On October 5, 2020 Puma Biotechnology, Inc. (NASDAQ: PBYI), a biopharmaceutical company, reported that efficacy results of neratinib in HER2-positive, hormone receptor-positive (HR+), early stage breast cancer (eBC) from the Phase III ExteNET trial were published in Clinical Breast Cancer (Press release, Puma Biotechnology, OCT 5, 2020, View Source [SID1234568118]). The manuscript appears in the October 5, 2020 online issue accessible at View Source(20)30258-5/fulltext.
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ExteNET was a multicenter, randomized, double-blind, Phase III trial of 2,840 HER2-positive eBC patients who received neratinib after neoadjuvant and/or adjuvant therapy with chemotherapy and trastuzumab. Patients were stratified by hormone receptor status and randomly assigned to one year of treatment with either oral neratinib 240 mg/day or placebo. The primary endpoint of the trial was invasive disease-free survival (iDFS) with overall survival as a key secondary endpoint. Within the European Union, neratinib is approved in patients with HR+ breast cancer who initiated treatment within one year of completing an adjuvant trastuzumab containing regimen.
The manuscript presents data focusing on HR+ patients who initiated treatment within a year of completing an adjuvant trastuzumab containing treatment (HR+ /< 1 yr) and subgroups of clinical interest including patients who did not achieve a pathological complete response (no pCR) after neoadjuvant treatment and therefore were at a high risk of disease recurrence. (HR+/ <1 yr, no pCR)
In the HR+ /< 1 yr patient population, the absolute 5-year invasive disease-free survival benefit versus placebo was 5.1% (HR=0.58, 95% CI 0.41‒0.82) and absolute 8-year overall survival benefit was 2.1%. (HR=0.79, 95% CI 0.55‒1.13). The 5-year cumulative incidence of CNS metastases was 0.7% in the neratinib arm and 2.1% in the placebo arm.
In the HR+/ <1 yr, no pCR subgroup of patients that were at a high risk of disease recurrence the absolute 5-year iDFS benefit in the neratinib arm versus placebo was 7.4% (HR=0.60; 95% CI 0.33‒1.07) and the 8-year overall survival benefit was 9.1% (HR=0.47; 95% CI 0.23–0.92).
Most common grade 3 adverse events were diarrhea (39% vs placebo, 1%; without mandatory anti-diarrheal prophylaxis), vomiting (4% vs <1%), and fatigue (2% vs <1%).
Professor Arlene Chan, Vice Chair Breast Cancer Research Centre – WA, said, "Deciding on which patients benefit most from a given therapy is an important goal for clinicians. This newly published study provides consistent and durable benefits of neratinib in a subset of HER2-positive early stage breast cancer patients who are considered to be at greater risk of relapse: namely patients with HR+ tumors that did not achieve a pCR after neoadjuvant treatment (no pCR). The benefits demonstrated are meaningful in all endpoints evaluated, including iDFS, OS and CNS recurrence, and thus should help guide future clinical decisions."
Hope S. Rugo, MD, Professor of Medicine, University of California San Francisco Comprehensive Cancer Center, said, "HER2-positive HR+ patients who do not achieve a pCR are at increased risk of recurrence, even after receiving current standard of care treatment. In a descriptive subset analysis, extended adjuvant therapy with neratinib demonstrated a positive benefit in these patients not only in iDFS, but also in OS. In addition, the trend toward lower CNS involvement is a very important consideration, given the profound impact of CNS metastasis on future prognosis. These data coupled with the recently published data from the CONTROL study, which shows improved tolerability with dose escalation, should allow more patients to benefit from this important therapy."
Alan H. Auerbach, Chief Executive Officer and President of Puma, added, "Although there have been many new treatment options for patients with early stage HER2-positive breast cancer, the risk of disease recurrence remains significant and more must be done. These newly published data demonstrate that neratinib provides a clinically meaningful reduction in the risk of recurrence and provides a very important option for these high risk patients."
About HER2-Positive Breast Cancer
Up to 20% of patients with breast cancer tumors over-express the HER2 protein (HER2-positive disease) and in the ExteNET study, 57% of patients were found to have tumors that were hormone-receptor positive. HER2-positive breast cancer is often more aggressive than other types of breast cancer, increasing the risk of disease progression and death. Although research has shown that trastuzumab can reduce the risk of early stage HER2-positive breast cancer recurring, up to 25% of patients treated with trastuzumab experience recurrence within 10 years, the majority of which are metastatic recurrences.