Breast Cancer
Conditions
Brief summary
This randomized, two-arm study evaluated the efficacy and safety of a combination of trastuzumab and capecitabine with or without pertuzumab in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer. The study population consisted of female patients, whose disease had progressed during or following previous trastuzumab therapy for metastatic disease. All patients in Arm A and Arm B received trastuzumab (8 mg/kg iv as loading dose and then 6 mg/kg iv every 3 weeks thereafter) and capecitabine oral twice daily for 14 days every 3 weeks (1250 mg/m2 twice daily in Arm A and 1000 mg/m2 twice daily in Arm B). In addition, patients in Arm B received pertuzumab (840 mg iv as loading dose and then 420 mg iv thereafter) every 3 weeks. Study treatment continued until disease progression or unacceptable toxicity.
Interventions
1000 mg/m2 po twice daily for 14 days every 3 weeks
840 mg iv loading, then 420 mg iv every 3 weeks
8 mg/kg iv loading, then 6 mg/kg iv every 3 weeks
Sponsors
Study design
Eligibility
Inclusion criteria
* Adult female patients \>/=18 years of age * Metastatic HER2 positive breast cancer * Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 * Disease progression during or following trastuzumab-based therapy for 1st line metastatic breast cancer (trastuzumab must have been part of the last prior treatment regimen) * Prior treatment with taxane-containing regimen * Left ventricular ejection fraction (LVEF) \>/=50 percent * For women of childbearing potential agreement to use highly effective non-hormonal form of contraception or two effective forms of non-hormonal contraception by patient and/or partner. Contraception must continue for duration of study treatment and for at least 6 months after last dose of study drug treatment
Exclusion criteria
* Prior treatment with pertuzumab or capecitabine * Concurrent treatment with other experimental drug * Concurrent immunotherapy or anticancer hormonal therapy * Serious concurrent disease (e.g. active infection, uncontrolled hypertension, cardiovascular disease) * Central nervous system (CNS) metastases, which are not well controlled * History of exposure to anthracycline cumulative dose equivalent to 360mg/m2 * History of congestive heart failure of any New York Heart Association criteria, or serious cardiac arrhythmia requiring treatment * History of myocardial infarction within 6 months prior to randomization * History of LVEF decline to below 50% during or after prior trastuzumab therapy or other cardiac toxicity during previous trastuzumab treatment that necessitated discontinuation of trastuzumab * History of another cancer which could affect compliance or result interpretation * Inadequate organ function * Pregnant or breastfeeding women * life expectancy \< 12 weeks
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Progression Free Survival (Independent Assessment) | Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 5.5 years). | Progression Free Survival (PFS) was defined as the time from randomization to first documented disease progression (PD), as determined by an Independent Review Facility (IRF) using Response Evaluation Criteria in Solid Tumors (RECIST) version 1.0, or death from any cause, whichever occurred first. PD was defined as at least a 20% increase in the sum of the longest diameter (LD) of target lesions taking as reference the smallest sum LD recorded since the treatment started or the appearance of one or more new lesions; or the appearance of one or more new lesions and/or unequivocal progression of existing non-target lesions. IRF review of tumor assessment ceased after the primary PFS analysis. The primary endpoint was analyzed after approximately 337 IRF-assessed PFS events were observed. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Overall Survival (OS) Rate Based on a 2-year Truncated Analysis | From randomization until death from any cause (up to 2 years) | The Overall Survival (OS) 2-year truncated analysis is the Kaplan-Meier estimate of the percentage of participants who were surviving at 2 years. OS is defined as the time from the date of randomization to the date of death from any cause, with censoring of all events and follow-up beyond the end of the second year. |
| Investigator Assessment Progression-Free Survival (PFS) | Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 7.5 years). | Investigator Assessment Progression-Free Survival (PFS) was defined as the time from randomization to the first documented progressive disease, as determined by the investigator using Response Evaluation Criteria in Solid Tumors (RECIST) v1.0, or death from any cause, whichever occurred first. PD is defined as at least a 20% increase in the sum of the longest diameter (LD) of target lesions taking as reference the smallest sum LD recorded since the treatment started or the appearance of one or more new lesions; or the appearance of one or more new lesions and/or unequivocal progression of existing non-target lesions. |
| Time to Progression (TTP) Based Upon Independent Review Facility (IRF) Assessment | Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 5.5 years). | Time to Progression (TTP) was defined as time between randomization and the first occurrence of progressive disease (PD), based on IRF assessment. |
| Overall Survival (OS) | From randomization until death from any cause (up to 7.5 years). | Overall Survival (OS) was defined as the time from the date of randomization to the date of death from any cause. The results of the final OS analysis are presented here. Participants who were alive or lost to follow-up at the time of the analysis were censored at the last known alive date. Participants with no postbaseline information were censored at the time of randomization plus 1 day. Prior to the final data analysis cut-off, it was ensured that all participants who were in survival follow-up had been contacted as recently as possible within the last 3 months to confirm current survival status. |
| Overall Objective Response Rate (ORR) | Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 5.5 years). | Overall Objective Response Rate is based upon investigator and IRF assessments. Objective Response Rate (ORR) was defined as the percentage of participants with a confirmed complete response (CR) or partial response (PR) among those who had measurable disease at baseline. CR was defined as the disappearance of all target lesions. PR was defined as at least a 30% decrease in the sum of the longest diameter (LD) of target lesions, taking as reference the baseline sum LD. |
| Clinical Benefit Rate (CBR) | Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 5.5 years). | Clinical Benefit Rate is based upon Independent Review Facility (IRF) assessments; defined as the percentage of participants a complete response (CR), partial response (PR), or stable disease for at least 8 cycles or 6 months. |
| Duration of Objective Response | Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 5.5 years). | Duration of Objective Response was defined for the subpopulation of responders as time from first Independent Review Facility (IRF)-assessed complete response (CR) or partial response (PR) to subsequent first documented, IRF-confirmed evidence of disease progression. Only participants with an objective response were included in the analysis of duration of objective response. |
| Time to Treatment Failure (TTF) Based Upon Independent Review Facility (IRF) Assessment | Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 5.5 years). | Time to Treatment Failure (TTF) was defined as time between randomization and date of disease progression based on independent review, death, or withdrawal of treatment due to adverse events, withdrawn informed consent, refusal of treatment/failure to cooperate, or failure to return, whichever occurred first. |
Countries
Argentina, Austria, Belgium, Brazil, Canada, Croatia, Czechia, Estonia, France, Germany, Hong Kong, Hungary, Italy, Mexico, Netherlands, Peru, Poland, Romania, Russia, South Korea, Spain, Thailand, United Kingdom
Participant flow
Recruitment details
452 participants were randomized to one of two treatment arms: trastuzumab and capecitabine (Arm A, 224 participants) or pertuzumab with trastuzumab and capecitabine (Arm B, 228 participants). Of participants randomized to Arm A: trastuzumab and capecitabine, 6 participants did not receive study treatment.
Participants by arm
| Arm | Count |
|---|---|
| A: Capecitabine + Trastuzumab Capecitabine \[Xeloda\]: 1250 mg/m2 po twice daily for 14 days every 3 weeks. Trastuzumab \[Herceptin\]: 8 mg/kg iv loading, then 6 mg/kg iv every 3 weeks. | 218 |
| B: Capecitabine + Trastuzumab + Pertuzumab Capecitabine \[Xeloda\]: 1000 mg/m2 po twice daily for 14 days every 3 weeks. Pertuzumab \[Perjeta\]: 840 mg iv loading, then 420 mg iv every 3 weeks. Trastuzumab \[Herceptin\]: 8 mg/kg iv loading, then 6 mg/kg iv every 3 weeks. | 228 |
| Total | 446 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Overall Study | Death | 136 | 134 |
| Overall Study | Withdrew consent or lost to follow-up | 36 | 29 |
Baseline characteristics
| Characteristic | A: Capecitabine + Trastuzumab | B: Capecitabine + Trastuzumab + Pertuzumab | Total |
|---|---|---|---|
| Age, Continuous | 55.1 years STANDARD_DEVIATION 10.1 | 53.0 years STANDARD_DEVIATION 11.21 | 54.0 years STANDARD_DEVIATION 10.72 |
| Region of Enrollment Argentina | 3 participants | 4 participants | 7 participants |
| Region of Enrollment Austria | 2 participants | 3 participants | 5 participants |
| Region of Enrollment Belgium | 12 participants | 11 participants | 23 participants |
| Region of Enrollment Brazil | 7 participants | 6 participants | 13 participants |
| Region of Enrollment Canada | 3 participants | 6 participants | 9 participants |
| Region of Enrollment Croatia | 4 participants | 3 participants | 7 participants |
| Region of Enrollment Czech Republic | 12 participants | 10 participants | 22 participants |
| Region of Enrollment France | 19 participants | 12 participants | 31 participants |
| Region of Enrollment Germany | 23 participants | 11 participants | 34 participants |
| Region of Enrollment Hong Kong | 5 participants | 11 participants | 16 participants |
| Region of Enrollment Hungary | 13 participants | 29 participants | 42 participants |
| Region of Enrollment Italy | 16 participants | 18 participants | 34 participants |
| Region of Enrollment Korea, Republic of | 14 participants | 24 participants | 38 participants |
| Region of Enrollment Mexico | 1 participants | 0 participants | 1 participants |
| Region of Enrollment Netherlands | 0 participants | 2 participants | 2 participants |
| Region of Enrollment Peru | 7 participants | 8 participants | 15 participants |
| Region of Enrollment Poland | 6 participants | 6 participants | 12 participants |
| Region of Enrollment Romania | 6 participants | 8 participants | 14 participants |
| Region of Enrollment Russian Federation | 8 participants | 3 participants | 11 participants |
| Region of Enrollment Spain | 39 participants | 31 participants | 70 participants |
| Region of Enrollment Thailand | 0 participants | 5 participants | 5 participants |
| Region of Enrollment United Kingdom | 18 participants | 17 participants | 35 participants |
| Sex: Female, Male Female | 218 Participants | 228 Participants | 446 Participants |
| Sex: Female, Male Male | 0 Participants | 0 Participants | 0 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 136 / 218 | 134 / 228 |
| other Total, other adverse events | 209 / 218 | 216 / 228 |
| serious Total, serious adverse events | 53 / 218 | 58 / 228 |
Outcome results
Progression Free Survival (Independent Assessment)
Progression Free Survival (PFS) was defined as the time from randomization to first documented disease progression (PD), as determined by an Independent Review Facility (IRF) using Response Evaluation Criteria in Solid Tumors (RECIST) version 1.0, or death from any cause, whichever occurred first. PD was defined as at least a 20% increase in the sum of the longest diameter (LD) of target lesions taking as reference the smallest sum LD recorded since the treatment started or the appearance of one or more new lesions; or the appearance of one or more new lesions and/or unequivocal progression of existing non-target lesions. IRF review of tumor assessment ceased after the primary PFS analysis. The primary endpoint was analyzed after approximately 337 IRF-assessed PFS events were observed.
Time frame: Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 5.5 years).
Population: All randomized participants.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| A: Capecitabine + Trastuzumab | Progression Free Survival (Independent Assessment) | 9.0 months |
| B: Capecitabine + Trastuzumab + Pertuzumab | Progression Free Survival (Independent Assessment) | 11.1 months |
Clinical Benefit Rate (CBR)
Clinical Benefit Rate is based upon Independent Review Facility (IRF) assessments; defined as the percentage of participants a complete response (CR), partial response (PR), or stable disease for at least 8 cycles or 6 months.
Time frame: Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 5.5 years).
Population: Participants without a post-baseline tumor assessment were considered to be non-responders and were not included in this outcome measure.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| A: Capecitabine + Trastuzumab | Clinical Benefit Rate (CBR) | 54.0 Percentage of participants |
| B: Capecitabine + Trastuzumab + Pertuzumab | Clinical Benefit Rate (CBR) | 63.6 Percentage of participants |
Duration of Objective Response
Duration of Objective Response was defined for the subpopulation of responders as time from first Independent Review Facility (IRF)-assessed complete response (CR) or partial response (PR) to subsequent first documented, IRF-confirmed evidence of disease progression. Only participants with an objective response were included in the analysis of duration of objective response.
Time frame: Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 5.5 years).
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| A: Capecitabine + Trastuzumab | Duration of Objective Response | 30.0 Weeks |
| B: Capecitabine + Trastuzumab + Pertuzumab | Duration of Objective Response | 51.6 Weeks |
Investigator Assessment Progression-Free Survival (PFS)
Investigator Assessment Progression-Free Survival (PFS) was defined as the time from randomization to the first documented progressive disease, as determined by the investigator using Response Evaluation Criteria in Solid Tumors (RECIST) v1.0, or death from any cause, whichever occurred first. PD is defined as at least a 20% increase in the sum of the longest diameter (LD) of target lesions taking as reference the smallest sum LD recorded since the treatment started or the appearance of one or more new lesions; or the appearance of one or more new lesions and/or unequivocal progression of existing non-target lesions.
Time frame: Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 7.5 years).
Population: All randomized participants.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| A: Capecitabine + Trastuzumab | Investigator Assessment Progression-Free Survival (PFS) | 9.0 Months |
| B: Capecitabine + Trastuzumab + Pertuzumab | Investigator Assessment Progression-Free Survival (PFS) | 11.8 Months |
Overall Objective Response Rate (ORR)
Overall Objective Response Rate is based upon investigator and IRF assessments. Objective Response Rate (ORR) was defined as the percentage of participants with a confirmed complete response (CR) or partial response (PR) among those who had measurable disease at baseline. CR was defined as the disappearance of all target lesions. PR was defined as at least a 30% decrease in the sum of the longest diameter (LD) of target lesions, taking as reference the baseline sum LD.
Time frame: Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 5.5 years).
Population: Participants without a post-baseline tumor assessment were considered to be non-responders and were not included in this outcome measure.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| A: Capecitabine + Trastuzumab | Overall Objective Response Rate (ORR) | Complete Response (CR) - IRF Assessment | 0 Percentage of participants |
| A: Capecitabine + Trastuzumab | Overall Objective Response Rate (ORR) | Partial Response (PR) - IRF assessment | 32.9 Percentage of participants |
| A: Capecitabine + Trastuzumab | Overall Objective Response Rate (ORR) | Complete Response (CR) - Investigator Assessed | 1.2 Percentage of participants |
| A: Capecitabine + Trastuzumab | Overall Objective Response Rate (ORR) | Partial Response (PR) - Investigator Assessed | 36.0 Percentage of participants |
| B: Capecitabine + Trastuzumab + Pertuzumab | Overall Objective Response Rate (ORR) | Partial Response (PR) - Investigator Assessed | 38.0 Percentage of participants |
| B: Capecitabine + Trastuzumab + Pertuzumab | Overall Objective Response Rate (ORR) | Complete Response (CR) - IRF Assessment | 1.8 Percentage of participants |
| B: Capecitabine + Trastuzumab + Pertuzumab | Overall Objective Response Rate (ORR) | Complete Response (CR) - Investigator Assessed | 6.7 Percentage of participants |
| B: Capecitabine + Trastuzumab + Pertuzumab | Overall Objective Response Rate (ORR) | Partial Response (PR) - IRF assessment | 38.7 Percentage of participants |
Overall Survival (OS)
Overall Survival (OS) was defined as the time from the date of randomization to the date of death from any cause. The results of the final OS analysis are presented here. Participants who were alive or lost to follow-up at the time of the analysis were censored at the last known alive date. Participants with no postbaseline information were censored at the time of randomization plus 1 day. Prior to the final data analysis cut-off, it was ensured that all participants who were in survival follow-up had been contacted as recently as possible within the last 3 months to confirm current survival status.
Time frame: From randomization until death from any cause (up to 7.5 years).
Population: All randomized participants.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| A: Capecitabine + Trastuzumab | Overall Survival (OS) | 28.1 Months |
| B: Capecitabine + Trastuzumab + Pertuzumab | Overall Survival (OS) | 37.2 Months |
Overall Survival (OS) Rate Based on a 2-year Truncated Analysis
The Overall Survival (OS) 2-year truncated analysis is the Kaplan-Meier estimate of the percentage of participants who were surviving at 2 years. OS is defined as the time from the date of randomization to the date of death from any cause, with censoring of all events and follow-up beyond the end of the second year.
Time frame: From randomization until death from any cause (up to 2 years)
Population: All randomized participants.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| A: Capecitabine + Trastuzumab | Overall Survival (OS) Rate Based on a 2-year Truncated Analysis | 55.0 Percentage of participants |
| B: Capecitabine + Trastuzumab + Pertuzumab | Overall Survival (OS) Rate Based on a 2-year Truncated Analysis | 74.9 Percentage of participants |
Time to Progression (TTP) Based Upon Independent Review Facility (IRF) Assessment
Time to Progression (TTP) was defined as time between randomization and the first occurrence of progressive disease (PD), based on IRF assessment.
Time frame: Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 5.5 years).
Population: All randomized participants.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| A: Capecitabine + Trastuzumab | Time to Progression (TTP) Based Upon Independent Review Facility (IRF) Assessment | 39.0 Weeks |
| B: Capecitabine + Trastuzumab + Pertuzumab | Time to Progression (TTP) Based Upon Independent Review Facility (IRF) Assessment | 50.6 Weeks |
Time to Treatment Failure (TTF) Based Upon Independent Review Facility (IRF) Assessment
Time to Treatment Failure (TTF) was defined as time between randomization and date of disease progression based on independent review, death, or withdrawal of treatment due to adverse events, withdrawn informed consent, refusal of treatment/failure to cooperate, or failure to return, whichever occurred first.
Time frame: Tumor assessments every 9 weeks from randomization until Week 27, then every 12 weeks thereafter, until IRF-determined PD, initiation of alternative anticancer medication, or death (up to 5.5 years).
Population: All randomized participants.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| A: Capecitabine + Trastuzumab | Time to Treatment Failure (TTF) Based Upon Independent Review Facility (IRF) Assessment | 39.0 Weeks |
| B: Capecitabine + Trastuzumab + Pertuzumab | Time to Treatment Failure (TTF) Based Upon Independent Review Facility (IRF) Assessment | 50.9 Weeks |