Measures of outcome in metastatic breast cancer: insights from a real-world scenario

Abstract

No gold standard treatment exists for metastatic breast cancer (MBC). Clinical decision making is based on knowledge of prognostic and predictive factors that are extrapolated from clinical trials and, sometimes, are not reliably transferable to a real-world scenario. Moreover, misalignment between endpoints used in drug development and measures of outcome in clinical practice has been noted. The roles of overall survival (OS) and progression-free survival (PFS) as primary endpoints in the context of clinical trials are the subjects of lively debate. Information about these parameters in routine clinical practice is potentially useful to design new studies and/or to interpret the results of clinical research. This study analyzed the impact of patient and tumor characteristics on the major measures of outcome across different lines of treatment in a cohort of 472 patients treated for MBC. OS, PFS, and postprogression survival (PPS) were analyzed. The study showed how biological and clinical characteristics may have different prognostic value across different lines of therapy for MBC. After first-line treatment, the median PPS of luminal A, luminal B, and human epidermal growth factor receptor 2 (HER2)-positive groups was longer than 12 months. The choice of OS as a primary endpoint for clinical trials could not be appropriate with these subtypes. In contrast, OS could be an appropriate endpoint when PPS is expected to be low (e.g., triple-negative subtype after the first line; other subtypes after the third line). The potential implications of these findings are clinical and methodological.

Keywords: Breast neoplasms; Outcome measure; Surrogate endpoint; Survival analysis.

Figure 1.

Comparison of OS, PFS at first line of treatment, and PPS after the first line of treatment between different immunophenotypes. Abbreviations: OS, overall survival; PFS, progression-free survival; PPS, postprogression survival.

Figure 2.

HER2+ population, comparison between hormone receptor-positive and -negative subgroups. Abbreviations: OS, overall survival; PFS, progression-free survival.