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Randomized Controlled Trial
. 2023 Feb 1;9(2):197-205.
doi: 10.1001/jamaoncol.2022.5610.

Tucatinib vs Placebo, Both in Combination With Trastuzumab and Capecitabine, for Previously Treated ERBB2 (HER2)-Positive Metastatic Breast Cancer in Patients With Brain Metastases: Updated Exploratory Analysis of the HER2CLIMB Randomized Clinical Trial

Affiliations
Randomized Controlled Trial

Tucatinib vs Placebo, Both in Combination With Trastuzumab and Capecitabine, for Previously Treated ERBB2 (HER2)-Positive Metastatic Breast Cancer in Patients With Brain Metastases: Updated Exploratory Analysis of the HER2CLIMB Randomized Clinical Trial

Nancy U Lin et al. JAMA Oncol. .

Erratum in

  • Errors in Affiliations.
    [No authors listed] [No authors listed] JAMA Oncol. 2023 Feb 1;9(2):284. doi: 10.1001/jamaoncol.2022.7864. JAMA Oncol. 2023. PMID: 36795114 Free PMC article. No abstract available.

Abstract

Importance: It is estimated that up to 50% of patients with ERBB2 (HER2)-positive metastatic breast cancer (MBC) will develop brain metastases (BMs), which is associated with poor prognosis. Previous reports of the HER2CLIMB trial have demonstrated that tucatinib in combination with trastuzumab and capecitabine provides survival and intracranial benefits for patients with ERBB2-positive MBC and BMs.

Objective: To describe overall survival (OS) and intracranial outcomes from tucatinib in combination with trastuzumab and capecitabine in patients with ERBB2-positive MBC and BMs with an additional 15.6 months of follow-up.

Design, setting, and participants: HER2CLIMB is an international, multicenter, randomized, double-blind, placebo-controlled clinical trial evaluating tucatinib in combination with trastuzumab and capecitabine. The 612 patients, including those with active or stable BMs, had ERBB2-positive MBC previously treated with trastuzumab, pertuzumab, and trastuzumab emtansine. The study was conducted from February 23, 2016, to May 3, 2019. Data from February 23, 2016, to February 8, 2021, were analyzed.

Interventions: Patients were randomized 2:1 to receive tucatinib (300 mg orally twice daily) or placebo (orally twice daily), both in combination with trastuzumab (6 mg/kg intravenously or subcutaneously every 3 weeks with an initial loading dose of 8 mg/kg) and capecitabine (1000 mg/m2 orally twice daily on days 1-14 of each 3-week cycle).

Main outcomes and measures: Evaluations in this exploratory subgroup analysis included OS and intracranial progression-free survival (CNS-PFS) in patients with BMs, confirmed intracranial objective response rate (ORR-IC) and duration of intracranial response (DOR-IC) in patients with measurable intracranial disease at baseline, and new brain lesion-free survival in all patients. Only OS was prespecified before the primary database lock.

Results: At baseline, 291 of 612 patients (47.5%) had BMs. Median age was 52 years (range, 22-75 years), and 289 (99.3%) were women. At median follow-up of 29.6 months (range, 0.1-52.9 months), median OS was 9.1 months longer in the tucatinib-combination group (21.6 months; 95% CI, 18.1-28.5) vs the placebo-combination group (12.5 months; 95% CI, 11.2-16.9). The tucatinib-combination group showed greater clinical benefit in CNS-PFS and ORR-IC compared with the placebo-combination group. The DOR-IC was 8.6 months (95% CI, 5.5-10.3 months) in the tucatinib-combination group and 3.0 months (95% CI, 3.0-10.3 months) in the placebo-combination group. Risk of developing new brain lesions as the site of first progression or death was reduced by 45.1% in the tucatinib-combination group vs the placebo-combination group (hazard ratio, 0.55 [95% CI, 0.36-0.85]).

Conclusions and relevance: This subgroup analysis found that tucatinib in combination with trastuzumab and capecitabine improved OS while reducing the risk of developing new brain lesions, further supporting the importance of this treatment option for patients with ERBB2-positive MBC, including those with BMs.

Trial registration: ClinicalTrials.gov Identifier: NCT02614794.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Lin reported receiving nonfinancial support from Seagen for manuscript preparation during the conduct of the study; grants from Genentech, Merck, AstraZeneca, Zion Pharmaceuticals, Seagen, Olema Pharmaceuticals, and Pfizer outside the submitted work; personal fees from Pfizer, Puma, Seagen, Daiichi Sankyo, Prelude Therapeutics, Denali Therapeutics, Olema Pharmaceuticals, AstraZeneca, Aleta BioPharma, Affinia Therapeutics, and Voyager Therapeutics outside the submitted work; consulting fees from Affinia Therapeutics, Aleta BioTherapeutics, AstraZeneca, Daiichi Sankyo, Denali Therapeutics, Olema Oncology, Pfizer, Prelude Therapeutics, Seagen, Voyager Therapeutics, and Artera Inc; and royalties from UpToDate outside the submitted work. Dr Murthy reported receiving grants from Seagen, Oncothyreon, and Cascadian Therapeutics during the conduct of the study; consulting fees and nonfinancial support for manuscript writing and travel from Seagen during the conduct of the study; grants from Genentech/Roche, Pfizer, Daiichi Sankyo, AstraZeneca, and EMD Serono outside the submitted work; and consulting fees from Novartis, AstraZeneca, Pfizer, Genentech/Roche, Puma, and Sanofi outside the submitted work. Dr Abramson reported serving on the advisory boards of Eisai, Seagen, and Daiichi Sankyo outside the submitted work; receiving consulting fees from AstraZeneca and Daiichi Sankyo; and receiving research funding from Genentech and Lilly. Dr Anders reported receiving grants from Seagen during the conduct of the study; consulting fees from Genentech, Eisai, Ipsen, Seagen Inc, AstraZeneca, Novartis, Immunomedics, Elucida Oncology, and Athenex outside the submitted work; grants from PUMA, Lilly, Merck, Nektar, Tesaro, G1 Therapeutics, Zion Pharma, Novartis, Pfizer, AstraZeneca, and Elucida outside the submitted work; and royalties from Jones and Bartlett and UptoDate.com outside the submitted work; and participating in an education program with Eisai. Dr Bachelot reported receiving consulting fees from AstraZeneca, Daiichi Sankyo, Lilly, Novartis, Pfizer, Roche, and Seagen; grants from AstraZeneca, Daiichi Sankyo, Novartis, Pfizer, Roche, and Seagen; and nonfinancial support from Pfizer outside the submitted work. Dr Bedard reported receiving grants from Seagen during the conduct of the study; grants from Amgen, Bicara, Bristol Myers Squibb, AstraZeneca, GlaxoSmithKline, Genentech/Roche, Novartis, Merck, Lilly, Seagen, Zymeworks, Pfizer, Medicenna, Nektar Therapeutics, Immunomedics, and Sanofi outside the submitted work; nonfinancial consulting relationship with Seagen, Lilly, Amgen, Merck, Gilead Sciences, Bristol Myers Squibb, and Pfizer; and serving in an uncompensated advisory capacity for Amgen, Lilly, Seagen, Zymeworks, Gilead, and Merck. Dr Borges reported receiving consulting fees and grants from Seagen during the conduct of the study; personal fees from AstraZeneca outside the submitted work; and grants from AstraZeneca, Olema Oncology, and Oncosec Medical; and having equity ownership in PERLATX. Dr Cameron reported receiving consulting fees from Novartis, Roche, and Seagen; receiving grants from AstraZeneca, Daiichi-Sankyo, GlaxoSmithKline, Novartis, Roche, and Seagen; and serving on the Independent Data Monitoring Committee for Synthon outside the submitted work. Dr Carey reported receiving research funding from Syndax Pharmaceuticals, Novartis, NanoString Technologies, AbbVie, Seagen, and Veracyte; having uncompensated relationships with Eisai, Sanofi-Aventis, Novartis, G1 Therapeutics, Genentech/Roche, GlaxoSmithKline, AstraZeneca/Daiichi Sankyo, Aptitude Health, and Exact Sciences; and having an immediate family member with a royalty-sharing agreement and investorship interest in licensed intellectual property to Falcon Therapeutics. Dr Chien reported receiving grants from Seagen during the conduct of the study; grants from Amgen, Merck, Puma Biotechnology, and Seagen; and grants from Merck, Amgen, and Puma paid to her institution outside the submitted work. Dr Curigliano reported serving on the advisory boards of Roche, Daiichi Sankyo, AstraZeneca, Lilly, Novartis, Pfizer, Celcuity, Exact Sciences, Ellipsis, Bristol Myers Squibb, Seagen, Merck, Menarini, and Gilead; receiving consulting fees from AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Daiichi Sankyo, Foundation Medicine, GlaxoSmithKline, Lilly, Novartis, Pfizer, Roche/Genentech, Samsung, and Seagen; receiving honoraria from Ellipses Pharma; receiving reimbursement for travel expenses from Pfizer and Roche/Genentech; serving on a speakers bureau for Daiichi Sankyo, Foundation Medicine, Lilly, Novartis, Pfizer, Roche/Genentech, Samsung, and Seagen; and receiving grants from Daiichi Sankyo and Merck outside the submitted work. Dr DiGiovanna reported receiving royalties from Dako and NeoMarkers; and grants from Cascadian Therapeutics, Genentech, and Seagen to conduct clinical research at Yale University. Dr Gelmon reported receiving consulting fees from AstraZeneca, Ayala Pharmaceuticals, Lilly, Merck, Mylan, Novartis, Pfizer, Roche, and Seagen outside the submitted work; serving on an advisory board for Gilead Sciences; and serving on a speakers bureau for AstraZeneca and Novartis. Dr Hortobagyi reported receiving grants from Seagen during the conduct of the study, consulting fees from Novartis outside the submitted work, and grants from Novartis. Dr Hurvitz reported having equity ownership in NKMax; receiving grants from Seagen during the conduct of the study; receiving grants from Ambrx, Amgen, Arvinas, AstraZeneca, Bayer, CytomX, Daiichi Sankyo, Dantari, Digitana, Genentech/Roche, G1 Therapeutics, Gilead Sciences, GlaxoSmithKline, Immunomedics, Lilly, MacroGenics, Novartis, OBI Pharma, Orinove, Pfizer, Phoenix Molecular Designs Ltd, Pieris Pharmaceuticals, Puma Biotechnology, Radius Health, Samumed, Sanofi, Seagen, and Zymeworks; and receiving reimbursement for travel expenses from Lilly outside the submitted work. Dr Krop reported receiving consulting fees from Bristol Myers Squibb, Context Therapeutics, Daiichi Sankyo, Genentech/Roche, Ionis Pharmaceuticals, MacroGenics, Merck, Novartis, Seagen, and Taiho Pharmaceuticals; receiving grants from Seagen paid to his institution during the conduct of the study; receiving honoraria from AstraZeneca and Genentech/Roche; receiving grants from Pfizer, MacroGenics, and Genentech/Roche; receiving personal fees from AstraZeneca, Daiichi Sankyo, MacroGenics, Genentech/Roche, Seagen, Merck, and Novartis outside the submitted work; and being an employee and equity owner of Freeline Therapeutics and PureTech Health. Dr Loi reported receiving research funding to her institution from Novartis, Bristol Meyers Squibb, Merck, Puma Biotechnology, Eli Lilly, Nektar Therapeutics, AstraZeneca, and Seagen. She has acted as consultant (not compensated) to Seagen, Novartis, Bristol Meyers Squibb, Merck, AstraZeneca, Eli Lilly, Pfizer, Gilead Therapeutics, and Roche-Genentech. She has acted as consultant (paid to her institution) to Aduro Biotech, Novartis, GlaxoSmithKline, Roche-Genentech, AstraZeneca, Silverback Therapeutics, G1 Therapeutics, PUMA Biotechnologies, Pfizer, Gilead Therapeutics, Seagen, Daiichi Sankyo, Merck, Amunix, Tallac Therapeutics, Eli Lilly, and Bristol Meyers Squibb. Dr Loi is supported by National Breast Cancer Foundation of Australia Endowed Chair and the Breast Cancer Research Foundation, New York. Dr Loibl reported receiving assistance from Seagen with manuscript preparation during the conduct of the study; receiving consulting fees from AbbVie, Amgen, AstraZeneca, Bristol Myers Squibb, Celgene, Daiichi Sankyo, EirGenix, GlaxoSmithKline, Gilead Sciences, Lilly, Merck, Novartis, Pfizer, Pierre Fabre, Seagen, Sanofi, and Roche; receiving honoraria from AbbVie, Amgen, AZ, Celgene/Bristol Meyers Squibb, DSI, Immunomedics/Gilead, Novartis, Pfizer, Roche, EirGenix, GlaxoSmithKline, Lilly, Mercl kGA, Pierre Fabre, Seagen, and Sanofi outside the submitted work; receiving research funding from AbbVie, AstraZeneca, Celgene, Daiichi Sankyo, Gilead, Novartis, Pfizer, and Roche; holding a patent for VM Scope GmbH with royalties paid to her institution; holding pending patents (EP14153692.0, EP21152186.9, EP15702464.7, and EP19808852.8); and being an employee of GBG Forschungs GmbH. Dr Mueller reported receiving personal fees from Seagen during the conduct of the study; receiving honoraria from Amgen, AstraZeneca, Daiichi-Sankyo, Eisai, GlaxoSmithKline, Pfizer, MSD, Medac, Novartis, Roche, Teva, Seagen, Onkowissen, high5 Oncology, Medscape, Gilead, Pierre Fabre, and Medscape; receiving consulting fees from Genomic Health, Hexal, Roche, Pierre Fabre, Amgen, ClinSol, Novartis, MSD, Daiichi-Sankyo, Eisai, Lilly, Sanofi, Seagen, Gilead, and Pierre Fabre; receiving grants from Novartis, Roche, Seagen, and Genentech; receiving grants from Roche, Pfizer, Daiichi Sankyo, and Gilead outside the submitted work; and serving on speakers bureaus for Amgen, AstraZeneca, Daiichi Sankyo, Eisai, GlaxoSmithKline, MSD, Novartis, Pfizer, Roche, Seagen Inc, Gilead, and Onkowissen.de. Dr Oliveira reported receiving grants from Seagen during the conduct of the study; receiving consulting fees from Roche, GlaxoSmithKline, Gilead, Puma Biotechnology, AstraZeneca, iTeos Therapeutics, Pierre Fabre, and MSD; receiving research funding from AstraZeneca, Genentech, Roche, Novartis, Immunomedics, Seagen, GlaxoSmithKline, Boehringer Ingelheim, Puma Biotechnology, and Zenith Epigenetics; receiving honoraria from Roche, Seagen, Novartis, AstraZeneca, and Eisai; receiving travel grants from Roche, Pierre Fabre, Novartis, and Eisai outside the submitted work; and being a member of the SOLTI executive board and scientific committee. Dr Paplomata reported receiving grants from Seagen during the conduct of the study; receiving personal fees from ICON Plc and OncLive; receiving consulting fees from Mylan, Novartis, Pfizer, Puma Biotechnology, R-pharm, and Biotheranostics; receiving honoraria from Mylan, Novartis, Pfizer, Puma, and R-pharm; receiving research funding from AbbVie, Cascadian Therapeutics, Corcept Therapeutics, Genentech, Hoosier Cancer Research Network, ImmunoGen, Merck, Novartis, Seagen Inc, and Immunogenicity; receiving reimbursement for travel expenses from Amgen, Genentech, Merck, Novartis, and Tesaro; receiving nonfinancial support from Tesaro; receiving nonfinancial support from Amgen outside the submitted work; and serving on a speakers bureau for OncLive Clinical Congress Consultants. Dr Pegram reported serving on the steering committee for Seagen during the conduct of the study and receiving consulting fees from Seagen and Roche/Genentech outside the submitted work. Dr Slamon reported receiving consulting fees from Lilly, Novartis, Pfizer, and Seagen; having equity ownership in Amgen, BioMarin Pharmaceutical, MSD, Pfizer, Seagen, 1200 Pharma, TORL BioTherapeutics, and Vertex Pharmaceuticals; receiving honoraria from Novartis; receiving research funding from Novartis, Pfizer, and Seagen; receiving reimbursement for travel expenses from BioMarin Pharmaceutical, Novartis, and Pfizer; serving on the advisory board for BioMarin Pharmaceutical; serving on the speakers bureau for Novartis; and founding 1200 Pharma and TORL BioTherapeutics outside the submitted work. Dr Zelnak reported receiving personal fees from Seagen during the conduct of the study; consulting fees from AstraZeneca, Gilead Sciences, Immunomedics, Novartis, Pfizer, and Puma Biotechnology; and personal fees from Gilead, AstraZeneca, Novartis, and Puma Biotechnology outside the submitted work. Dr Ramos reported being an employee of Seagen and receiving equity. Dr Feng reported being an employee of Seagen and receiving equity. Dr Winer reported receiving consulting fees from Carrick Therapeutics, Genentech/Roche, GlaxoSmithKline, and Jounce Therapeutics; honoraria from Carrick Therapeutics, Genentech/Roche, Genomic Health, GlaxoSmithKline, Jounce Therapeutics, and Leap Therapeutics; and research funding from Genentech/Roche outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. CONSORT Diagram
aTwo enrolled patients did not undergo baseline brain magnetic resonance imaging (1 in the tucatinib-combination group and 1 in the placebo-combination group). bTucatinib, trastuzumab, and capecitabine. cPlacebo, trastuzumab, and capecitabine. dPatients with brain metastases that were previously treated and did not progress since most recent CNS-directed therapy. ePatients with brain metastases that were either untreated or previously treated and progressed since most recent CNS-directed therapy. fOriginal randomized treatment, not including crossover.
Figure 2.
Figure 2.. Efficacy of Tucatinib Combination Therapy in Patients With Brain Metastases
A, Median overall survival was 21.6 months (95% CI, 18.1-28.5 months) for patients who received tucatinib plus trastuzumab and capecitabine (TUC + Tras + Cape) and 12.5 months (95% CI, 11.2-16.9 months) for those who received placebo plus trastuzumab and capecitabine (Pbo + Tras + Cape). B, Median progression-free survival was 9.9 months (95% CI, 8.4-11.7 months) for patients who received TUC + Tras + Cape and 4.2 months (95% CI, 3.6-5.7 months) for those who received Pbo + Tras + Cape. CNS indicates central nervous system.
Figure 3.
Figure 3.. New Brain Lesion–Free Survival According to Investigator Assessment for All Patients
Median new brain lesion–free survival was 24.9 months (95% CI, 17.8 to inestimable) for patients who received tucatinib plus trastuzumab and capecitabine (TUC + Tras + Cape) and 13.8 months (95% CI, 9.6 to inestimable) for those who received placebo plus trastuzumab and capecitabine (Pbo + Tras + Cape).

Comment in

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