• Impact of tucatinib on health-related quality of life in patients with HER2+metastatic breast cancer with stable and active brain metastases

  Wardley, Andrew M; Mueller, V.; Paplomata, E.; Crouzet, L.; Iqbal, N.; Aithal, S.; Block, M.; Cold, S.; By, M. A.; Hahn, O.; et al. (2021)

  Background Patients (pts) with human epidermal growth factor receptor 2 positive (HER2+) metastatic breast cancer (MBC) who have brain metastases (BM) have limited treatment options and lower health-related quality of life (HRQoL) compared with pts without BM (Hurvitz 2019). HER2CLIMB is a randomized trial (2:1) of tucatinib vs. placebo in combination with trastuzumab and capecitabine in pts with HER2+ MBC that included pts with stable and active brain metastases (NCT02614794). In HER2CLIMB, the addition of tucatinib to trastuzumab + capecitabine demonstrated a statistically significant and clinically meaningful improvement in overall survival (OS) in pts with HER2+ MBC and in those with stable and active BM, with importantly, a tolerable and manageable safety profile (Murthy 2020). An evaluation of the impact of tucatinib on HRQoL in pts with stable and active BM is presented here. Methods HRQoL data were available from 330 of 612 pts, including 163 pts with BMs. HRQoL was assessed using the EQ-5D-5L tool which includes a visual analog scale (EQ-VAS) and a descriptive system (EQ-5D) comprising 5 dimensions of health: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems, and extreme problems. Data were collected at Cycle 1 Day 1, Cycles 3-9 (every 2 cycles; 21-day cycles), Cycle 12 and beyond (every 3 cycles), and at the 30-day follow-up. The EQ-5D-5L scores were summarized by cycle for each treatment arm. Time to deterioration, defined as a >7-point change from baseline on the EQ-VAS, was estimated by the Kaplan-Meier approach. The median time to deterioration (and 95% CIs) were computed for each arm. Results In total, 163 pts with stable and active BM were included in this HRQoL analysis, 107 pts on the tucatinib arm and 56 pts on the placebo arm. Compared to the placebo arm, pts on the tucatinib arm had an approximately 49% reduction in the risk of deterioration (hazard ratio: 0.51; 95% CI: 0.28, 0.93); the median time to deterioration has not been reached in the tucatinib arm with available follow-up and was 5.5 months (95% CI; 4.2, -) in the placebo arm. Decline in all domains of the EQ-5D-5L and the EQ-VAS scores were seen once pts discontinued therapy, particularly on the ‘usual activities’ domain. Additional available QoL data will be presented. Conclusions Pts with MBC and BM treated with tucatinib in combination with trastuzumab + capecitabine demonstrated significantly longer and clinically meaningful time to deterioration of HRQoL. HRQoL was maintained throughout the treatment course, allowing them to receive full benefit of the therapeutic approach and resulting in statistically significant and clinically meaningful improvement in OS.
• Statins reduce disease recurrence in patients with ulcerated primary melanoma

  von Schuckmann, L. A.; Khosrotehrani, K.; Ghiasvand, R.; Hughes, M. C. B.; van der Pols, J. C.; Malt, M.; Smithers, M.; Green, Adèle C; Department of Population Health, University of Queensland, Herston, Queensland, Australia (2021)

  Background: Statins may restrict cellular functions required for melanoma growth and metastasis. We examined whether long‐term statin use commenced before diagnosis of the primary is associated with reduced risk of melanoma recurrence. Patients and methods: We prospectively followed a cohort of patients newly diagnosed between 2010 and 2014 with localised tumour‐stage T1b to T4b melanoma in Queensland, Australia. We used Cox‐regression analyses to examine associations between long‐term statin use and melanoma recurrence for the entire cohort, and then separately by sex and by presence of ulceration due to evidence of effect modification. Results: Amongst 700 patients diagnosed with stage T1b to T4b primary melanoma (mean age 62, 59% male, 28% with ulcerated tumors), 94 patients (13%) developed melanoma recurrence within 2 years. Long‐term statin users (n = 204, 29%) had a significantly lower risk of disease recurrence compared to non‐users (Adjusted hazard ratio (HRadj) 0.55, 95% Confidence Interval (CI) 0.32–0.97) regardless of statin subtype or potency. Compared to non‐statin users, risk of recurrence was significantly decreased in male statin‐users (HRadj 0.39, 95% CI: 0.19–0.79) but not female statin users (HRadj 0.82, 95% CI: 0.29–2.27) and in statin‐users with ulcerated (HRadj 0.17, 95% CI: 0.05–0.52) but not non‐ulcerated (HRadj 0.91, 95% CI: 0.46–1.81) primary melanoma. Conclusion: Statins commenced before melanoma diagnosis, may reduce the risk of melanoma recurrence, especially in males and those with ulcerated tumors. Clinical trial evaluation of the potential role of statins in improving the prognosis of high‐risk melanoma is warranted.
• Primary efficacy results from AIPAC: A double-blinded, placebo controlled, randomized multinational phase IIb trial comparing weekly paclitaxel plus eftilagimod alpha (soluble LAG-3 protein) vs. weekly paclitaxel plus placebo in HR-positive metastatic breast cancer patients

  Wildiers, H.; Armstrong, Anne C; Cuypere, E.; Dalenc, F.; Dirix, L.; Chan, S.; Marme, F.; Schroder, C. P.; Huober, J.; Wagemans, J.; et al. (2021)

  Background:Eftilagimod alpha (efti, IMP321),a soluble LAG-3 protein (LAG-3Ig) that binds to a subset of MHC class II molecules, mediates antigen-presenting cell (APC) activation followed by CD8 T-cell activation. AIPAC (Active Immunotherapy PAClitaxel; NCT02614833) investigatedcombinations of the APC activator efti + weekly paclitaxel compared to paclitaxel + placebo in metastatic breast carcinoma (MBC) patients (pts). Methods:The placebo-controlled, double-blinded, 1:1 randomized, multinational, phase IIb trial enrolled pts with measurable disease, hormone receptor-positive (HR+) MBC with indications for first line weekly paclitaxel without indication for HER2/neu targeted therapy. Pts received paclitaxel (80 mg/m² IV at D1, D8, D15 plus efti (30 mg) or placebo at D2, D16 (injected SC every 2 weeks) for 6 cycles (1 cycle = 4 weeks). Maintenance phase followed in which pts benefitting from treatment received efti or placebo for an additional 52 weeks. Primary endpoint was progression-free survival (PFS) (RECIST1.1) determined by blinded independent central read (BICR). Secondary endpoints included local read PFS, RECIST 1.1 tumor response, pharmacodynamic effects, quality of life and overall survival. The study was powered (80 %) to detect 0.667 hazard ratio (HR) based on 5% one-sided alpha and planned to enroll 226 pts. Results: From Jan 2017-Jul 2019, 227 pts were randomized. All except 1 received ≥ 1 treatment and were included in the full analysis set [(efti (n = 114); placebo (n = 112)]. Data cut-off was 10th Jan 2020 with 12 month median follow-up. HR for PFS assessed by BICR was 0.93 [95 % CI 0.67-1.30], p =0.341. In the efti group 63 % (95% CI 52- 71%) were progression free at 6 months compared to 54 % (95% CI 43-63%) in the placebo group. ORR was 48.3 % in the efti group compared to 38.4 % in the placebo group as assessed by BICR (p=0.118). Efti increased numbers of PBMCs and T cells (CD4 and CD8) significantly compared to placebo. In predefined subgroups such as pts with low monocytes at baseline, luminal B subtype or age <65 years, clinically meaningful improvement in PFS was observed. TEAE rates leading to death (or discontinuation) in the two groups were similar, at 1.8 % (5.3 %) and 2.7 % (6.3 %) for the efti and placebo groups, respectively. Three pts (1.3 %) were withdrawn from treatment due to grade 3-4 immediate hypersensitivity reactions to efti, while 4 pts (1 in efti group vs. 3 in placebo group) were withdrawn from the study due to grade 2-3 hypersensitivity to paclitaxel. The most frequent (≥10%) TEAEs ≥ grade 3 were gamma-glutamyl transferase increase (19.3% vs 29.5%), aspartate aminotransferase increase (8.8% vs 10.7%) and neutropenia (15.8% vs 14.3%) reported in the efti and placebo group, respectively. Injection site reaction (34.2% vs 3.6%) and injection site erythema (30.7% vs 1.8%) were more frequent in efti versus placebo arms. Conclusion: Efti did not prolong overall median PFS in women with HR+ MBC receiving first line chemotherapy. Tested in a randomized setting against placebo in pts receiving paclitaxel, efti is well tolerated and did not add clinically significant toxicity while inducing a sustained, significant increase in CD8 T cells in blood and clinical benefits in some predefined subgroups. Relevant subgroups and overall survival will be investigated.
• A randomised phase IB/IIA study of CApecitabine plus Radium-223 in breast cancer patients with BONe metastases (CARBON) - Safety and preliminary efficacy findings

  Winter, M.; Kendall, J.; Brown, S.; Rathbone, E.; Wilson, C.; Howell, Sacha J; Twelves, C.; Palmieri, C.; Anand, A.; MacPherson, I.; et al. (2021)

  Background: Bone metastases (BMs) occur in approximately 70% of patients (pts) with metastatic breast cancer (MBC). Despite significant advances in the management of BMs with bone-targeted agents and the associated reduction in skeletal-related events, there remains an unmet need for further treatment options to improve median overall survival beyond 2-3 years. Radium-223 [R] dichloride is an alpha-emitting radiopharmaceutical that is avidly taken up, like calcium, into the bone where it emits high-energy, short-range alpha-particles resulting in a targeted anti-tumour effect on BMs. Combining R with current systemic therapy could potentially enhance efficacy in MBC with BMs. Methods: CARBON is a UK, open-label, multi-centre phase IB/IIA study evaluating the combination of capecitabine [C] (1000mg/m2 bd days 4-17, 12x21 day cycles) with R 55kBq/kg day 1 given on a 6-weekly schedule in pts with BMs from MBC (+/- other sites of disease) with ≥2 bone lesions on radionuclide bone scan and/or ≥1 lesion confirmed on plain radiographs, CT or MRI. Other eligibility criteria included ECOG PS 0-2, ≤ 2 lines of chemotherapy for MBC and current use of a bisphosphonate / denosumab for ≥6 weeks. To establish the feasibility and safety of C+R the phase IB opened in August 2016 registering 6 pts; the primary endpoint was dose-limiting toxicities (DLTs), defined as ≥grade 3 gastrointestinal toxicity lasting >48 hours or ≥grade 4 haematological toxicity lasting >7 days. Subsequently, between April 2017 and March 2019 28 pts were randomised (2:1) to C+R vs C in phase IIa to further characterise the safety profile, with frequency of CTC grade 3-4 toxicities and diarrhoea as primary endpoints. Preliminary evaluation of efficacy through assessment of bone turnover marker changes from baseline to end of cycle 5 and time to progression in bone and overall was made. Results: Baseline clinico-pathologic characteristics and prior treatments were well balanced between the arms; 13 C+R and 9 C pts had visceral metastases. There were 0 DLTs in the 6 phase IB pts, therefore the same C+R dose and schedule was studied in phase IIA. 2 pts randomised to C+R received C alone and are included in the C arm. The safety population consists of 34 pts (23 C+R, 11 C). Median number of cycles received was 8.5 (range 3-12) in C+R arm and 12 (range 1-12) in C arm. 38/307 (12%) treatment cycles were delayed (25 [13%] C+R arm, 13 [12%] C arm). 11 (48%) C+R and 6 (55%) C pts had a permanent C dose reduction. 94/95 (99%) prescribed R cycles were administered. 9 (39%) C+R and 9 (82%) C pts completed all 12 cycles. Other reasons for discontinuation were: progressive disease in 12 (52%) C+R and 0 in C pts; toxicity in 1 (4%) C+R and 1 (9%) C pt; clinician decision in 1 (9%) C pt; progressive disease and toxicity in 1 (4%) C+R pt. Only 25/575 (4%) reported AEs were grade 3-4 (n=21 in 11 [48%] C+R pts, n=4 in 4 [36%] C pts) with 0 episodes of grade 3-4 diarrhoea. Table 1 shows maximum grades of diarrhoea and haematological AEs experienced by arm. 18 SAEs occurred (n=11 in 8 C+R pts, n=7 in 2 C pts). 8 (44%) SAEs were grade 3 (C+R: 6, C: 2); none were related to diarrhoea. There were 0 SUSARs. Conclusion: In the first completed trial evaluating R with chemotherapy in MBC pts, the combination of C+R is safe and well-tolerated. Preliminary efficacy analyses including bone markers are ongoing and will be presented at the meeting. The creation of the data was supported in part by Bayer Plc and Yorkshire Cancer Research.
• 

  Checkpoint-blocker-induced autoimmunity is associated with favourable outcome in metastatic melanoma and distinct T-cell expression profiles

  Ye, W.; Olsson-Brown, A.; Watson, R. A.; Cheung, V. T. F.; Morgan, Robert David; Nassiri, I.; Cooper, R.; Taylor, C. A.; Akbani, U.; Brain, O.; et al. (2021)

  Background: Immune checkpoint blockers (ICBs) activate CD8+ T cells, eliciting both anti-cancer activity and immune-related adverse events (irAEs). The relationship of irAEs with baseline parameters and clinical outcome is unclear. Methods: Retrospective evaluation of irAEs on survival was performed across primary (N = 144) and secondary (N = 211) independent cohorts of patients with metastatic melanoma receiving single agent (pembrolizumab/nivolumab-sICB) or combination (nivolumab and ipilimumab-cICB) checkpoint blockade. RNA from pre-treatment and post-treatment CD8+ T cells was sequenced and differential gene expression according to irAE development assessed. Results: 58.3% of patients developed early irAEs and this was associated with longer progression-free (PFS) and overall survival (OS) across both cohorts (log-rank test, OS: P < 0.0001). Median survival for patients without irAEs was 16.6 months (95% CI: 10.9-33.4) versus not-reached (P = 2.8 × 10-6). Pre-treatment monocyte and neutrophil counts, but not BMI, were additional predictors of clinical outcome. Differential expression of numerous gene pathway members was observed in CD8+ T cells according to irAE development, and patients not developing irAEs demonstrating upregulated CXCR1 pre- and post-treatment. Conclusions: Early irAE development post-ICB is associated with favourable survival in MM. Development of irAEs is coupled to expression of numerous gene pathways, suggesting irAE development in-part reflects baseline immune activation.

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