Original article

Neoadjuvant chemotheralargoGe

, N. Zis i, j,. Reand Nens Ho

ralia

University of Newcastle, Newcastle, NSW, Australia

with large operablestic. Epirubicin andearly breast cancer.n promising results.ne into neoadjuvant

) or T3-4, N0-1, M0d cyclophosphamideimary endpoint wasegative and HER2-lymph nodes, clin-

(84%) completed all

phylactic G-CSF was recommended due to excess neutropenia. The HER2-negative cohort was closed toaccrual because it did not meet the pre-specied target for pCR, and the HER2-positive cohort was closed

q Presentations: Presented in part at the 34th Annual San Antonio Breast Cancer Symposium, San Antonio, TX, December 2011.* Corresponding author. Present address: ICON Cancer Care Wesley, Wesley Medical Centre, 40 Chasely Street, Auchenower, QLD 4066, Australia. Tel.: 61 7

3737 4636; fax: 61 7 3737 4601.

Contents lists available at ScienceDirect

The Breast

journal homepage: www.elsevier .com/brst

The Breast 23 (2014) 142e151E-mail address: NMcCarthy@iconcancercare.com.au (N. McCarthy).cycles of chemotherapy, and 78 (96%) proceeded to surgery. pCR was achieved by 12 (20%) patients withHER2-negative, and 9 (53%) with HER2-positive disease. At the rst interim analysis, addition of pro-gWellington Cancer Centre, Wellington Hospital, Wellington, New ZealandhBallarat Oncology and Haematology Service, Ballarat, VIC, Australiai Peter MacCallum Cancer Centre, Melbourne, VIC, AustraliajDepartment of Medicine, St. Vincents Hospital, University of Melbourne, VIC, AustraliakBox Hill Hospital, Box Hill, VIC, AustralialMaroondah Breast Clinic, Maroondah Hospital, Ringwood East, VIC, AustraliamMonash University, VIC, AustralianTweed Hospital, Tweed Heads, NSW, AustraliaoGrifth University- Gold Coast, Southport, QLD, AustraliapNational Health and Medical Research Council Clinical Trials Centre, Sydney, NSW, AustraliaqWestmead Cancer Care Centre, Westmead Hospital, University of Sydney, NSW, AustraliarDepartment of Surgical Oncology, Calvary Mater Newcastle, Newcastle, NSW, Australia

a r t i c l e i n f o

Article history:Received 18 July 2013Received in revised form4 November 2013Accepted 4 December 2013

Keywords:Locally advanced breast cancerNeoadjuvant chemotherapyGemcitabinePhase 2Pathologic complete response

a b s t r a c t

Background: Neoadjuvant chemotherapy has a sound rationale for use in womenbreast cancer, and achievement of pathological complete response (pCR) is prognocyclophosphamide followed by docetaxel is a standard chemotherapy regimen forIn metastatic breast cancer the combination of gemcitabine and a taxane has showThis phase II study investigated the efcacy and safety of incorporating gemcitabitherapy.Methods: Female patients with operable breast cancer that was clinically T2 (3 cmwere enrolled to receive 24 weeks of neoadjuvant chemotherapy using epirubicin anfollowed by docetaxel and gemcitabine, plus trastuzumab if HER2-positive. The prthe pathological complete response (pCR) rate in the breast in separate HER2-npositive cohorts. Secondary endpoints included pCR in both the breast and axillaryical and radiological response rates, disease free survival and safety.Results: 81 patients were enrolled: 63 HER2-negative and 18 HER2-positive. 67University of Sydney, Sydney, NSW, AustraliaeAustralia and New Zealand Breast Cancer Trials Group, Newcastle, NSW, Australiafwith gemcitabine forcancer: ANZ 0502 (Ne

N. McCarthy a,b,*, F. Boyle c,d

G. Kannourakis h, P.A. FrancD. Zannino p, N. Wilcken q, Lon behalf of the Australia aaCancer Care Services, Royal Brisbane and WombUniversity of Queensland, Brisbane, QLD, Austc The Mater Hospital, Sydney, NSW, Australiad0960-9776/$ e see front matter 2013 Elsevier Ltd.http://dx.doi.org/10.1016/j.breast.2013.12.001py with sequential anthracyclineedocetaxele operable or locally advanced breastm)q

denkowski e,f, J. Bull e, E. Leong e, A. Simpson g,J. Chirgwin f,k, l,m, E. Abdi n,o, V. Gebski p, A.S. Veillard p,by e, D.F. Lindsay e, H.D. Badger e, J.F. Forbes e,f,r,ew Zealand Breast Cancer Trials Groupspital, Buttereld St, Herston, Brisbane, QLD 4029, AustraliaAll rights reserved.

medcer.emciedrow

landACTRN12606000191594.

regimen followed by a combination of gemcitabine and docetaxel,

operable or locally advancedbreast cancer.

Materials and methods

Patient selection

Patients with histologically conrmedtion) T

Brelocally advanced (at initial presenta

M0 primary breast cancer were eligible. Oincluded age 18 years, no prior chemunilateral, operable or2 (3 cm), T3-4, N0-1,ther eligibility criteria

tuzumab schedule was used based on the prevailing neoadjuvantliterature, in which weekly trastuzumab was combined withconcurrent chemotherapy [13]. After surgery, H was administeredat 6 mg/kg IV every 3 weeks up to a total of one year.

Patients with oestrogen (ER) and/or progesterone receptor (PgR)positive tumours were recommended to receive adjuvant endo-crine therapy, as chosen by the investigator, for a minimum of 5years. An aromatase inhibitor, tamoxifen, or a sequential combi-nation of the two was recommended for postmenopausal women.Phase II study in women with large 4 mg/kg followed by 2 mg/kg IV weekly for 12 weeks. This tras-with or without trastuzumab (depending on HER2 status), in thiscycle for 4 cycles. In HER2-positive patients, H was commencedwith the taxane phase of chemotherapy using a loading dose ofIntroduction

Large operable and locally advanced breast cancers areassociated with a relatively poor prognosis and higher risk ofmicrometastatic disease [1] and require multimodality therapy.Neoadjuvant or induction chemotherapy is the standard treat-ment for inoperable locally advanced breast cancer and is alsoused for large operable cancers to help achieve breast conserva-tion. Although a survival benet has not been demonstrated withneoadjuvant compared with adjuvant chemotherapy, there issound rationale for using neoadjuvant chemotherapy [2]. Apartfrom improving the likelihood of breast conservation [3], neo-adjuvant chemotherapy provides early treatment to the primarytumour and micrometastatic disease and also provides an earlyindication of the effectiveness of the particular chemotherapeuticagents [4]. Furthermore, the pathologic complete response (pCR)rate following neoadjuvant chemotherapy has been shown to be astrong prognostic measure of long-term disease-free survival(DFS) and overall survival (OS) [5,6], at least in oestrogen receptor(ER) negative disease.

Anthracycline-based chemotherapy remains the core of mostpre- and post-operative chemotherapy regimens for womendiagnosed with high risk locally advanced breast cancer. Theaddition of a taxane following 4 cycles of an anthracycline-basedregimen has been associated with increased pathologic completeresponse rate in the neoadjuvant setting [2] and further incre-mental survival benet in the adjuvant setting [7]. Standardtreatment for the human epidermal growth factor receptor 2(HER2) over-expressing breast cancer subgroup now incorporatestrastuzumab, most frequently given concurrently with a taxane[8]. Gemcitabine, a nucleoside analogue anti-metabolite, hasestablished safety and efcacy in metastatic breast cancer [9].Combining gemcitabine with docetaxel is active in patients withanthracycline pre-treated metastatic disease, without excesstoxicity [10]. Trastuzumab has also been combined successfullywith taxanes and gemcitabine either alone or in combination,with promising results in patients with HER2 positive metastaticdisease [11,12].

We therefore sought to test the feasibility and activity of aneoadjuvant regimen consisting of a standard anthracycline-baseddue to slow accrual. At arelapse of their breast canConclusion: Neoadjuvant gdid not reach the pre-specwas observed, requiring gcannot be recommended.Australia and New Zea

N. McCarthy et al. / Theotherapy or hormonalian follow-up of 24 months, 12 of 81 (15%) patients had experienced a

itabine, when added to docetaxel, after epirubicin and cyclophosphamide,expectations for pCR rate in HER2-negative tumours. Excess neutropeniath factor support. Addition of gemcitabine to docetaxel in this schedule

Clinical Trials Registry (www.anzctr.org.au) registration number

2013 Elsevier Ltd. All rights reserved.

therapy for breast cancer or other invasive cancer and ECOG per-formance status 0e2. Eligible patients were required to haveadequate bone marrow, neurological, hepatic, renal and cardiacfunction. Patients with inoperable, inammatory or metastaticbreast cancer were excluded.

Study design

This was a Phase II study with a planned enrolment of 147patients across two cohorts, 84 HER2-negative and 63 HER2-positive. All enrolled patients were planned to receive combinedepirubicin (E) and cyclophosphamide (C) followed by combineddocetaxel (Taxotere, D) and gemcitabine (Gemzar, G) chemo-therapy in the neoadjuvant setting. Patients with HER2 positivetumours also received trastuzumab (Herceptin, H) in combina-tion with DG followed by adjuvant H for a total of 1-year. Theprimary endpoint of the study was the pCR rate of the primarytumour in the breast after neoadjuvant chemotherapy, at the timeof surgery. Secondary endpoints were (i) pCR rate in both thebreast and axillary lymph nodes, (ii) clinical and radiologicalcomplete response rates following neoadjuvant anthracyclinechemotherapy and after all neoadjuvant chemotherapy, (iii)disease-free and overall survival and (iv) safety prole of thisneoadjuvant chemotherapy regimen.

The study was conducted in accordance with Good ClinicalPractice guidelines and the tenets of the Declaration of Helsinki.Participants provided written, informed consent. It was approvedby local Human Research Ethic Committees, underwent review bythe Consumer Advisory Panel of the ANZBCTG and was registeredwith the Australia and New Zealand Clinical Trials Registry (www.anzctr.org.au), registration number ACTRN12606000191594.

Treatment plan

Neoadjuvant chemotherapy consisted of a rst phase of E90 mg/m [2] and C 600 mg/m [2] both intravenous (IV) on day 1 ofa 21-day cycle for 4 cycles (Appendix A). This was followed by asecond phase of chemotherapy starting 3 weeks after the start ofthe 4th cycle of EC and consisting of D 75mg/m [2] IV on day 1 andG 1000 mg/m [2] (30 min IV infusion) on days 1 and 8 of a 21-day

ast 23 (2014) 142e151 143Tamoxifen was recommended for premenopausal women.

BreTamoxifen could be combined with ovarian suppression in locallyadvanced cases, in line with national guidelines.

Prophylactic anti-emetics were administered according toinstitutional guidelines. In the initial protocol, secondary pro-phylaxis with granulocyte-colony stimulating factor (G-CSF) waspermitted, using subcutaneous lgrastim 5 mg/kg day 2 to day 7,after an episode of febrile neutropenia or delayed neutrophilcount recovery beyond day 21. If the neutrophil count was 0.5e1.0 109/L when day 8 G was due, G was given, and peglgrastim6 mg was added on day 9, or lgrastim 5 mg/kg was added fromday 9 to day 15 of that cycle. Gemcitabine was omitted if theneutrophil count on day 8 was 50% decrease in the product of the di-

N. McCarthy et al. / The144ameters of the tumour; stable disease: between 50% decrease and25% increase in size; progressive disease: more than 25% increase inthe size of the lesion or appearance of new ipsilateral adenopathy.Radiological responses using ultrasound, were dened as com-plete: complete disappearance of lesions; partial: more than 50%reduction in the product of the perpendicular diameters of thetumour; stable: between 50% decrease and 25% increase in size;progressive: more than 25% increase in size (Appendix C). Toxicitieswere graded according to the National Cancer Institute CommonToxicity Criteria version 3.0 [15].

Statistical considerations

Enrolled patients who received at least 1 cycle of chemotherapywere evaluable for efcacy and safety. The study had a Simon two-stage designwith the decision to proceed to the second stage basedon interim analysis of efcacy in patients in each cohort in the rststage. The combination of EC followed by DG/DGH chemotherapywas expected to achieve a pCR rate of 35% in the HER2-negativecohort and 39% in the HER2-positive cohort, with the lowest limitof therapeutic efcacy being a pCR rate of 22% in the HER2-negativecohort and 24% in the HER2-positive cohort. Based on these as-sumptions, 84 HER2-negative and 63 HER2-positive patients wererequired to detect evidence of treatment activity based on a powerof 80% and 95% level of signicance. The 95% condence intervalsfor pCR rates were based on theWilson method. Statistical analyseswere carried out using Statistical Analysis System (SAS Version 9.2)software.

An interim efcacy analysis was planned. Seven or moreresponses (pCR) among the rst 27 evaluable patients in the HER2-negative cohort were required to complete recruitment of 84patients. Five or more responses (pCR) among the rst 17 evaluablepatients in the HER2-positive cohort were required to continuerecruitment of 63 patients. Planned interim safety analyses werescheduled with consideration being given by the Independent Dataand Safety Monitoring Committee (IDSMC) to modify or stop theprotocol if the number of dened adverse events exceeded thethresholds listed in Table 1 [16].

Results

Patient characteristics

From August 2006 to April 2009, 81 patients were enrolledfrom 14 institutions in Australia and New Zealand. Baseline de-mographic and clinical patient characteristics are summarised inTable 2. Median age was 49 years (range 28e71 years). Medianprimary tumour size on physical examination was 6.0 cm (range3.0e15.0 cm), 31 (38%) were grade III, 63 (78%) were HER2-negative and 18 (22%) were HER2-positive. Overall, 44 (54%)were hormone receptor (ER and/or PgR) positive/HER2 negative,19 (23%) hormone receptor (HR) negative/HER2-negative (triplenegative), 8 (10%) HR-negative/HER2-positive and 10 (12%) HR-positive/HER2-positive. The CONSORT diagram (Fig. 1) shows thenumber of patients who completed assigned treatments.

Efcacy

Of the 81 enrolled patients, 78 (96%) proceeded to surgicalresection after neoadjuvant chemotherapy. Of the 3 patients whodid not undergo surgery, one was ineligible for inclusion in thestudy due to inoperable disease at baseline; one stoppedchemotherapy due to multiple adverse events from DG (grade 3fatigue, mucositis, myalgia) and withdrew consent for surgery;and one withdrew consent for surgery after completing all

ast 23 (2014) 142e151chemotherapy cycles. In addition, one patient withdrew consent

for DG after completing 4 cycles of EC, and 3 patients withdrewconsent for further DG after receiving at least one cycle. Thesepatients all proceeded to surgery and were evaluable for studyoutcomes. Sixty one (78%) of those who underwent resectionwere HER2-negative, and 17 (22%) HER2-positive. Breastconserving surgery was performed in 20 patients (26%). Of the 78patients who underwent surgical resection, 21 (27%) achievedpCR (Table 3) including 12/61 (20%) in the HER2-negative cohortand 9/17 (53%) in the HER2-positive cohort. Within the HER2-negative cohort who underwent resection, 5/43 (12% [95%CI:5%e24%]) with HR-positive tumours achieved pCR comparedwith 7/18 (39% [95% CI: 20%e61%]) with triple negative tumours.Of the assessable patients with HR-positive HER2-positive tu-mours, 5/10 (50% [95%CI: 24%e76%]) achieved a pCR.Four out of

Table 1Planned interim safety analyses.

Interim analysis

1 2 3

Number of patients completing at least8 cycles of chemotherapy

20 30 40

Minimum number of non-haematologicaltoxicities (expected rate 20% grade 3/4)

7 10 13

Minimum number of events of pneumonitis(expected rate 5% grade 2)

3 4 5

Minimum number of cardiac events(expected rate 4% grade 3/4)

2 3 4

Minimum number of grade 2, 3 or 4 toxicities required to be observed beforeconsideration will be given to either modifying the regimen or ceasing accrual [16].

N. McCarthy et al. / The Breseven (57% [95%CI: 25%e84%]) with HR-negative HER2-positivetumours achieved a pCR. Of the 21 patients who had pCR inthe breast, 2 had positive axillary lymph nodes resulting in a totalof 19 patients (24%) with pCR in both the breast and axillarynodes.

Table 2Baseline characteristics.

HER2 negative HER2 positive Total

n 63 (78%) n 18 (22%) n 81 (100%)Demographic dataMedian age at registration

(range)50 (28e71) 44 (32e64) 49 (28e71)

ECOG 0 58 (92%) 18 (100%) 76 (94%)ECOG 1 5 (8%) 0 (0%) 5 (6%)Clinical TNMTumour StagecT2 23 (37%) 9 (50%) 32 (40%)

cT3 36 (57%) 8 (44%) 44 (54%)cT4 4 (6%) 1 (6%) 5 (6%)

Axillary lymph node statuscN0 24 (38%) 3 (17%) 27 (33%)cN1 39 (62%) 15 (83%) 54 (67%)

Breast cancer diagnosisHistopathologic typeInltrating ductal

carcinoma46 (73%) 17 (94%) 63 (78%)

Inltrating lobularcarcinoma

13 (21%) 0 (0%) 13 (16%)

Other 4 (6%) 1 (6%) 5 (6%)Histologic gradeUnable to be assessed 28 (44%) 5 (28%) 33 (41%)G1: Low 0 (0%) 1 (6%) 1 (1%)G2: Intermediate 16 (25%) 0 (0%) 16 (20%)G3: High 19 (30%) 12 (67%) 31 (38%)

Hormone receptor status at diagnosisER and/or PgR positive 44 (70%) 10 (56%) 54 (67%)ER and PgR negative 19 (30%) 8 (44%) 27 (33%)After 40 patients had completed neoadjuvant therapy andundergone surgical resection, a planned efcacy analysis showedthat 3 of the 27 patients (11%) with HER2-negative tumours hadachieved a pCR. Within this cohort, 3 of 9 (33%) who had a triplenegative tumour achieved a pCR and none of the 18 patients whohad HR-positive HER2-negative tumours had achieved a pCR. Onthe basis that a pre-dened futility boundary had been crossed, theIDSMC recommended that the HER2-negative cohort be closed toaccrual. The steering committee also elected to close the HER2-positive cohort due to slow accrual.

Following all cycles of neoadjuvant chemotherapy, 52 patients(64%) had a clinical response, 27 (33%) of which were completeclinical responses. Objective radiological response was observedin 38 (47%) patients of which 8 (10%) were complete radiologicalresponses. A pCR was observed in 5 of the 8 patients with acomplete radiological response in the breast and axilla, while 14patients had a pCR but did not achieve a conrmed completeradiological response. Following the EC cycles, 40 patients (49%)had a clinical response, 11 (14%) of which were complete clinicalresponses. Twenty eight patients (35%) had a radiologicalresponse, only 1 (1%) of which was a complete radiologicalresponse. Four patients had clinical progressive disease during EC,one of whom changed to DG after 2 cycles, while the remaining 3completed 4 cycles of EC. These patients all had clinical responsesafter completing 4 cycles of DG. Four patients had clinical orradiological progressive disease after 4 cycles of DG and onestopped DG after 3 cycles due to clinical progression and pro-ceeded to surgery.

Toxicity

A protocol amendment mandated G-CSF for each cycle of DGafter an interim safety analysis found 22 (96%) of 23 patients hadexperienced grade 3 neutropenia. After primary G-CSF was star-ted, the rate of grade 3/4 neutropenia decreased from 75% to 60%,while the rate of febrile neutropenia remained relatively stable, at9% before and 12% after the amendment. Overall, grade 3/4 febrileneutropenia was experienced by 10% of patients, while grade 3/4neutropenia was recorded in 70% of patients (Table 4). Grade 3/4fatigue was experienced by 15% of patients. Apart from fatigue andhaematological toxicity, 47% of patients experienced at least grade3 toxicity (41% grade 3, 6% grade 4). Gemcitabine was omitted ordelayed in 38% of patients on at least one occasion due to haema-tologic toxicity. After primary G-CSF was started, the relative doseintensity of gemcitabine increased from 84 to 92% and the relativedose intensity of docetaxel remained stable at 99%. No treatment-related deaths occurred.

Survival

After median follow-up of 24 months, DFS for the evaluablepopulation was 86%. In HER2-negative patients, the DFS was 87%(95% CI 76e93%) compared with 83% (95% CI 57e94%) in HER2--positive patients (Fig. 2). At the time of analysis, 10 patients (12%)had relapsed: 3 were HR-positive/HER2-negative, 4 were triplenegative, 1 was HR-positive/HER2-positive, and 2 were HR-nega-tive/HER2-positive. The relapses were local only in 2 patients,distant only in 6 patients and both local and distant in 2 patients. Ofthe local recurrences, 3 patients had in-breast recurrences afterbreast conserving surgery; one had a chest wall recurrence aftermastectomy. In addition to those patients who relapsed, two pa-tients withdrew consent for surgery after completion of chemo-therapy. Both patients had residual disease and subsequentlydeveloped local progression, and one developed distant metastases

ast 23 (2014) 142e151 145and died. Overall survival at 24 months was 94% with 5 deaths

Fig. 1. CONSORT diagram.

N. McCarthy et al. / The Breast 23 (2014) 142e151146

recorded, all attributed to breast cancer. All 5 patients had docu-mented metastatic disease from breast cancer prior to death. Three

reports [24]. We cannot comment on intrinsic subtype, as Ki-67was not assessed. The low pCR rate (19%) seen in the 53 patients(65%) with HR positive disease reduced the overall pCR rate in theHER2 negative cohort and was a major factor in the trials early

Table 3Pathological response.

pCR breasta pCR breast andaxillary nodesb

n (%) 95% CI n (%) 95% CI

HER2-negative, HR-positive 5/43 (12) 5e24 4/43 (9) 4e22HER2-negative, HR-negative

(TNBC)7/18 (39) 20e61 7/18 (39) 20e61

Total HER2 negative 12/61 (20) 12e31 11/61 (18) 10e29HER2-positive, HR-positive 5/10 (50) 24e76 5/10 (50) 24e76HER2-positive, HR-negative 4/7 (57) 25e84 3/7 (43) 16e75Total HER2 positive 9/17 (53) 31e74 8/17 (47) 26e69Totalc 21/78 (27) 18e38 19/78 (24) 16e35

a No histologic evidence of invasive carcinoma in the surgical breast specimen.b No evidence of invasive carcinoma in the breast or axillary lymph nodes.c 3 patients did not proceed to surgery: ER and/or PgR positive/HER2-negative

(n 2), ER and PgR negative/HER2-positive (n 1).

N. McCarthy et al. / The Breof these patients had triple negative disease, while 2 had HR-negative HER2-positive disease.

Discussion

This Phase II study was designed when there was greatenthusiasm for the improved pCR rates seen when docetaxel wasadded following adriamycin and cyclophosphamide in NSABP B-27, and the increasing evidence for the prognostic signicance ofpCR. A chemotherapy doublet in the metastatic setting had alsoshown superior response rates and progression free survival withthe addition of either capecitabine to docetaxel [17], or gemci-tabine to paclitaxel [18]. Our study showed that the addition ofanother cytotoxic agent gemcitabine to docetaxel, whichrequired a docetaxel dose reduction compared to docetaxelmonotherapy, did not result in pCR rates sufcient to justifyfurther study.

Recent studies in the neoadjuvant and adjuvant setting havereported similar ndings. In the randomised NSABP B-38 study,4894 patients were treated with either TAC or dose dense ACfollowed by paclitaxel gemcitabine in the adjuvant setting andthere was no signicant difference in OS or DFS [19]. The UKtAnGo trial, which randomised 3152 patients to EC followed byP G, did not demonstrate an advantage for the addition of G

Table 4

Adverse events.

HER2 negative HER2 positive Total

n 63 (%) n 18 n 81No. of patients (%) No. of patients (%) No. of patients (%)

Toxicity AnyGrade

Grade3e4

AnyGrade

Grade3e4

AnyGrade

Grade3e4

Fatigue 60 (95) 11 (17) 17 (94) 1 (6) 77 (95) 12 (15)Febrile

neutropenia5 (8) 5 (8) 3 (17) 3 (17) 8 (10) 8 (10)

Infection andGrade 3/4neutrophils

5 (8) 3 (5) 2 (11) 1 (6) 7 (9) 4 (5)

Neutropenia 63 (100) 45 (71) 18 (100) 12 (67) 81 (100) 57 (70)Thrombocytopenia 63 (100) 5 (8) 18 (100) 1 (6) 81 (100) 6 (7)Rash 24 (38) 2 (3) 7 (39) 1 (6) 31 (38) 3 (4)Mucositis/

stomatitis40 (63) 5 (8) 11 (61) 1 (6) 51 (63) 6 (7)

Diarrhoea 45 (71) 4 (6) 13 (72) 3 (17) 58 (72) 7 (9)Pain 54 (86) 5 (8) 14 (78) 2 (11) 68 (84) 7 (9)

Toxicity graded using NCI CTCAE V3.0 [15], 3% (total) G3/4 shown.[20]. Adjuvant trials adding capecitabine to docetaxel have alsobeen negative [21]. In the randomised Neo-tAnGo study, theaddition of G to paclitaxel (P) either before or after EC, did notmarkedly improve pCR rates (15% vs 20%) [22]. The NSABP B-40study randomised 1206 patients with operable HER-2 negativebreast cancer. G did not improve the pCR rate when added to D,followed by AC, at a cost of increased toxicity [23]. Thus, in thisstudy in the neoadjuvant setting, adding an additional cytotoxicagent to a taxane did not show an advantage compared with thesignicant improvement in pCR rates seen with the addition oftargeted therapy in patients with HER2 positive breast cancer[8].

When the NeoGem protocol was developed, the low pCR rateassociated with hormone receptor (HR) positive breast cancer,particularly the luminal A subtype, was not well established.However, a pooled analysis of neoadjuvant studies has sinceshown a low 13% pCR rate in those women with ER positive tu-mours, which did not correlate with DFS or OS [24]. Our un-planned subset analysis by ER, PgR and HER2 involves smallnumbers, but the pCR rates seen are consistent with published

Fig. 2. Disease-free survival.

ast 23 (2014) 142e151 147closure. Future neoadjuvant trials should be designed to assessHER2 positive, triple negative and hormone receptor positiveHER2 negative cohorts separately.

Neoadjuvant therapy may be advantageous for large or locallyadvanced HR positive breast cancers in order to obtain breastconservation. We found no advantage from adding an additionalcytotoxic agent in this group, and alternative strategies areneeded. The relatively low rate of breast conserving surgery in ourpopulation (26%) is likely to relate to the large median tumour sizeof 6 cm. In addition, despite becoming eligible for breastconserving surgery after neoadjuvant chemotherapy, many pa-tients and/or surgeons will opt for a mastectomy [25]. We did notcollect data on patient preference or suitability for breastconserving surgery.

The role of neoadjuvant endocrine therapy appears promising[26], but needs further evaluation. This Iranian group randomised101 patients to CAF chemotherapy with or without concurrentletrozole. Encouragingly, the pCR rate with combination therapywas 31%, compared with 10% with chemotherapy alone, in the 62

Products, Pty Limited (Australia) and Eli Lilly Australia gaveresearch grants and study drugs and Sano-Aventis supplied

F Boyle (S Baron-Hay, D Bell, K Moore, J Page, A Spillane, M

Vincents Hospital, Melbourne.E Abdi (H AL-Saig, B Brigham, D Martin, J Polong, R Srivastav, C

Brepatients with ER positive tumours. Other potential strategiesinclude combining letrozole with a cyclin dependent kinase(CDK) 4/6 inhibitor [27] or targeting the PI3K-Akt-mTOR pathwayin combination with endocrine therapy [28,29].

Patients with HER2 positive or triple negative breast cancer(TNBC) have higher response rates to neoadjuvant therapy. pCRcorrelates with prognosis and may be useful as a surrogateendpoint in clinical trials [24]. Our denitions of pathological,clinical and radiological response were based on those used by theNSABP [14], however pCR in the breast and axilla has subsequentlybeen shown to be a more robust predictor of outcome [24]. Ratherthan adding cytotoxic agents, the use of dual HER2-targeted ther-apy with pertuzumab [30] or lapatinib [31] has been shown toimprove pCR rates. The inherent heterogeneity of TNBC makestargeted therapy a challenge and a number of new agents are beingtested [32e34].

In the NeoGem study, the addition of G to D after EC increasedhaematological toxicity, requiring primary growth factor supportto maintain dose intensity. In 38% of patients, one or more dosesof gemcitabine were omitted or delayed due to haematologicaltoxicity. This led to concern that efcacy may have beencompromised due to insufcient exposure to gemcitabine. Afterprimary G-CSF was added to the protocol, relative dose intensityincreased.

The rate of haematological toxicity in this study was compara-tively high. In SUCCESS and NSABP B38, two large studies usingsecondary G-CSF with adjuvant taxane G following ananthracycline-containing regimen, the rate of febrile neutropeniawas 4% in the gemcitabine arm [19,35]. Low rates of neutropenia(G3/4 11%) and febrile neutropenia (1%) were achieved in a studyusing peglgrastim as primary prophylaxis with a dose denseneoadjuvant triplet G (2000 mg/m2), E (50 mg/m2) and albumin-bound paclitaxel (175 mg/m2) [36]. However, in a rst-line meta-static study using G with a taxane, grade 3/4 neutropenia wasbetween 39.3% and 56.5% [37]. Peglgrastim has been shown to besuperior to lgrastim at preventing febrile neutropenia, which mayreect better compliance with a simpler dosing schedule [38].Alternate scheduling, such as that used in sarcoma, using gemci-tabine D1 then gemcitabine and docetaxel D8, may have optimiseddose intensity due to less neutropenia-related chemotherapyomission at D8 [39].

Apart from ER, PgR and HER-2, established predictive breastcancer biomarkers are lacking. NeoGem biomarker substudies areyet to be completed, but we hope to identify a subset of patientswho may benet from the addition of gemcitabine, for incorpora-tion into future trials. A Ki-67 of >20% or a basal-like PAM50 sub-type have been shown to predict for benet when G is added to ataxane-containing regimen [40,41].

Conclusion

This schedule of gemcitabine, added to a taxane andanthracycline-containing neoadjuvant regimen, cannot be rec-ommended. The pathological response rate was lower than ex-pected, particularly in patients with ER positive HER2 negativetumours. It was difcult to maintain dose intensity due to a highrate of neutropenia, requiringG-CSF support. Alternative strategiesare required to continue to improve outcomes, including betterpatient selection, and evaluation of novel agents in the neo-adjuvant setting.

Role of the funding source

This study was sponsored by the Australia and New Zealand

N. McCarthy et al. / The148Breast Cancer Trials Group (ANZBCTG) and the National HealthChorlton) The Tweed Hospital.A Simpson (C Barrow, J Edwards, B King, B Luey, A ODonnell, K

Clarke, J Bowers, M Kler) Wellington Hospital.M Pitcher (R de Boer, M Green, C Oakman, S Wong, LWilkinson)

Western Hospital.

AuthorshipSywak, D Dash, K Sheather) Mater Hospital, Sydney.P Francis (F Day, K Field, R Jennens, D Kee, E Lim, G Mallasara, L

Mileshkin, KA Phillips, N Potasz, J Power, A Marshall, N Roylance)Peter MacCallum Cancer Centre.

N McCarthy (G Beadle, A Hadley, B Hughes, P Inglis, D Wyld, AEarley, C Fletcher, W Pritchard, N Roberts) Royal Brisbane andWomens Hospital.

B Mann (S Ananda, D Carden, J Collins, R de Boer, M Green, GLindeman, J Miller, C Murphy, C Scott, J Tie, M Lieschke, C Master-son, A Sherman) The Royal Melbourne Hospital.

R Snyder (I Burns, A Dowling, P Francis, SA McLachlan, GNewnham, A Wirth, D Gaitanis, L Pasanen, N Ranieri, S Vickery) Ststudy drug. Data was collected by the ANZBCTG and analysed incollaboration with the National Health and Medical ResearchCouncil Clinical Trials Centre. All authors had full access to thedata and had nal responsibility for the decision to submit forpublication.

Contributors

Australia and New Zealand Breast Cancer Trials Group andsupporting staff (2004e2012).

Principal investigator: Nicole McCarthy.Administrative ofce: Dianne Lindsay, Heath Badger, Lauren

Macnab, Kristy Taubman, Rose Lucas, Former staff: Kristy Schmidt.Statisticians: Val Gebski, Anne-Sophie Veillard, Diana Zannino.Steering Committee: N McCarthy, F Boyle, JF Forbes, G Kan-

nourakis, C Underhill, J Chirgwin, B Robinson, C Shannon, P Francis,BMann, R Snyder, E Abdi, A Simpson, M Pitcher, S Guthrie, V Gebski,R Sutherland, D Lindsay, H Badger.

Collaborators

Names in brackets show co-investigators and trial coordinators.G Kannourakis (H Francis, R Bond, C Carden, L Cartledge, R

Cotton, A Ewan) Ballarat Oncology and Haematology Services.C Underhill (P Bilinski, K Clarke, R Eek, B Francis, D Kee, C Steer, C

Hodgkins) Border Medical Oncology.J Chirgwin (D Campbell, S Chua, G Goss, R Masters, L Pellegrini, J

Dryden, D Rapson) Box Hill Hospital.B Robinson (B Fitzharris, D Gibbs, D Harris, I Henderson, M

Jeffery, A Landers, A Rahman, P Tan, B Egan, A Smith, L Thompson)Christchurch Hospital.

J Chirgwin (S Chua, G Goss, J Dryden, J Flynn) MaroondahHospital.

C Shannon (P Mainwaring, M Xavier, N Arnold, G Crosbie, JMarshall, M Pawsey) Mater Adult Hospital, Brisbane.and Medical Research Council (project grant ID 455513). Roche

ast 23 (2014) 142e151Each author has signicantly contributed to the study.

Conict of interest statement

Prudence Francis: Education travel assistance from Sano-Aventis.

No other authors have a conict of interest to declare, includingemployment, consultancies, stock ownership, honoraria, paidexpert testimony, patent applications/registrations and grants orother funding.

Acknowledgements

We thank the women who participated in the study, theirdoctors and the research teams at each of the participating hospi-tals; the Australia and New Zealand Breast Cancer Trials Group ANZ0502 Study Team; the NeoGem steering committee, and the Na-tional Health and Medical Research Council of Australia (projectgrant ID 455513). Roche Products, Pty Limited (Australia) (drug,research grants), Eli Lilly Australia (drug, research grant), Sano-Aventis (drug), supported the trial and commented on ndings ofthis study, but had no input into data analysis or interpretation.

Appendix A

Appendix B

Patient assessments

Before study entry, all patients had a history, physical exami-nation (including ECOG score, and breast and axilla clinical tumourmeasurement), haematology and biochemistry blood tests, radio-logical investigations of the breast (mammogram, ultrasound),evaluation of cardiac function (ECG and echocardiogram or multi-ple gated acquisition (MUGA)) and staging investigations (CT chest/abdomen/pelvis, bone scan). A core biopsy from the breast tumourwas performed in all patients before treatment. A biopsy was alsoobtained from the axilla if there were clinically or radiologicallysuspicious axillary nodes. Repeat core biopsy was collectedfollowing completion of 2 cycles of EC for translational researchpurposes (to be reported elsewhere). History, physical examination(including clinical tumour response), recording of toxicity andblood tests were performed before each chemotherapy cycle and 21days after the last cycle of DG/DGH. Repeat LVEF measurement andbreast ultrasound were performed after the 4th cycle of EC andafter the 4th cycle of DG/DGH.

Dose modications

Granulocyte-colony stimulating factor (G-CSF) was permittedfor treatment of febrile neutropenia and for delayed recovery of

N. McCarthy et al. / The Breast 23 (2014) 142e151 149Study schema.

Additional treatmentmodications were recommended for E, D,G and H. E was ceased in the event of symptoms of signs ofcongestive cardiac failure, persistent arrhythmia, or LVEF fallingbelow normal range or by >15% from baseline. D was withheld inthe event of grade 2 neurosensory toxicity lasting 3 weeks, anddose-reduced if persisting for>3 weeks, or in the event of grade 3e4 neurosensory toxicity. It was also stopped after recurrent grade 3,or a single episode of grade 4, anaphylactoid and hypersensitivityreactions. The day 8 dose of G was omitted if the day 8 neutrophilcount was

high-risk early breast cancer (EBC): rst report of the primary endpoint,

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Neoadjuvant chemotherapy with sequential anthracyclinedocetaxel with gemcitabine for large operable or locally advanced br ...IntroductionMaterials and methodsPatient selectionStudy designTreatment planPatient assessmentsStatistical considerations

ResultsPatient characteristicsEfficacyToxicitySurvival

DiscussionConclusionRole of the funding sourceContributorsCollaboratorsAuthorshipConflict of interest statementAcknowledgementsAppendix AAppendix BPatient assessmentsDose modifications

Appendix CResponse definitionsPathologic responseClinical responseRadiological response

Appendix DReferences