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Breast Cancer Treatments
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Breast cancer (BC) is the most frequent cancer diagnosed in women worldwide. This heterogeneous disease can be classified into four molecular subtypes (luminal A, luminal B, HER2 and triple-negative breast cancer (TNBC)) according to the expression of the estrogen receptor (ER) and the progesterone receptor (PR), and the overexpression of the human epidermal growth factor receptor 2 (HER2). Current BC treatments target these receptors (endocrine and anti-HER2 therapies) as a personalized treatment. Along with chemotherapy and radiotherapy, these therapies can have severe adverse effects and patients can develop resistance to these agents. Moreover, TNBC do not have standardized treatments. Hence it is essential to develop new treatments to target more effectively each BC subgroup. 

  • breast cancer
  • personalized therapies
  • molecular subtypes
  • breast cancer treatment
  • luminal
  • HER2
  • TNBC
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Subjects: Oncology
Contributor :
View Times: 118
Revisions: 2 times (View History)
Update Time: 06 Sep 2021

1. Introduction

Breast cancer (BC) is the most frequent cancer and the second cause of death by cancer in women worldwide. According to Cancer Statistics 2020, BC represents 30% of female cancers with 276,480 estimated new cases and more than 42,000 estimated deaths in 2020 [1].
Invasive BC can be divided into four principal molecular subtypes by immunohistological technique based on the expression of the estrogen receptor (ER), the progesterone receptor (PR), and the human epidermal growth factor receptor 2 (HER2) [2]. Luminal A BC (ER+ and/or PR+, and HER2-) represents around 60% of BC and is associated with a good prognosis [3]. Luminal B BC (ER+ and/or PR+, and HER2+) represents 30% of BC and is associated with high ki67 (>14%), a proliferation marker, and a poor prognosis [4]. HER2 BC (ER-, PR-, and HER2+) represents 10% of BC and is also associated with a poor prognosis [5]. Lastly, triple-negative BC (TNBC) (ER-, PR-, and HER2-) represents 15–20% of BC and is associated with more aggressivity and worse prognosis compared to other BC molecular subtypes and often occurs in younger women [6]. Characteristics of BC by molecular subtypes are described in Figure 1.
Figure 1. Characteristics of breast cancer molecular subtypes. ER: estrogen receptor; PR: progesterone receptor; HER2: human epidermal growth factor receptor 2; TNBC: triple-negative breast cancer. a. Frequency derived from Al-thoubaity et al. [7] and Hergueta-Redondo et al. [8]. b. Grade derived from Engstrom et al. [9]. c. Prognosis derived from Hennigs et al. [10] and Fragomeni et al. [11]. d. The 5–year survival rate derived from the latest survival statistics of SEER [12].
The 5-year relative BC-specific survival rate of BC is encouraging with 90.3% for all subtypes and stages. However, for metastatic BC the 5-year relative cancer-specific survival rate is still low: 29% regardless of subtype and can drop to 12% for metastatic TNBC [12]. This clearly indicates that strategies of treatment for metastatic BC patients are not effective enough to ensure a good survival rate. Thus, it is crucial to find new solutions for the treatment of metastatic BC and especially TNBC.
Treatment choice is based on the grade, stage, and BC molecular subtype to have the most personalized, safe, and efficient therapy. The grade describes the appearance of tumor cells compared to normal cells. It includes tubule differentiation, nuclear pleomorphism, and the mitotic count [13]. The stage is used to classify the extent of cancer in the body and is defined using the TNM system comprising tumor size, lymph node status, and the presence of metastases [14]. For non-metastatic BC, the strategic therapy involves removing the tumor by complete or breast-conserving surgery with preoperative (neoadjuvant) or postoperative (adjuvant) radiotherapy and systemic therapy including chemotherapy, and targeted therapy. Targeted therapy comprises endocrine therapy for hormone receptor-positive (HR+) BC and anti-HER2 therapy for HER2+ BC. Unfortunately, there is no available targeted therapy for the TNBC subtype. For metastatic BC the priority is to contain tumor spread as this type of BC remains incurable. The same systemic therapies are used to treat metastatic BC [15].
Challenges in the treatment of BC including dealing with treatment resistance and recurrence. Indeed, 30% of early-stage BC have recurrent disease, mostly metastases [16]. Thus, it is crucial to develop new strategic therapies to treat each BC subgroup effectively.

2. Common Treatments for All Breast Cancer Subtypes

In addition to surgery, radiotherapy and chemotherapy are used routinely to treat all BC subtypes [17].

2.1. Surgery

The most standard breast surgery approaches are either total excision of the breast (mastectomy), usually followed by breast reconstruction, or breast-conserving surgery (lumpectomy). Lumpectomy entails the excision of the breast tumor with a margin of surrounding normal tissue. The recommended margins status is defined as “no ink on tumor”, meaning no remaining tumor cells at the tissue edge [18]. Studies show that total mastectomy and lumpectomy plus irradiation are equivalent regarding relapse-free and overall survival (OS) [19]. Contraindications for breast-conserving surgery include the presence of diffuse microcalcifications (suspicious or malignant-appearing), disease that cannot be incorporated by local excision with satisfactory cosmetic result, and ATM (ataxia-telangiesctasia mutated) mutation (biallelic inactivation) [18].

2.2. Radiotherapy

Radiation therapy has been used to treat cancer since Röngten discovered the X-ray in 1895 [20]. High-energy radiations are applied to the whole breast or a portion of the breast (after breast-conservative surgery), chest wall (after mastectomy), and regional lymph nodes [21]. Postmastectomy radiation to the chest wall in patients with positive lymph nodes is associated with decreased recurrence risk and BC mortality compared to patients with negative lymph nodes [22]. A radiation boost to the regional node radiation treatment can be incorporated after mastectomy for patients at higher risk for recurrence [23]. Radiotherapy can be administered concurrently with personalized therapy (anti-HER2 therapy or endocrine therapy).
Radiation therapy is used to treat all BC subtypes, but its implication is more important for TNBC, as there is no personalized therapy for this subtype. It has been shown that radiotherapy benefits TNBC patients both after conserving surgery and mastectomy [24].

2.3. Chemotherapy

BC chemotherapy comprises several families of cytotoxic drugs, including alkylating agents, antimetabolites and tubulin inhibitors [25]. Cyclophosphamide is a nitrogen mustard alkylating agent causing breakage of the DNA strands [26]. The mechanism of action for anthracyclines (doxorubicin, daunorubicin, epirubicin, and idarubicin) includes DNA intercalation, thereby inhibiting macromolecular biosynthesis [27]. Taxanes, including docetaxel and paclitaxel, bind to microtubules and prevent their disassembly, leading to cell cycle arrest and apoptosis [28].
Chemotherapy can be administered in the neoadjuvant or adjuvant setting and for metastatic BC treatment.

3. Current Personalized Treatments for Breast Cancer: Strengths and Weaknesses

The current strategies of treatment are principally based on the tumor progression and BC molecular subtypes in order to offer the most personalized treatment for BC patients. The algorithm of BC treatment is represented in Figure 2.
Figure 2. Breast cancer treatment flow diagram. (A). Early-stage breast cancer. (B). Metastatic/advanced breast cancer. a Neoadjuvant chemotherapy for HR+ BC patients is not systematic. It is mainly administered to luminal B BC patients and/or elder BC patients. HR+: hormone receptors positive; HER2+: human epidermal growth factor receptor 2 positive; TNBC: triple-negative breast cancer; AIs: aromatase inhibitors; T-DM1: trastuzumab-emtansine.

3.1. Endocrine Therapy

Endocrine therapy is the main strategy to treat HR positive invasive BC. The purpose of this therapy is to target the ER directly (selective estrogen receptors modulators and degraders) or the estrogen synthesis (aromatase inhibitors) [29]. The most common types of endocrine therapy are selective estrogen receptor modulators (SERMs), selective modulators estrogen receptor degraders (SERDs), and aromatase inhibitors (AIs) [30]. Endocrine therapy mechanism of action and resistance are described in Figure 3.
Figure 3. Endocrine therapy mechanisms of action and resistance. The left part of the figure shows the mechanism of endocrine therapy through aromatase inhibitors, tamoxifen, and fulvestrant. The right part of the figure describes the mechanisms of resistance to endocrine therapy through the epigenetic modifications, the increase of coactivators and cell cycle actors, and the activation of other signaling pathways. Estrogens can go through the plasma membrane by a. diffusion as they are small non-polar lipid soluble molecules; b. binding to membrane ER initiating the activation of Ras/Raf/MAPK and PI3K/Akt signaling pathways which are blocked by tamoxifen. 1: inhibition of ER dimerization; 2: blockage of nucleus access; 3: ER degradation. ER: estrogen receptor; AIB1: amplified in breast cancer 1; IGF-1R: insulin growth factor receptor 1; IGF: insulin growth factor; HER: human epidermal receptors; EGF: epidermal growth factor; HB-EGF: heparin-binding EGF-like growth factor; TGF-α: transforming growth factor alpha; MEK/MAPK: mitogen activated protein kinase; PI3K: phosphoinositide 3-kinase; mTOR: mammalian target of rapamycin; Me: methylation; Ac: acetylation.

3.2. Anti-HER2 Therapy

The overexpression of HER2 is associated with worse survival outcome compared to HR-positive/HER2-negative BC [31][32]. Hence, therapies targeting HER2 are essential to treat HER2-positive BC. The current anti-HER2 therapies comprise antibodies that target specific HER2 epitopes, tyrosine kinase inhibitors (TKIs) and, more recently, antibody-drug conjugates (ADCs) [33]. Anti-HER2 mechanisms of action and resistance are described in Figure 4.
Figure 4. Anti-HER2 therapy mechanisms of action and resistance. The left part of the figure describes the mechanism of action of anti-HER2 therapy through anti-HER2 antibody (trastuzumab and pertuzumab), tyrosine kinase inhibitors (lapatinib and nerotinib), and the antibody-drug conjugate trastuzumab-emtansine (T-DM1). The right part of the figure describes the mechanism of resistance to anti-HER2 therapy through constitutive active p95HER2 fragment, activation of other signaling pathways, and rapid recycling of HER2-T-DM1. ADCC: antibody-dependent cellular cytotoxicity; HER2: human epidermal growth factor receptor 2; EGF: epidermal growth factor, HB-EGF: heparin-binding EGF-like growth factor; TGF-α: transforming growth factor alpha; T-DM1: trastuzumab-emtansine; IGF-1R: insulin growth factor receptor 1; IGF: insulin growth factor; HGF: hepatocyte growth factor; MEK/MAPK: mitogen activated protein kinase; PI3K: phosphoinositide 3-kinase; mTOR: mammalian target of rapamycin; PTEN: phosphatase and tensin homolog.

3.3. PARP Inhibitors

The prevalence of BRCA (Breast Cancer genes) mutations in TNBC patients is approximately 20% [34]. BRCA1 and BRCA2 are proteins involved in the DNA damage response to repair DNA lesions [35]. Mutations in BRCA 1/2 genes are associated with an increased risk of breast and ovarian cancers [36]. PARP (poly-(ADP-ribose) polymerase protein) proteins are also involved in the DNA damage response as they recruit DNA repair proteins, such as BRCA1 and BRCA2, to the damage site [37]. PARP inhibitors (PARPi) were developed to inhibit DNA repair in BRCA-mutated BC since cells defective in BRCA functions cannot repair DNA damage when PARP is inhibited [38]. The principal PARPis currently in clinical development are olaparib, talazoparib, veliparib, and rucaparib [39]. PARP inhibitors mechanisms of action and resistance are described in Figure 5.
Figure 5. PARP inhibitors mechanisms of action and resistance. The left part of the figure describes the mechanism of PARP inhibitors in the context of BRCA mutated breast cancer. The right part of the figure describes the mechanism of resistance to PARP inhibitors through secondary intragenic mutations restoring BRCA proteins functions and the decrease of the recruitment of nucleases (MUS81 or MRE11) to protect the replication fork. PARP: poly-(ADP-ribose) polymerase protein; PARPi: PARP inhibitors; BRCA: breast cancer protein; MUS81: methyl methanesulfonate ultraviolet sensitive gene clone 81; MRE11: meiotic recombination 11.

4. New Strategies and Challenges for Breast Cancer Treatment

4.1. Emerging Therapies for HR-Positive Breast Cancer

The major mechanisms of action of current endocrine therapy resistance occur via (1) the mTOR/PI3K/Akt signaling pathway and (2) the actors of the cell cycle progression CDK4/6. Therefore, emerging therapies for HR+ BC mainly target the actors of these pathways to bypass estrogen-independent cell survival [40]. The most recent completed clinical trials on emerging therapies for HR+ BC are presented in Table 1.
Table 1. Most recent completed clinical trial on emerging therapies for HR-positive breast cancer.

Targeted Therapy

Drug Name

Trial Number

Patient Population

Trial Arms

Outcomes

Pan-PI3K inhibitors

Buparlisib

BELLE-2

Phase III

NCT01610284

[41]

HR+/HER2-

Postmenopausal

Locally advanced or MBC

Prior AI treatment

Buparlisib + fulvestrant vs. placebo + fulvestrant

PFS 6.9 months vs. 5.0 months (HR 0.78; p  =  0.00021)

PFS 6.8 months vs. 4.0 months in PI3K mutated (HR 0.76; p  =  0.014)

BELLE-3

Phase III

NCT01633060

[42]

HR+/HER2-

Postmenopausal

Locally advanced or MBC

Prior endocrine therapy or mTOR inhibitors

Buparlisib + fulvestrant vs. placebo + fulvestrant

PFS 3.9 months vs. 1.8 months (HR 0.67; p  =  0.0003)

BELLE-4

Phase II/III

NCT01572727

[43]

HER2-

Locally advanced or MBC

No prior chemotherapy

Buparlisib + pacliatxel vs. placebo + paclitaxel

PFS 8.0 months vs. 9.2 months (HR 1.18, 95% CI 0.82–1.68)

PFS 9.1 months vs. 9.2 months in PI3K mutated (HR 1.17, 95% 0.63–2.17)

Pictilisib

FERGI

Phase II

NCT01437566

[44]

HR+/HER2-

Postmenopausal

Prior AI treatment

Pictilisib + fulvestrant vs. placebo + fulvestrant

PFS 6.6 months vs. 5.1 months (HR 0.74; p  =  0.096)

PFS 6.5 months vs. 5.1 months in PI3K mutated (HR 0.74; p  =  0.268)

PFS 5.8 months vs. 3.6 months in non-PI3K mutated (HR 0.72; p  =  0.23)

PEGGY

Phase II

NCT01740336

[45]

HR+/HER2-

Locally recurrent

or MBC

Pictilisib + paclitaxel vs. placebo + paclitaxel

PFS 8.2 months vs. 7.8 months (HR 0.95; p  =  0.83)

PFS 7.3 months vs. 5.8 months in PI3K mutated (HR 1.06; p  =  0.88)

Isoform-specific inhibitors

Alpelisib

Phase Ib

NCT01791478

[46]

HR+/HER2-

Postmenopausal

MBC

Prior endocrine therapy

Alpelisib + letrozole

CBR 35% (44% in patients with PIK3CA mutated and 20% in PIK3CA wild-type tumors; 95% CI [17%; 56%])

SOLAR-1

Phase III

NCT02437318

[47]

HR+/HER2-

Advanced BC

Prior endocrine therapy

Alpelisib + fulvestrant vs. placebo + fulvestrant

PFS 7.4 months vs. 5.6 months in non-PI3K mutated (HR 0.85, 95% CI 0.58–1.25)

PFS 11.0 months vs. 5.7 months in PI3K mutated (HR 0.65; p  =  0.00065)

NEO-ORB

Phase II

NCT01923168

[48]

HR+/HER2-

Postmenopausal

Early-stage BC

Neoadjuvant setting

Alpelisib + letrozole vs. placebo + letrozole

ORR 43% vs. 45% (PIK3CA mutant), 63% vs. 61% (PIK3CA wildtype)

pCR rates low in all groups

Taselisib

SANDPIPER

Phase III

NCT02340221

[49]

HR+/HER2-

Postmenopausal

Locally advanced or MBC

PIK3CA-mutant

Prior AI treatment

Taselisib + fulvestrant vs. placebo + fulvestrant

PFS 7.4 months vs. 5.4 months (HR 0.70; p  =  0.0037)

LORELEI

Phase II

NCT02273973

[50]

HR+/HER2-

Postmenopausal

Early-stage BC

Neoadjuvant setting

Taselisib + letrozole vs. placebo + letrozole

ORR 50% vs. 39.3% (OR 1.55; p  =  0.049)

ORR 56.2% vs. 38% in PI3K mutated (OR 2.03; p  =  0.033)

No significant difference in pCR

mTOR inhibitors

Everolimus

BOLERO-2

Phase III

NCT00863655

[51]

HR+/HER2-

Advanced BC

Prior AI treatment

Everolimus + exemestane

vs. placebo + exemestane

PFS 6.9 months vs. 2.8 months (HR 0.43; p < 0.001)

TAMRAD

Phase II

NCT01298713

[52]

HR+/HER2-

Postmenopausal

MBC

Prior AI treatment

Everolimus + tamoxifen vs. tamoxifen alone

CBR 61% vs. 42%

TTP 8.6 months vs. 4.5 months (HR 0.54)

PrE0102

Phase II

NCT01797120

[53]

HR+/HER2-

Postmenopausal

MBC

Prior AI treatment

Everolimus + fulvestrant

vs. placebo + fulvestrant

PFS 10.3 months vs. 5.1 months (HR 0.61; p = 0.02)

CBR 63.6% vs. 41.5% (p = 0.01)

Akt inhibitors

Capivasertib

FAKTION

Phase II

NCT01992952

[54]

HR+/HER2-

Postmenopausal

Locally advanced or MBC

Prior AI treatment

Capivasertib + fulvestrant vs. placebo + fulvestrant

PFS 10.3 months vs. 4.8 months (HR 0.57; p  =  0.0035)

Phase I

NCT01226316

[55]

ER+

AKT1E17K-mutant

MBC

Prior endocrine treatment

Capivasertib + fulvestrant vs. Capivasertib alone

CBR 50% vs. 47%

ORR 6% (fulvestrant-pretreated) and 20% (fulvestrant-naïve) vs. 20%

CDK4/6 inhibitors

Palcociclib

PALOMA-1

Phase II

NCT00721409

[56]

HR+/HER2-

Postmenopausal

Advanced BC

No prior systemic treatment

Palbocilib + letrozole vs. letrozole alone

PFS 20.2 months vs. 10.2 months (HR 0.488; p = 0.0004)

PFS 26.1 months vs. 5.7 months (HR 0.299; p < 0.0001) in non-Cyclin D1 amplified

PFS 18.1 months vs. 11.1 months (HR 0.508; p = 0.0046) in Cyclin D1 amplified

PALOMA-2

Phase III

NCT01740427

[57]

HR+/HER2-

Postmenopausal

Advanced BC

No prior systemic treatment

Palbocilib + letrozole vs. placebo + letrozole

PFS 24.8 months vs. 14.5 months (HR 0.58; p < 0.001)

PALOMA-3

Phase III

NCT01942135

[58]

HR+/HER2-

MBC

Prior endocrine therapy

Palbociclib + fulvestrant

vs. placebo + fulvestrant

PFS 9.5 months vs. 4.6 months (HR 0.46; p < 0.0001)

Ribociclib

MONALEESA-2

Phase III

NCT01958021

[59]

HR+/HER2-

Postmenopausal

Advanced or MBC

Ribociclib + letrozole vs. placebo + letrozole

PFS 25.3 months vs. 16.0 months (HR 0.568; p < 0.0001)

MONALEESA-3

Phase III

NCT02422615

[60]

HR+/HER2-

Advanced BC

No prior treatment or prior endocrine therapy

Ribociclib + fulvestrant vs. placebo + fulvestrant

PFS 20.5 months vs. 12.8 months (HR 0.593; p < 0.001)

Abemaciclib

MONARCH-2

Phase III

NCT02107703

[61]

HR+/HER2-

Advanced or MBC

Prior endocrine treatment

Abemaciclib + fulvestrant vs. fulvestrant alone

PFS 16.4 months vs. 9.3 months (HR 0.553; p < 0.001)

MONARCH-3

Phase III

NCT02246621

[62]

HR+/HER2-

Advanced or MBC

Prior endocrine treatment

Abemaciclib + anastrozole or letrozole vs. placebo + anastrozole or letrozole

PFS 28.18 months vs. 14.76 months (HR 0.546; p < 0.0001)

HR+: hormone receptors positive; HER2-: human epidermal growth factor receptor 2 negative; MBC: metastatic breast cancer; BC: breast cancer; PFS: progression free survival; CBR: clinical benefit rate; ORR: objective response rate; pCR: pathologic complete response; HR: hazard ratio.

4.2. New Strategic Therapies for HER2-Positive Breast Cancer

HER2+ BC is currently treated with specific HER2 targeting antibodies or tyrosine kinase inhibitors (TKIs), and more recently, with TDM-1, an antibody-drug conjugate. These treatments have greatly improved HER2+ BC survival. However, 25% of HER2+ BC patients will still develop resistance to anti-HER2 treatment. Hence, new therapeutic strategies are emerging, such as new antibodies targeting HER2, new TKIs, vaccines, and PI3K/mTOR and CDK4/6 inhibitors [63]. The most recent completed clinical trials on new strategies for HER2+ BC treatment are gathered in Table 2.
Table 2. Most recent completed clinical trials on emerging therapies for HER2+ breast cancer.

Targeted Therapy

Drug Name

Trial Number

Patient Population

Trial Arms

Outcomes

Antibodies drug conjugate (ADC)

Trastuzumab-deruxtcan

(DS-8201a)

DESTINY-Breast01

Phase II

NCT03248492

[64]

HER2+

MBC

Prior trastuzumab-emtansine treatment

Trastuzumab-deruxtcan monotherapy

PFS 16.4 months

Trastuzumab-duocarmycin (SYD985)

Phase I dose-escalation and dose-expansion

NCT02277717

[65]

HER2+

Locally advanced or metastatic solid tumors

Trastuzumab-duocarmycin monotherapy

ORR 33%

Modified antibodies

Margetuxumab (MGAH22)

SOPHIA

Phase III

NCT02492711

[66]

HER2+

Advanced or MBC

Prior anti-HER2 therapies

Margetuximab + chemotherapy vs. trastuzumab + chemotherapy

PFS 5.8 months vs. 4.9 months (HR 0.76; p = 0.03)

OS 21.6 months vs. 19.8 months (HR 0.89; p = 0.33)

ORR 25% vs. 14% (p < 0.001)

Tyrosine kinase inhibitors

Tucatinib

HER2CLIMB

Phase II

NCT02614794

[67]

HER2+

Locally advanced or MBC

Prior anti-HER2 therapies

Tucatinib + trastuzumab and capecitabine vs. placebo + trastuzumab and capecitabine

PFS 33.1% (7.8 months) vs. 12.3% (5.6 months) (HR 0.54; p < 0.001)

PFS 24.9% vs. 0% (HR 0.48; p < 0.001) in brain metastases patients

OS 44.9% vs. 26.6% (HR 0.66; p = 0.005)

Poziotinib

NOV120101-203

Phase II

NCT02418689

[68]

HER2+

MBC

Prior chemotherapy and trastuzumab

Poziotinib monotherapy

PFS 4.04 months

HER2-derived peptide vaccine

E75 (NeuVax)

Phase I/II

NCT00841399

NCT00854789

[69]

HER2+

Node-positive or high-risk node-negative BC

HLA2/3+

E75 vaccination vs. non-vaccination

DFS 89.7% vs. 80.2% (p = 0.008)

DFS 94.6% in optimal dosed patients (p = 0.005 vs. non-vaccination)

GP2

Phase II

NCT00524277

[70]

HER2 (IHC 1-3+)

Disease free

Node-positive or high-risk node-negative BC

HLA2+

GP2 + GM-CSF vs. GM-CSF alone

DFS 94% vs. 85% (p = 0.17)

DFS 100% vs. 89% in HER2-IHC3+ (p = 0.08)

AE37

Phase II

NCT00524277

[71]

HER2 (IHC 1-3+)

Node-positive or high-risk node-negative BC

AE37 + GM-CSF vs. GM-CSF alone

DFS 80.8% vs. 79.5% (p = 0.70)

DFS 77.2% vs. 65.7% (p = 0.21) HER2-low

DFS 77.7% vs. 49.0% (p = 0.12) TNBC

PI3K inhibitors

Alpelisib

Phase I

NCT02167854

[72]

HER2+

MBC with a PIK3CA mutation Prior ado-trastuzumab emtansine and pertuzumab

Alpelisib + Trastuzumab + LJM716

Toxicities limited drug delivery 72% for alpelisib 83% for LJM716

Phase I

NCT02038010

[73]

HER2+

MBC

Prior trastuzumab-based therapy

Alpelisib + T-DM1

PFS 8.1 months

ORR 43%

CBR 71% and 60% in prior T-DM1 patients

Copanlisib

PantHER

Phase Ib

NCT02705859

[74]

HER2+

Advanced BC

Prior anti-HER2 therapies

Copanlisib + trastuzumab

Stable disease 50%

mTOR inhibitors

Everolimus

BOLERO-1

Phase III

NCT00876395

[75]

HER2+

Locally advanced BC

No prior treatment

Everolimus + trastuzumab vs. placebo + trastuzumab

PFS 14.95 months vs. 14.49 months (HR 0.89; p = 0.1166)

PFS 20.27 months vs. 13.03 months (HR 0.66; p = 0.0049)

BOLERO-3

Phase III

NCT01007942

[76]

HER2+

Advanced BC

Trastuzumab-resistant

Prior taxane therapy

Everolimus + trastuzumab and vinorelbine vs. placebo + trastuzumab and vinorelbine

PFS 7.00 months vs. 5.78 months (HR 0.78; p = 0.0067)

CDK4/6 inhibitors

Palbociclib

SOLTI-1303 PATRICIA

Phase II

NCT02448420

[77]

HER2+

ER+ or ER-

MBC

Prior standard therapy including trastuzumab

Palbociclib + trastuzumab

PFS 10.6 months (luminal) vs. 4.2 months (non-luminal) (HR 0.40; p = 0.003)

Ribociclib

Phase Ib/II

NCT02657343

[78]

HER2+

Advanced BC

Prior treatment with trastuzumab, pertuzumab, and trastuzumab emtansine

Ribociclib + trastuzumab

PFS 1.33 months

No dose-limiting toxicities

Abemaciclib

MonarcHER

Phase II

NCT02675231

[79]

HER2+

Locally advanced or MBC

Prior anti-HER2 therapies

Abemaciclib + trastuzumab and fulvestrant (A) vs. abemaciclib + trastuzumab (B) vs. standard-of-care chemotherapy + trastuzumab (C)

PFS 8.3 months (A) vs. 5.7 months (C) (HR 0.67; p = 0.051)

PFS 5.7 months (B) vs. 5.7 months (C) (HR 0.97; p = 0.77)

HER2+: human epidermal growth factor receptor 2 positive; ER+: estrogen receptor positive; HLA2/3: human leucocyte antigen 2/3; MBC: metastatic breast cancer; BC: breast cancer; PFS: progression free survival; CBR: clinical benefit rate; ORR: objective response rate; DFS: disease-free survival OS: overall survival GM-CSF: granulocyte macrophage colony-stimulated factor; HR: hazard ratio.

4.3. Emerging Therapies for Triple Negative Breast Cancer (TNBC)

TNBC is the most aggressive BC subtype. The fact that TNBC lacks ER and PR expression and does not overexpress HER2, combined with its high heterogeneity, has contributed to the difficulties in developing efficient therapies [80]. Thus, multiple strategic therapies have been developed to treat all TNBC subtypes. These include conjugated antibodies, targeted therapy, and immunotherapy. An overview of the most recent and completed clinical trials on emerging therapies for TNBC is presented in Table 3.
Table 3. Most recent completed clinical trials on emerging therapies for TNBC.

Targeted Therapy

Drug Name

Trial Number

Patient Population

Trial Arms

Outcomes

Antibodies Drug Conjugate

Sacituzumab govitecan

ASCENT

Phase III

NCT02574455

[81]

TNBC

MBC

Prior standard treatment

Sacituzumab govitecan vs. single-agent chemotherapy

PFS 5.6 months vs. 1.7 months (HR 0.41; p < 0.001)

PFS 12.1 months vs. 6.7 months (HR 0.48; p < 0.001)

VEGF inhibitors

Bevacizumab

BEATRICE

Phase III

NCT00528567

[82]

Early TNBC

Surgery

Bevacizumab + chemotherapy vs. chemotherapy alone

IDFS 80% vs. 77%

OS 88% vs. 88%

CALGB 40603

Phase II

NCT00861705

[83]

TNBC

Stage II to III

Bevacizumab + chemotherapy vs. chemotherapy alone or Carboplatin + chemotherapy vs. chemotherapy alone

pCR 59% vs. 48% (p = 0.0089) (Bevacizumab)

pCR 60% vs. 44% (p = 0.0018) (Carboplatin)

EGFR inhibitors

Cetuximab

TBCRC 001

Phase II

NCT00232505

[84]

TNBC

MBC

Cetuximab + carboplatin

Response < 20%

TTP 2.1 months

Phase II

NCT00463788

[85]

TNBC

MBC

Prior chemotherapy treatment

Cetuximab + cisplatin vs. cisplatin alone

ORR 20% vs. 10% (p = 0.11)

PFS 3.7 months vs. 1.7 months (HR 0.67; p = 0.032)

OS 12.9 months vs. 9.4 months (HR 0.82; p = 0.31)

mTORC1 inhibitors

Everolimus

Phase II

NCT00930930

[86]

TNBC

Stage II or III

Neoadjuvant treatment

Everolimus + cisplatin and paclitaxel vs. placebo + cisplatin and paclitaxel

pCR 36% vs. 49%

Akt inhibitors

Ipatasertib

LOTUS

Phase II

NCT02162719

[87]

TNBC

Locally advanced or MBC

No prior sytemic therapy

Ipatasertib + paclitaxel vs. placebo + paclitaxel

PFS 6.2 months vs. 4.9 months (HR 0.60; p = 0.037)

PFS 6.2 months vs. 3.7 moths (HR 0.58; p = 0.18) in PTEN-low patients

FAIRLANE

Phase II

NCT02301988

[88]

Early TNBC

Neoadjuvant treatment

Ipatasertib + paclitaxel vs. placebo + paclitaxel

pCR 17% vs. 13%

pCR 16% vs. 13% PTEN-low patients

pCR 18% vs. 12% PIK3CA/AKT1/PTEN-altered patients

Capivasertib

PAKT

Phase II

NCT02423603

[89]

TNBC

MBC

No prior chemotherapy treatment

Capivasertib + paclitaxel vs. placebo + paclitaxel

PFS 5.9 months vs. 12.6 months (HR 0.61; p = 0.04)

Androgen receptor inhibitors

Bicalutamide

Phase II

NCT00468715

[90]

HR-

AR+ or AR-

MBC

Bicalutamide monotherapy

CBR 19%

PFS 12 weeks

Enzalutamide

Phase II

NCT01889238

[91]

TNBC

AR+

Locally advanced or MBC

Enzalutamide monotherapy

CBR 25%

OS 12.7 months

CYP17 inhibitors

Abiraterone acetate

UCBG 12-1

Phase II

NCT01842321

[92]

TNBC

AR+

Locally advanced or MBC

Centrally reviewed

Prior chemotherapy

Abiraterone acetate + prednisone

CBR 20%

ORR 6.7%

PFS 2.8 months

Anti-PDL1 antibodies

Atezolizumab

Impassion 130

Phase III

NCT02425891

[93]

TNBC

Locally advanced or MBC

No prior treatment

Atezolizumab + nab-paclitaxel vs. placebo + nab-paclitaxel

OS 21.0 months vs. 18.7 months (HR 0.86; p = 0.078)

OS 25.0 months vs. 18.0 months (HR 0.71, 95% CI 0.54–0.94)) in PDL-1+ patients

Impassion 031

Phase III

NCT03197935

[94]

TNBC

Stage II to III

No prior treatment

Atezolizumab + chemotherapy vs. placebo + chemotherapy

pCR 95% vs. 69% p = 0.0044

Durvalumab

GeparNuevo

Phase II

NCT02685059

[95]

TNBC

MBC

Stromal tumor-infiltrating lymphocyte (sTILs)

Durvalumab vs. placebo

pCR 53.4% vs. 44.2%

pCR 61.0% vs. 41.4% in window cohort

SAFIRO BREAST-IMMUNO

Phase II

NCT02299999

[96]

HER2-

MBC

Prior chemotherapy

Durvalumab vs. maintenance chemotherapy

HR of death 0.37 for PDL-1+ patients

HR of death 0.49 for PDL-1- patients

Phase I

NCT02484404

[97]

Recurrent women’s cancers including TNBC

Durvalumab + cediranib + olaparib

Partial response 44%

CBR 67%

Avelumab

JAVELIN

Phase Ib

NCT01772004

[98]

MBC

Prior standard-of-care therapy

Avelumab monotherapy

ORR 3.0% overall

ORR 5.2% in TNBC

ORR 16.7% in PDL-1+ vs. 1.6% in PDL-1- overall

ORR 22.2.% in PDL-1+ vs. 2.6% in PDL-1- in TNBC

Anti-PD1 antibodies

Pembrolizumab

KEYNOTE-086

Phase II

NCT02447003

[99]

TNBC

MBC

Prior or no prior systemic therapy

Pembrolizumab monotherapy

Previously treated patients:

ORR 5.3% overall

ORR 5.7% PDL-1+ patients

PFS 2.0 months

OS 9.0 months

Non-previously pretreated:

ORR 21.4%

PFS 2.1 months

OS 18.0 months

KEYNOTE-119

Phase III

NCT02555657

[100]

TNBC

MBC

Prior systemic therapy

Pembrolizumab vs. chemotherapy

OS 12.7 months vs. 11.6 months (HR 0.78; p = 0.057) in PDL1+ patients

OS 9.9 months vs. 10.8 months (HR 0.97, 95% CI 0.81–1.15)

KEYNOTE-355

Phase III

NCT02819518

[101]

TNBC

MBC

No prior systemic therapy

Pembrolizumab + chemotherapy vs. placebo + chemotherapy

PFS 9.7 months vs. 5.6 months (HR 0.65; p = 0.0012) in PDL-1+ patients

PFS 7.6 months vs. 5.6 months (HR 0.74; p = 0.0014)

KEYNOTE-522

Phase III

NCT03036488

[102]

Early TNBC

Stage II to III

No prior treatment

Pembrolizumab + paclitaxel and carboplatin vs. placebo + paclitaxel and carboplatin

pCR 64.8% vs. 51.2 % (p < 0.001)

Anti-CDL4 antibodies

Tremelimumab

Phase I

[103]

Incurable MBC

Tremelimumab + radiotherapy

OS 50.8 months

Vaccines

PPV

Phase II

UMIN000001844

[104]

TNBC

MBC

Prior systemic therapy

PPV vaccine

PFS 7.5 months

OS 11.1 months

STn-KLH

Phase III

NCT00003638

[105]

MBC

Prior chemotherapy

Partial or complete response

STn-KLH vaccine vs. non-vaccine

TTP 3.4 months vs. 3.0 months

TNBC: triple negative breast cancer; HER2: human epidermal growth factor receptor; HR: hormonal receptor; MBC: metastatic breast cancer; BC: breast cancer; AR: androgen receptor; PPV: personalized peptide vaccine; PFS: progression free survival; CBR: clinical benefit rate; ORR: objective response rate; IDFS: invasive disease-free survival; OS: overall survival; TTP: time to progression; pCR: pathologic complete response; HR: hazard ratio.

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    Durocher, F. Breast Cancer Treatments. Encyclopedia. Available online: https://encyclopedia.pub/entry/13868 (accessed on 01 July 2022).
    Durocher F. Breast Cancer Treatments. Encyclopedia. Available at: https://encyclopedia.pub/entry/13868. Accessed July 01, 2022.
    Durocher, Francine. "Breast Cancer Treatments," Encyclopedia, https://encyclopedia.pub/entry/13868 (accessed July 01, 2022).
    Durocher, F. (2021, September 02). Breast Cancer Treatments. In Encyclopedia. https://encyclopedia.pub/entry/13868
    Durocher, Francine. ''Breast Cancer Treatments.'' Encyclopedia. Web. 02 September, 2021.
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