Molecular Heterogeneity and Response to Neoadjuvant Human Epidermal Growth Factor Receptor 2 Targeting in CALGB 40601, a Randomized Phase III Trial of Paclitaxel Plus Trastuzumab With or Without Lapatinib.

Abstract

PURPOSE:

Dual human epidermal growth factor receptor 2 (HER2) targeting can increase pathologic complete response rates (pCRs) to neoadjuvant therapy and improve progression-free survival in metastatic disease. CALGB 40601 examined the impact of dual HER2 blockade consisting of trastuzumab and lapatinib added to paclitaxel, considering tumor and microenvironment molecular features.

PATIENTS AND METHODS:

Patients with stage II to III HER2-positive breast cancer underwent tumor biopsy followed by random assignment to paclitaxel plus trastuzumab alone (TH) or with the addition of lapatinib (THL) for 16 weeks before surgery. An investigational arm of paclitaxel plus lapatinib (TL) was closed early. The primary end point was pCR in the breast; correlative end points focused on molecular features identified by gene expression-based assays.

RESULTS:

Among 305 randomly assigned patients (THL, n = 118; TH, n = 120; TL, n = 67), the pCR rate was 56% (95% CI, 47% to 65%) with THL and 46% (95% CI, 37% to 55%) with TH (P = .13), with no effect of dual therapy in the hormone receptor-positive subset but a significant increase in pCR with dual therapy in those with hormone receptor-negative disease (P = .01). The tumors were molecularly heterogeneous by gene expression analysis using mRNA sequencing (mRNAseq). pCR rates significantly differed by intrinsic subtype (HER2 enriched, 70%; luminal A, 34%; luminal B, 36%; P < .001). In multivariable analysis treatment arm, intrinsic subtype, HER2 amplicon gene expression, p53 mutation signature, and immune cell signatures were independently associated with pCR. Post-treatment residual disease was largely luminal A (69%).

CONCLUSION:

pCR to dual HER2-targeted therapy was not significantly higher than single HER2 targeting. Tissue analysis demonstrated a high degree of intertumoral heterogeneity with respect to both tumor genomics and tumor microenvironment that significantly affected pCR rates. These factors should be considered when interpreting and designing trials in HER2-positive disease.

• Authors: Lisa A Carey, Donald A Berry, Constance T Cirrincione, William T Barry, Brandelyn N Pitcher, Lyndsay N Harris, David W Ollila, Ian E Krop, Norah Lynn Henry, Douglas J Weckstein, Carey K Anders, Baljit Singh, Katherine A Hoadley, Michael Iglesia, Maggie Chon U Cheang, Charles M Perou, Eric P Winer, Clifford A Hudis
• Journal: Journal of clinical oncology : official journal of the American Society of Clinical Oncology (J Clin Oncol) Vol. 34 Issue 6 Pg. 542-9 (Feb 20 2016) ISSN: 1527-7755 [Electronic] United States
• PMID: 26527775 (Publication Type: Clinical Trial, Phase III, Journal Article, Randomized Controlled Trial, Research Support, N.I.H., Extramural, Research Support, Non-U.S. Gov't)
• Copyright: © 2015 by American Society of Clinical Oncology.

Chemical References

• ESR1 protein, human
• Estrogen Receptor alpha
• Immunoglobulin G
• Quinazolines
• RNA, Messenger
• Receptors, Estrogen
• Receptors, Progesterone
• Tumor Suppressor Protein p53
• Lapatinib
• ERBB2 protein, human
• Receptor, ErbB-2
• Trastuzumab
• Paclitaxel

Topics

• Adult
• Aged
• Antineoplastic Combined Chemotherapy Protocols (therapeutic use)
• Breast Neoplasms (chemistry, drug therapy, surgery)
• Carcinoma (chemistry, drug therapy, surgery)
• Estrogen Receptor alpha (genetics)
• Female
• Gene Expression
• Humans
• Immunoglobulin G (metabolism)
• Lapatinib
• Middle Aged
• Neoadjuvant Therapy
• Neoplasm, Residual
• Paclitaxel (administration & dosage)
• Quinazolines (administration & dosage)
• RNA, Messenger (metabolism)
• Receptor, ErbB-2 (antagonists & inhibitors, genetics)
• Receptors, Estrogen (analysis)
• Receptors, Progesterone (analysis)
• Trastuzumab (administration & dosage)
• Treatment Outcome
• Tumor Microenvironment
• Tumor Suppressor Protein p53 (genetics)
• Young Adult