Nab-paclitaxel weekly versus dose-dense solvent-based paclitaxel followed by dose-dense epirubicin plus cyclophosphamide in high-risk HR+/HER2- early breast cancer: results from the neoadjuvant part of the WSG-ADAPT-HR+/HER2- trial
- PMID: 37062416
- DOI: 10.1016/j.annonc.2023.04.002
Nab-paclitaxel weekly versus dose-dense solvent-based paclitaxel followed by dose-dense epirubicin plus cyclophosphamide in high-risk HR+/HER2- early breast cancer: results from the neoadjuvant part of the WSG-ADAPT-HR+/HER2- trial
Abstract
Background: In high-risk hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) early breast cancer (EBC), nanoparticle albumin-bound (nab)-paclitaxel showed promising efficacy versus solvent-based (sb)-paclitaxel in neoadjuvant trials; however, optimal patient and therapy selection remains a topic of ongoing research. Here, we investigate the potential of Oncotype DX® recurrence score (RS) and endocrine therapy (ET) response (low post-endocrine Ki67) for therapy selection.
Patients and methods: Within the WSG-ADAPT trial (NCT01779206), high-risk HR+/HER2- EBC patients were randomized to (neo)adjuvant 4× sb-paclitaxel 175 mg/m2 q2w or 8× nab-paclitaxel 125 mg/m2 q1w, followed by 4× epirubicin + cyclophosphamide (90 mg + 600 mg) q2w; inclusion criteria: (i) cN0-1, RS 12-25, and post-ET Ki67 >10%; (ii) cN0-1 with RS >25. Patients with cN2-3 or (G3, baseline Ki67 ≥40%, and tumor size >1 cm) were allowed to be included without RS and/or ET response testing. Associations of key factors with pathological complete response (pCR) (primary) and survival (secondary) endpoints were analyzed using statistical mediation and moderation models.
Results: Eight hundred and sixty-four patients received neoadjuvant nab-paclitaxel (n= 437) or sb-paclitaxel (n = 427); nab-paclitaxel was superior for pCR (20.8% versus 12.9%, P = 0.002). pCR was higher for RS >25 versus RS ≤25 (16.0% versus 8.4%, P = 0.021) and for ET non-response versus ET response (15.1% versus 6.0%, P = 0.027); no factors were predictive for the relative efficacy of nab-paclitaxel versus sb-paclitaxel. Patients with pCR had longer distant disease-free survival [dDFS; hazard ratio 0.42, 95% confidence interval (CI) 0.20-0.91, P = 0.024]. Despite favorable prognostic association of RS >25 versus RS ≤25 with pCR (odds ratio 3.11, 95% CI 1.71-5.63, P ≤ 0.001), higher RS was unfavorably associated with dDFS (hazard ratio 1.03, 95% CI 1.01-1.05, P = 0.010).
Conclusions: In high-risk HR+/HER2- EBC, neoadjuvant nab-paclitaxel q1w appears superior to sb-paclitaxel q2w regarding pCR. Combining RS and ET response assessment appears to select patients with highest pCR rates. The disadvantage of higher RS for dDFS is reduced in patients with pCR. These are the first results from a large neoadjuvant randomized trial supporting the use of RS to help select patients for neoadjuvant chemotherapy in high-risk HR+/HER2- EBC.
Keywords: albumin-bound paclitaxel; breast neoplasms; neoadjuvant therapy; paclitaxel.
Copyright © 2023 European Society for Medical Oncology. Published by Elsevier Ltd. All rights reserved.
Conflict of interest statement
Disclosure OG received consulting fees from Celgene, Genomic Health/Exact Sciences, Lilly, MSD, Novartis, Pfizer, Roche, Seagen, Pierre Fabre, Gilead, and Molecular health; honoraria from Genomic Health/Exact Sciences, Roche, Celgene, Pfizer, Novartis, NanoString Technologies, and AstraZeneca; payment for expert testimony from Genomic Health; and travel support from Roche, all outside of the submitted work; and co-director position at West German Study Group. SK received research funding from Roche and Novartis; consulting fees from Amgen, AstraZeneca, Celgene, Daiichi-Sankyo, Genomic Health/Exact Science, Lilly, MSD, Novartis, Seagen, Pfizer, pfm Medical, Roche, Somatex, and Gilead; travel support from Roche and Daiichi Sankyo; and other financial or non-financial interests for Non-Continuing Medical Education services from Somatex, Roche, Novartis, and Lilly, all outside of the submitted work; and co-director position at West German Study Group. UN received research funding paid to institution from Agendia, Amgen, Celgene, Genomic Health, NanoString Technologies, Roche, and Sanofi; consulting fees from Genomic Health and Roche; honoraria from Agendia, Amgen, Celgene, Genomic Health, NanoString Technologies, Novartis pharma, Pfizer Pharmaceuticals, Roche/Genentech, and Teva; payment for expert testimony from Genomic Health; travel support from Genomic Health, Pfizer Pharmaceuticals, and Roche; participation on a Data Safety Monitoring Board or Advisory Board at Roche, Seagen, and Exact Sciences, all outside of the submitted work; and co-director position at West German Study Group. MB received honoraria from AstraZeneca, Exact Sciences, Novartis, Pfizer, Roche, Teva, MSD; travel support from AstraZeneca, Celgene, Medac, Novartis, Roche, Daiichi Sankyo; and reports consulting/advisory role for AstraZeneca, Exact Sciences, Novartis, Puma, Roche, all outside of the submitted work. HF received honoraria from Roche and iOMEDICO (lecture); and travel support from Celgene and Amgen, all outside of the submitted work. CU received consulting fees from Tesaro, Novartis, Roche; research funding paid to institution from West German Study Group, German Breast Group, Novartis, AstraZeneca, Tesaro, Palleos Healthcare Services Gmbh, Pierre Fabre, AGO-Studiengruppe; travel support from German Breast Group, West German Study Group, AGO-Studiengruppe; and provided expert testimony for Pfizer, Novartis, Roche, PharmaMar, AstraZeneca, all outside of the submitted work. BA received honoraria from Pfizer, Roche Pharma, MSD, onkowissen.de, Novartis Pharma, AstraZeneca, PharmaMar, Lilly, promedicis, all outside of the submitted work. RK received consulting fees from AstraZeneca, Daiichi Sankyo, Lilly, MSD, Novartis, Pierre Fabre, Pfizer Pharmaceuticals, Roche/Genentech, Sandoz, and Seattle Genetics; and honoraria from Amgen, AstraZeneca, Genomic Health, Novartis, Pfizer Pharmaceuticals, Pierre Fabre, Roche/Genentech, and Zodiac Pharma, all paid to immediate family member and outside of the submitted work; and co-director position at West German Study Group. MG received consulting fees from AstraZeneca and travel support from Daiichi Sankyo, all outside of the submitted work. RW received consulting fees, honoraria, and travel support from Agendia, Amgen, Aristo, AstraZeneca, Boeringer Ingelheim, Carl Zeiss, Celgene, Daiichi-Sankyo, Eisai, Exact Sciences/Genomic Health, Gilead, Glaxo Smith Kline, Hexal, Lilly, Medstrom Medical, MSD, Mundipharma, Mylan, Nanostring, Novartis, Odonate, Paxman, Palleos, Pfizer, Pierre Fabre, PumaBiotechnology, Riemser, Roche, Sandoz/Hexal, Sanofi Genzyme, Seattle Genetics/Seagen, Tesaro Bio, Teva, Veracyte, and Viatris; and other financial or non-financial interests from FomF (Forum for medical education in Germany), Aurikamed, Clinsol, Pomme Med, all outside of the submitted work. RB is a current employee of and owns stock in Exact Sciences Corporation. HHK received honoraria for lectures from Roche Pharma, Novartis, Genomic Health, AstraZeneca, Lilly, and Pfizer; and participation in Data Safety Monitoring Board or Advisory Board at Roche Pharma, Genomic Health, and AstraZeneca, all outside of the submitted work. NH received research funding paid to institution from Lilly, MSD, Novartis, Pfizer, and Roche/Genentech; honoraria for lectures and/or consulting from Amgen, AstraZeneca, Daiichi Sankyo, Gilead, Lilly, MSD, Novartis, Pierre Fabre, Pfizer Pharmaceuticals, Roche/Genentech, Sandoz, Sanofi, and Seagen, all outside of the submitted work. All other authors have declared no conflicts of interest.
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