Sequential versus concurrent trastuzumab in adjuvant chemotherapy for breast cancer

Abstract

Purpose: NCCTG (North Central Cancer Treatment Group) N9831 is the only randomized phase III trial evaluating trastuzumab added sequentially or used concurrently with chemotherapy in resected stages I to III invasive human epidermal growth factor receptor 2-positive breast cancer.

Patients and methods: Patients received doxorubicin and cyclophosphamide every 3 weeks for four cycles, followed by paclitaxel weekly for 12 weeks (arm A), paclitaxel plus sequential trastuzumab weekly for 52 weeks (arm B), or paclitaxel plus concurrent trastuzumab for 12 weeks followed by trastuzumab for 40 weeks (arm C). The primary end point was disease-free survival (DFS).

Results: Comparison of arm A (n = 1,087) and arm B (n = 1,097), with 6-year median follow-up and 390 events, revealed 5-year DFS rates of 71.8% and 80.1%, respectively. DFS was significantly increased with trastuzumab added sequentially to paclitaxel (log-rank P < .001; arm B/arm A hazard ratio [HR], 0.69; 95% CI, 0.57 to 0.85). Comparison of arm B (n = 954) and arm C (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.

Conclusion: DFS 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.

Trial registration: ClinicalTrials.gov NCT00005970.

Fig 1.

CONSORT diagram. (A) Second interim analysis of the comparison of arm A and arm B. (B) First interim analysis of the comparison of arm B and arm C. HER2, human epidermal growth factor receptor 2; LLN, lower limit of normal; LVEF, left ventricular ejection fraction; q3wk, once every 3 weeks.

Fig 2.

Kaplan-Meier curves showing (A) disease-free survival (DFS) and (B) overall survival (OS) for the comparison of arm A and arm B and (C) DFS and (D) OS for the comparison of arm B and arm C. Hazard ratios (HRs; with 95% CIs and P values) for pairwise comparisons were obtained by using stratified proportional hazards modeling. AC, doxorubicin and cyclophosphamide; H, trastuzumab; T, paclitaxel.