patients if LVEF decreased more than 15% or if it decreased more than 10% and was at least 1% below the LLN. [16] If
the dose was withheld, LVEF was reassessed in four weeks. Trastuzumab was permanently discontinued if it had to be with withheld
for two consecutive or a total of three doses.

Figure 1.
N9831 trial design scheme.[16] Radiation therapy or tamoxifen or both were allowed after six months if needed.

Figure 2.
B-31 trial design scheme.[16]

A total of 3676 women were included in the analysis. The final endpoint for definitive analysis of the two trials was 710 disease-free-
survival (DFS) events.[16] The interim analysis was carried out once 355 events occurred, with the intention of stopping the trials if
equivalency was rejected with a significance level of 2p = 0.001. Intention to treat was maintained in both trials and the analysis. DFS
was the primary endpoint; OS and time to first distant recurrence (TTDR) were secondary endpoints. The average follow-up at the
point of analysis was 2 years (2.4 years for B-31 and 1.5 years for N9831).
Following analysis of the interim results, both trials were closed because equivalency was rejected in favor of trastuzumab and the
predetermined significance criteria were met.[16] The combined DFS almost four years after randomization was 85% for patients in the
trastuzumab groups and 67% for patients in the nontrastuzumab groups (hazard ratio [HR] = 0.48, 2p = 3 x 10-12). This was significant
for all subgroups regardless of age, hormone-receptor status, and tumor size. It was not significant for node-negative patients, as the
number of node-negative patients in the two trials was probably too small to detect a significant difference. OS was 91% for those on
trastuzumab and 87% for those not on trastuzumab (HR = 0.67, 2p = 0.015). The TTDR was measured as the percentage without
distant recurrence and was 90% for patients treated with trastuzumab and 74% for those not treated with trastuzumab (HR = 0.47, 2p =
8 x 10-10).
Cardiac adverse events were analyzed for each trial. Nine months after randomization in N9831, 12 of 542 (2.2%) patients in group B
and 20 of 602 (3.3%) patients in group C experienced a cardiac event, compared with 0 of 544 patients in group A.[16] Nineteen of the
20 patients with cardiac events in group C experienced CHF, with one death. Three years after doxorubicin and cyclophosphamide
therapy was completed in B-31, the cumulative incidence of cardiac events was 4% with trastuzumab, compared with 0.8% without
trastuzumab.[16] The trastuzumab group had 31 patients who developed CHF, with no deaths due to CHF. Among patients not on
trastuzumab, 4 patients developed CHF and one died of it. Age and post-doxorubicin and cyclophosphamide therapy LVEF were
independent predictors of trastuzumab-associated CHF.
The HERA trial is the third randomized trial.[17] Five thousand ninety patients are enrolled in this international trial. All enrolled
patients have HER2-positive invasive breast cancer, are either node positive or node negative with a tumor at least 1 cm in diameter,
have completed at least four cycles of adjuvant or neoadjuvant chemotherapy, have a baseline LVEF of at least 55%, and have known
hormone-receptor status. Patient demographics for this trial are shown in Table 2 .
All women had surgery plus adjuvant or neoadjuvant chemotherapy and possibly radiation therapy before randomization. This trial
was less rigorous than the previous two trials because different adjuvant regimens were allowed. Patients were stratified based on
adjuvant chemotherapy, nodal status, hormone-receptor status, endocrine therapy, age, and region. They were then randomized and
either given trastuzumab for one or two years or observed following other chemotherapy treatments. Patients in both trastuzumab
groups of this trial were given trastuzumab following other chemotherapy, not concurrently. The design of this trial is shown in Figure
3.

Figure 3.
HERA trial design scheme.[17] Patients were stratified based on nodal status, adjuvant chemotherapy regimen, hormone-receptor status,
endocrine therapy, age, and region affected.

As in the other trials, the primary endpoint was DFS between either trastuzumab group and the observation group. [17] Secondary
endpoints included OS, relapse-free survival (RFS), distant-disease-free survival (DDFS), and DFS comparing one year of
trastuzumab with two years. The safety endpoint was a 4% absolute increase in cardiac events compared with the observation group.
Most patients in this trial were node positive; however, a larger fraction, about one third, were node negative. Also, most of the
patients in this study did not receive a taxane.[17]
The results of the HERA trial were similar to the combined analysis of B-31 and N9831. Only patients in groups A and C were
compared (trastuzumab for one year versus observation) at the interim analysis. Two years after randomization, the DFS was 85.8% in
group A and 77.4% in group C (HR = 0.54, p < 0.0001). This result was consistent in most subgroups, including node-negative
patients. OS in the trastuzumab group was 96%, versus 95% in the observation group (HR = 0.76, p = 0.26). The RFS was 87.2% in
group A, versus 78.6% in group C (HR = 0.50, p < 0.0001), and the DDFS was 89.7% in group A, versus 81.8% in group C (HR =
0.51, p < 0.0001). About 8% of patients in the trastuzumab group experienced grade 3 or 4 adverse effects, compared with 4.3% in the
observation group. The treatment withdrawal rate in the trastuzumab group was 8.5%, with 6% being for safety reasons.
Cardiotoxicity was also assessed, and 7.1% of patients in the trastuzumab group and 2.2% of patients in the observation group
experienced at least a 10-percentage-point decrease in LVEF concurrently with an LVEF of less than 50%; 0.5% of patients had
symptomatic CHF that was diagnosed as being New York Heart Association function class III or IV by a cardiologist. The death rate
for cardiotoxicity was 0% in the trastuzumab group and 0.1% in the observation group.[17]
The fourth trial is being conducted by the BCIRG. BCIRG 006 is another multicenter, randomized, Phase III trial testing the addition
of trastuzumab to adjuvant therapy in women with either node-positive or high-risk node-negative operable breast cancer. This study
includes 3150 women randomized to one of three groups: cyclophosphamide and doxorubicin followed by docetaxel,
cyclophosphamide and doxorubicin followed by docetaxel and trastuzumab, and docetaxel, carboplatin, and trastuzumab given
concurrently. Thus, one objective of this study is to determine the safety and efficacy of trastuzumab without prior anthracycline
therapy. The primary endpoint of this trial is DFS. OS, toxicity, and quality of life are secondary endpoints. An interim analysis of this
trial is planned for the first quarter of 2006.[18]
Study Limitations
Limitations exist regarding interpretation of these studies. Longer follow-up may be needed to assess cardiac toxicity in these trials, as
the long-term implications of a mild decline in cardiac function due to trastuzumab are unclear. The decision to combine N9831 and
B-31 for the interim analysis was made after the trials were designed and initiated.[16] Finally, these trials were not blinded. While these
limitations exist, the fact that the survival endpoints were drastically affected by the time of the interim analysis is a strong indicator
that trastuzumab has a place as part of adjuvant chemotherapy in HER2-positive women.
Clinical and Economic Considerations
Evidence supports the adjuvant use of trastuzumab in HER2-positive women with node-positive breast cancer and normal cardiac
function. Further analysis of the current trials and possibly new trial designs will be necessary before the optimum duration of therapy
and concurrent regimens are known. Additionally, further analysis or trials with more node-negative patients may be needed before
treatment in this population can be evaluated.
Trastuzumab, like any other drug, is associated with risks and benefits that need to be weighed for each individual before the decision
to use the drug can be made. It should not be used in women with compromised cardiac function, and cardiac function should be
monitored periodically for all patients on the drug. The implications of cardiac toxicity are different in adjuvant therapy versus
metastatic therapy. Patients with metastatic disease have a significantly shorter life expectancy, and the majority will probably die of
cancer before heart failure. In the adjuvant setting, however, the risks and benefits of trastuzumab will have to be considered over a
longer lifespan. Additionally, there is a risk of a life-threatening infusion reaction in all patients, and trastuzumab should be infused
with caution, especially with the first dose.
The average wholesale price of trastuzumab is $2,928.89 for 440 mg.[19] For a 70-kg woman, each 2-mg/kg dose would cost about
$1,000, and a yearly regimen would cost about $50,000. While about 5 to 10 women per 100,000 population have metastatic breast
cancer, between 90 and 100 per 100,000 have localized breast cancer, and around 40 per 100,000 have regional breast cancer. [20] Thus,
with a U.S. female population of over 143,000,000, about 7,000 to 14,000 women may have metastatic breast cancer, about 130,000 to
140,000 have localized breast cancer, and about 60,000 have regional breast cancer.[21] If trastuzumab is to be a standard part of an
adjuvant regimen for HER2-positive patients, the cost of treating this population could increase by almost $1 billion for trastuzumab
treatment alone. Additional costs for treating heart failure would also be incurred.
The interim results presented at the ASCO meeting regarding the use of trastuzumab in adjuvant breast cancer treatment are
encouraging. The use of trastuzumab in the adjuvant setting is associated with significantly increased DFS, RFS, and DDFS. As a
result of the efficacy of trastuzumab supported by the combined interim analysis, N9831 and B-31 have been closed. The effects of
trastuzumab on OS were favorable, if not significantly increased, in all trials. Although a higher fraction of patients in all trastuzumab
groups experienced decreases in LVEF and cardiac events, the death rate from CHF was comparable to that of patients who did not
receive trastuzumab. Longer follow-up should give more information regarding the reversibility of these decreases in LVEF, risks of
cardiac events, and long-term risks.
Currently, trastuzumab does not have approval from FDA for use in adjuvant treatment for breast cancer; however, it is currently under
review, and an expanded indication is expected in 2006. Due to the large number of women with operable breast cancer and the
relatively large proportion who are HER2 positive, the decision to make this treatment part of the standard of care is financially
significant. Individually, the appropriateness of the therapy will have to be considered based on HER2 status, costs, and toxicities.
Conclusion
The use of trastuzumab as adjuvant therapy in patients with HER2-positive breast cancer can lead to increased survival. The
appropriateness of trastuzumab therapy should be considered based on HER2 status, cost, and risk of toxicity.