force2017-txofhereditarybreastcafinal6/13/17 2 overview of topics to be covered • breast cancer...

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Treating Breast Cancer in People with Mutations

Steven J. Isakoff, MD, PhD

Massachusetts General Hospital Cancer Center

June 9, 2017

[email protected]

Disclosures

Company

Relationship

² Myriad Genetics ² Paid Consultant

² AbbVie

² Paid Data Safety Monitor Committee Member

AbbVie Pharmamar

AstraZeneca

Genetech/Roche OncoPep

² Research Support to Institution

Off Label Use

•  I will be discussing off label use of medications today. –  None of the PARP inhibitors discussed are approved for breast

cancer

–  Lurbinectedin (PM1183) is not approved

–  No immunotherapy medications are approved for breast caner

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Overview of topics to be covered

•  Breast cancer subtypes and association with BRCA1/2

•  Triple negative breast cancer

•  BRCA1/2 breast cancer

•  PARP inhibitors

•  Other new treatments

•  Immunotherapy

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Breast Cancer is more than One Disease

Past Breast Cancer

HER2+ HER2-

Molecular Subtypes, BRCA-associated Future

Present ER/PR + ER/PR -

“Triple negative” breast cancer

•  Immunohistochemistry

•  High grade ductal

PR HER2

• ER and PR <1% nuclear with positive normal breast internal control

• HER2 “negative” is 0 or 1+ staining or 2+ staining with negative FISH.

ER

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•  About 15% of tumors

• Low HER2 cluster expression

• Low ER (and related genes) cluster expression

• High basal cluster (CK 5, 17, EGFR, αB crystallin, c-kit etc) expression

• Very proliferative

Intrinsic Molecular Subtypes: Basal-like Breast Cancer

HER2

Basal

Luminal

Proliferation

Luminal A B Basal HER2

Sorlie et al, PNAS 2001

Basal-like Tumors are Associated with a Poor Prognosis

Sorlie et al, PNAS 2001

•  Most cancers in BRCA1 mutation carriers are basal-like But •  Most basal-like breast cancers are not in BRCA1 carriers

= BRCA1+ Sorlie T et al. PNAS 03

Basal-like

= BRCA2+

Intrinsic gene list applied to Van’t Veer dataset (Nature 2002)

Guilt by Association: Basal-like Breast Cancer and BRCA1

slide courtesy of Lisa Carey, MD

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Further classification of TNBC: the Vanderbilt TNBC Subtypes Treatment implications of TNBC heterogeneity

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Basal-like 1 (BL1): Cell cycle proliferation, DNA damage response genes

Basal-like 2 (BL2): Growth factor signaling (EGF, MET, Wnt/β-catenin, IGF1R

Immunomodulatory (IM) Immune cell and cytokine signaling (overlap with medullary breast cancer gene signature)

Mesenchymal (M) Cell Motility and differentiation (Wnt, ALK, TGF- β)

Mesenchymal stem-like (MSL) Mesenchymal-like but increased growth factor signaling, low proliferation, enrichment of genes associated with stem cells

Luminal Androgen Receptor (LAR) Enriched in hormonally regulated pathways, estrogen receptor signaling, androgen receptor signaling. Shows luminal expression patterns (molecular apocrine carcinomas)

Lehmann B, J Clin Invest. 2011 Jul;121(7):2750-67.

Prognosis for BRCA1/2 carriers

•  Controversy about whether BRCA1/2 carriers have different outcome compared to BRCA wild type

•  A large meta-analysis of 66 studies found no clear difference when adjusted for other factors –  (van den Broek, 2015 PLoS ONE 10(3))

•  Recent studies may suggest a better prognosis in some subgroups

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Prospective Study of Outcomes for Sporadic versus Hereditary Breast Cancer (POSH)

•  3053 patients from UK 2000-2008 –  Invasive breast cancer ≤ 40 yo

•  Tested for BRCA1 and BRCA2 in 2016

•  2759 samples analyzed –  379 (14%) had BRCA1 or 2 or both

–  212 BRCA1

–  170 BRCA2

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Characteristic All (2759) BRCA1+ (212) BRCA2+ (170) Node positive 52% 36% 59% ER+ 67% 27% 83% HER2+ 28% 9% 16% Triple Negative 19% 53% 10%

Eccles, SABCS 2016

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•  Overall Survival BRCA+ vs WT (8 yr follow up) –  No difference

–  Similar results comparing BRCA1 vs WT

13 Eccles, SABCS 2016


•  In Triple negative breast cancer (511 cases): –  11% difference at 10 years favoring BRCA+

14 Eccles, SABCS 2016

BRCA1/2 Function makes it a therapeutic target for chemotherapy

•  BRCA1 and 2 play key roles in Double Strand Break repair

•  BRCA1 also is involved in mismatch repair pathways

•  Some chemotherapy agents cause DNA damage

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Cisplatin and Breast Cancer

•  Sledge (JCO 1988 6:1811-1814) reported 47% response rate in first line metastatic disease unselected for subtype

–  RR range 42-54% in older studies in first line therapy

–  RR 0-9% in previously treated unselected patients

•  Abandoned for many years because of concerns about toxicity and development of taxanes

•  Interest emerged in early 2000’s in patients with triple negative breast cancer

•  Association of TNBC and BRCA1

Platinum for Neoadjuvant Therapy in Sporadic TNBC and BRCA1 Mutation Carriers

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Sporadic TNBC > 2cm, Stage II/ III

Research Core Biopsy N=28

Cisplatin 75mg/m2 q3wks x 4

cycles

Assess Responseà

Standard Adjuvant

Therapy per MD

pCR 22% Garber et al, SABCS 2006; Silver et al, JCO 2010

ALLIANCE/CALGB 40603 Study evaluating addition of Carboplatin and Bevacizumab in Neoadjuvant Tx for Triple Neg Breast Cancer

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N=443 ER/PR/HER2- Stage II-IIIB

Sikov J Clin Oncol 2015. 33:13-21

Carboplatin improves pCR

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GeparSixto Trial: Neoadjuvant carboplatin for Triple Negative Breast Cancer

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315 pts (~53% TNBC) 40% node pos

pCR Rates by germline BRCA status and Carboplatin in TNBC

•  gBRCA tumors are highly sensitive to chemotherapy •  Platinum does not add much

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Randomized Phase II trial: Neoadjuvant Cisplatin vs AC

in Women with Newly Diagnosed Breast Cancer and Germline BRCA Mutations

N. Tung, PI

Is cisplatin better than AC for preoperative therapy for BRCA carriers?

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Schema: INFORM trial

Eligibility: BRCA1/2 + HER2-neg T> 1.5 cm

Research biopsy

Cisplatin 75 mg/m2 x 4

AC x 4 dd or q 21 days

Surgery

Adjuvant Chemo

Primary aims: pCR and RCB Secondary aim: biomarkers of response

N=85

N=85

What about in the Advanced Setting?

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TBCRC009: Single agent Cisplatin or Carboplatin in First or Second Line Therapy for Advanced Triple Negative Breast Cancer

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Primary Endpoint 1 % (number) (95% Confidence Interval) Overall Response Rate (RR) 25.6 % (16.8-36.1)

Complete Response (CR) 4.7%

Partial Response (PR) 3.5%

Response Rate by BRCA Mutation Status

RR

BRCA1/2 positive (N-11) 54.5% (23.4-83.3)

BRCA1/2 Wild Type (N=65) 19.7% (10.9-31.3)

BRCA1/2 Unknown (N=10) 33.3% (19.1-48.5)

•  BRCA1/2 germline mutation carriers had significantly higher response rate

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RANDOMI Z E

Carboplatin AUC 6 x 6 cycles

Docetaxel 100mg/m2 X 6 cycles

Metastatic TNBC Trial -- ‘TNT’ – Triple Negative Trial (Tutt, PI)

•  N=376

•  Triple negative

•  Met or locally adv

•  No prior chemo for MBC (except for anthracycline).

•  BRCA carriers stratified

Crossover at progression, limit to 6 cycles of therapy.

Tutt, SABCS 2014

Triple Negative Trial - Top Line Results

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TNT – BRCA results

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TNT – BRCA results

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Is Cisplatin Preferred For The Treatment Of BRCA-Associated or Sporadic TNBC?

•  Platinum is active in early and metastatic TNBC

•  But, no difference observed in the TNT randomized trial

•  Triple negative breast cancer is sensitive to a wide variety of chemotherapeutic agents

•  There is a selective advantage for mutation carriers and may be a good option for BRCA1/2+ advanced breast cancer

•  Unclear if Platinum is better for BRCA1/2+ in early stage disease

New Therapies for BRCA1/2 Carriers

•  PARP Inhibitors

•  PM01183

•  Sapecitabine-Seliciclib

•  Immunotherapy

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Late Clinical Development

Future Directions

Investigational

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31 NATURE | VOL 434: 914 | 14 APRIL 2005

PARP Inhibitors Mechanism of Action

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1. Single Strand Breaks in DNA Recognized by PARP

2. PARP flags DNA for repair and recruits help, and adds PAR to itself

3. After DNA is fixed, the help is released

BRCA1/2 --

PARP

PARP BRCA1/2

PARP

Cancer Cell able to repair single strand break

Cancer Cell treated with PARP inhibitor

BRCA Cancer Cell treated with PARP inhibitor

Cancer Cell dies

PALB2 and other mutations may have similar sensitivity

PARP Inhibitors Mechanism of Action

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1. Single Strand Breaks in DNA Recognized by PARP

2. PARP flags DNA for repair and recruits help, and adds PAR to itself

3. After DNA is fixed, the help is released

BRCA1/2 --

PARP

PARP BRCA1/2

PARP

Cancer Cell able to repair single strand break

Cancer Cell treated with PARP inhibitor

BRCA Cancer Cell treated with PARP inhibitor

Cancer Cell dies

PALB2 and other mutations may have similar sensitivity

Inhibit Catalytic Activity

PARP trapping

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PARP Inhibitors in development

Olaparib (AZD2281) AstraZeneca FDA Approved OvCa, Ph3 breast Veliparib (ABT-888) AbbVie Ph3 in breast Niraparib (MK-4827) Tesaro Ph3 in breast, approved in OvCa Talazoparib (BMN-673) Medivation Ph3 in breast Rucaparib (AG-14699) Clovis Ph2 in breast

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Clinical Opportunities to Use PARP inhibitors in BRCA1/2 Patients

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Prevention

Adjuvant

Neoadjuvant

Metastatic Monotherapy

Combinations

The first Phase II trial in BRCA-deficient advanced breast cancer: Olaparib

Olaparib 100 mg bid

(n=27)

6 (22) 0

6 (22) 12 (44)

Overall Response Rate, n (%) Complete Response, n (%) Partial Response, n (%) Stable Disease n (%)

11 (41) 1 (4)

10 (37) 12 (44)

Olaparib 400 mg bid

(n=27) ITT cohort

Adverse Events: Fatigue grade 1 or 2, 56% grade 3, 15% Nausea grade 1 or 2, 26%, grade 3 11%

• Median of 3 prior lines of chemotherapy.

Tutt, Lancet 2010 36

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Single Agent PARP inhibition: FDA Registration Studies for BRCA1/2+ Advanced Breast Cancer

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gBRCA1/BRCA2 Carriers

Advanced

anthracycline+taxane resistant breast cancer

PARP inhibitor as continuous

exposure

Physican Choice within Standard of

Care options: Capecitabine

or Vinorelbine

or Eribulin

or Gemcitabine

R

Primary endpoint:

Progression free survival

Olaparib – OLYMPIAD – NCT02000622 (Accrual is complete) Niraparib – BRAVO – NCT01905592 Talazoparib– EMBRACA – NCT01945775 (BMN673)

OLYMPIA RESULTS – Hot off the press from ASCO…

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OlympiAD: Phase III trial of olaparib monotherapy versus chemotherapy for patients with HER2-negative metastatic breast cancer and a germline BRCA mutation

Presented By Mark Robson at 2017 ASCO Annual Meeting

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OlympiAD study design


Patient characteristics


Primary endpoint: progression-free survival by BICR


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Time to second progression or death (PFS2) <br />by investigator assessment


Overall survival (interim analysis; 46% data maturity)


Objective response by BICR


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OlympiAD: Additional findings

•  Compared to standard chemotherapy: –  Similar activity regardless of prior chemotherapy exposure

–  More effective in Triple Negative than ER+

–  Similar activity with or without prior platinum chemotherapy

–  Side effects generally similar:

•  Olaparib had more nausea

•  Chemotherapy had more low white count

–  Olaparib had improved Quality of Life

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Olaparib

•  Based on OlympiAD study, we anticipate Olaparib will get FDA approval for metastatic BRCA1/2 associated breast cancer in 2018.

•  This will be the FIRST drug FDA approved specifically for BRCA1/2 breast cancer

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Phase 1 study of: Cisplatin/Navelbine/Veliparib (300mg BID selected)

•  RR = 57% in BRCA1/2 carriers (31% in non-carriers) •  CBR 71% in BRCA1/2 carriers •  35% of patients had prior platinum •  Most common AE: Nausea, Fatigue, Platelets, Anemia, Neutrophil •  PARPi may protect against nephrotoxicity and neuropathy

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On the other hand…Cisplatin/olaparib

•  Phase 1 study •  Cisplatin 75mg/m2 •  Olaparib continuous

–  Not tolerable

•  Olaparib intermittent –  50mg BID D1-5 Tolerable

–  Cisplatin 60mg/m2

•  ORR in BRCA1/2 breast ca = 71% •  Continuous monotherapy after 6 cycles had durable responses •  Dose limiting toxicity included

–  Neutropenia, lipase elevation

49 Balmana Annals of Oncology 25: 1656–1663, 2014

BROCADE

•  A randomized phase 2 study comparing carboplatin/taxol to carboplatin/taxol+veliparib or temozolomide+veliparib

50

This presenta,on is the intellectual property of the authors/presenter. Contact them at Hyo.Han@moffi:.org for permission to reprint and/or distribute.

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San Antonio Breast Cancer Symposium, December 6 -‐ 10, 2016

BROCADE: Study Design Veliparib 120 mg D1–7 BID

+ CarboplaCn AUC 6/ Paclitaxel 175 mg/m2

Q3W* N = 97

Veliparib 40 mg D1–7 BID + TMZ 150 to 200 mg/m2 QD, D1–5†

N = 94

Placebo + CarboplaCn AUC 6/ Paclitaxel 175 mg/m2

Q3W* N = 99

*Carbopla,n/Paclitaxel administered on D3, 21-‐day cycle. †28-‐day cycle.

Pa,ents were treated un,l progression or unmanageable toxicity. If both carbopla,n and paclitaxel or if TMZ was discon,nued, placebo/veliparib

was discon,nued.

MetastaCc breast cancer with BRCA1/2 mutaCon

≤ 2 lines of chemo No prior plaCnum

N = 290 (86 sites, 20 countries)

StraCficaCon factors for randomizaCon •  ER and PgR status (posi,ve

or nega,ve) •  Prior cytotoxic therapy (yes

or no) •  ECOG status (0–1 or 2)

1:1:1

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Progression-‐Free Survival

Months Since RandomizaCon

Prob

ability of

Progression-‐Free Survival

Number at risk Placebo + C/P Veliparib + C/P

98 95

82 80

61 60

35 38

20 22

8 13

4 4

0 2

01

Placebo + C/P Veliparib + C/P 0.0

0.4

0.8

0.2

0.6

1.0

0 4 8 12 16 20 24 28 32

Median (95% CI) PFS, Veliparib + TMZ: 7.4 (5.9–8.5) months; HR = 1.858 (1.278–2.702), P = 0.001. (SABCS program number: P4-‐22-‐02)

Placebo + C/P

N = 98

Veliparib + C/P

N = 95 HR P

value* Median PFS, months (95% CI)

12.3 (9.3–14.5)

14.1 (11.5–16.2)

0.789 (0.536–1.162)

0.231

TMZ/Vel was inferior


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Tumor Response Placebo + C/P

N = 98 Veliparib + C/P

N = 95 ORR (CR + PR), n/N, % (95% CI)

49/80 (61.3%) (49.7–71.9)

56/72 (77.8%)* (66.4–86.7)

CBR (week 18 progression-‐free rate), % (95% CI)

87.0% (78.3–92.4)

90.7% (82.2–95.2)

DOR, median months, (95% CI)

11.1 (9.5–15.7)

11.7 (8.5–14.1)

ProporCon of PaCents with ORR, % (95% CI)

49/80 (61.3%)

56/72 (77.8%)

Placebo + C/P

Veliparib + C/P

0 20 40 60 80 100

P = 0.027

*P <0.05 for placebo +C/P vs veliparib + C/P. Tumor assessments were per independent radiology reviewer. ORR, CR, and PR shown represent confirmed responses; these analyses included all pa,ents with measurable disease at baseline. DOR analysis included all pa,ents with an objec,ve response. CBR analysis included all randomized pa,ents who had a deleterious BRCA1/2 muta,on per the core lab. DOR, dura,on of response; PR, par,al response.


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Conclusions

•  The addi,on of veliparib to carbopla,n/paclitaxel resulted in trends toward improved PFS and OS, and a significant increase in ORR

–  Final OS analysis will occur when the prespecified number of events is reached

•  Further evalua,on of the efficacy and safety of veliparib with weekly paclitaxel and carbopla,n in pa,ents with BRCA-‐mutated advanced breast cancer is ongoing in the phase 3 randomized trial BROCADE3 (NCT02163694)

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PARP inhibitors: Adjuvant Therapy

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PARP inhibitors for Early Stage Breast Cancer

•  OLYMPIA study: –  Currently accruing – goal 1320 patients

–  Adjuvant Olaparib

–  Assess for improvement in disease free survival (10 yr f/u)

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• Triple negative breast cancer or high risk ER positive • BRCA mutation+ • Complete at least 6 cycles of chemotherapy

12 months of olaparib

12 months of placebo

Mechanisms of Resistance to PARP inhibitors

•  Reversion of BRCA1/2 Truncated mutations

•  P glycoprotein efflux pumps

•  Stabilization of BRCA1/2 mutant protein

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•  Loss of 53BP1 –  Results in restoration

of HR in BRCA1/2 cells

•  Presence of hypomorphic BRCA1/2 –  Low level expression

of BRCA1/2 can be stimulated

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Beyond PARP inhibitors for BRCA1/2 carriers

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PM01183 - Lurbinectedin

•  A novel intravenous chemotherapy

•  2nd generation derived from the Sea Squirt

•  Binds to DNA Minor Groove

•  Blocks transcription

•  Causes double strand DNA breaks

•  Related to trabectedin which is approved in Europe and Japan

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PM1183BRCA normal

BRCA mutation Cell death

PM01183 – Ongoing Study in BRCA+ Advanced Breast Cancer

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• Advanced breast cancer • 0-3 lines of prior therapy

Group A BRCA1/2 mutation

Group B No BRCA1/2 mutation

53 patients

64 patients (closed early)

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PM01183

•  41% Response Rate in Arm A –  Some >1 year

•  Main side effects: –  Nausea, anemia, neutropenia,

Transaminase increase

•  Current status: –  Additional 20 patient cohort in

prior PARP inhibitor treated patients

–  Phase 3 trial in development

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Combination of Sapacitabine and Seliciclib

•  Sapacitabine – –  Oral DNA analog that gets inserted into DNA and causes single

strand breaks

–  Results in double strand breaks

•  Seliciclib – –  Oral Cyclin Dependent Kinase (CDK) 2,5,7,9 inhibitor

–  Inhibits double strand break repair

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N

N N

N

HN

NH

HO

Cancer Cell dies

Sapacitabine

Seliciclib

Phase 1 study of Sapacitabine + Seliciclib

•  22 Non-BRCA carriers

•  16 BRCA carriers –  (8 breast, 7 ovary, 1 pancreas)

–  4 responses (25%, 3PR, 1 CR)

–  2 stable disease

–  1 patient on 4 years so far

•  New expansion cohort –  20 BRCA1/2 patients

63 Dr. Sara Tolaney, DFCI ASCO 2016

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Immunotherapy

•  Potential Future Directions for BRCA1/2 treatment

•  How can we harness our own immune system to help treat BRCA1/2 breast cancer?

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Why doesn’t our immune system attack cancer? The ‘Secret Handshake’ that steps on the breaks.

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The tumor cell tells the Immune T-cell “I am one of you, don’t attack!”

Why doesn’t our immune system attack cancer? The ‘Secret Handshake’ that steps on the breaks.

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Now we have immunotherapy antibody drugs that prevent the handshake and “release the breaks” so the immune T cell can attack

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Immune cells are often found mixed in with tumor cells, and PDL1 is often found on breast cancer cells

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Without infiltrating Lymphocytes (T-cells)

With infiltrating Lymphocytes (T-cells)

Evidence of activity in breast cancer

•  Atezolizumab targets PDL1

•  In a phase 1 study presented at April 2015 AACR meeting: –  54 patients with metastatic triple negative breast cancer

–  69% had PDL1 on tumors

–  Objective response rate was19%

–  27% had no progression at 6 months

–  Drugs are well tolerated with fatigue, mild nausea, fever

68 Emens, AACR 2015

Slide 4

Presented By Sylvia Adams at 2017 ASCO Annual Meeting

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Pembrolizumab Antitumor Activity in Previously Treated and Previously Untreated mTNBC


Pembrolizumab Antitumor Activity in Previously Treated and Previously Untreated mTNBC


Immunotherapy for Advanced Breast Cancer

•  Checkpoint inhibitors against PD-1 or PD-L1 are active as single agents, but less so after 1st line

•  The future of immunotherapy in breast cancer is most likely with combinations

•  Combination with chemotherapy and targeted therapies are underway

72

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I-SPY 2 TRIAL Schema: HER2- Signatures

Presented By Rita Nanda at 2017 ASCO Annual Meeting

Immunotherapy in Pre-operative breast cancer

Pembrolizumab graduated in all HER2- signatures:<br />Both HR+/HER2- and TN



Pembrolizumab graduated in all HER2- signatures:<br />Both HR+/HER2- and TN



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Immunotherapy and potential future Directions for BRCA1/2 carriers

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•  Expression of Immunotherapy Targets in Triple negative breast cancer (Basu et al, ASCO 2014) •  10 of 38 Triple Negative breast cancers had PDL1

(28%) •  But 7 of 7 BRCA1+ patient had PDL1+ expression

•  High expression of PD-L1 in BRCA1+ tumors suggests that anti PD-1/PD-L1 therapy in combination with platinum and/or PARP inhibitors may be a synergistic treatment strategy that warrants further study

•  However,Tung et al (ASCO 2015) showed BRCA1+ have similar PDL1 expression as sporadic TNBC

Immunotherapy and PARP inhibitors

•  Biologic rationale: –  PARPi can increase cell death and inflammation à improved CD8+ T

cell infiltration and activation concurrent with immune checkpoint modulators

–  PARPi can increase tumor somatic mutations à neo-antigens that prime anti-tumor CD8+ T cells in the presence of immune checkpoint modulation

–  BRCA1 tumors may have high frequency of PDL1

–  Veliparib has demonstrated synergy with anti-CTLA-4 in BRCA deficient pre-clinical models (Higuchi et al, 22nd CRI Symposium, 2014)

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Immunotherapy and PARP inhibitors – Clinical Studies

•  TOPACIO Study (KEYNOTE 162)

•  Phase 1/2 Clinical Study of Niraparib in Combination with Pembrolizumab in Patients with Advanced or Metastatic Triple-Negative Breast Cancer and in Patients with Recurrent Ovarian Cancer –  Phase 2 will enroll 48 Triple negative breast cancer patients

–  No prior progression on platinum allowed

–  Nearly complete

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Immunotherapy and PARP inhibitors – Clinical Studies

•  MTD durvalumab 1500 mg q 4 weeks and olaparib 300 mg BID

•  Only 2 of 11 patients were breast ca –  Both were BRCA wt triple negative breast ca

–  1/11 (8% response)

–  9/11 (83%) disease control > 4 months

•  Expansion cohort now open in TNBC

79 Lee, ASCO 2016

Novel Prevention Strategies in BRCA Carriers

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Prevention strategies in BRCA1/2 carriers

•  Preclinical data demonstrates veliparib and olaparib can prevent development of tumors in BRCA1 deficient mice –  Clinical studies likely will be delayed until longer term safety data

–  Rare association with MDS reported

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•  RANKL inhibitors –  BRCA1 tumor cell of origin likely a

luminal progenitor

–  RANKL signaling is important in mammary hormonal signaling

–  RANKL inhibition attenuates tumor onset in BRCA-def mice

–  BRCA patients treated with denosumab have decreased Ki67 (proliferation)

–  Denosumab may be a chemoprevention strategy in BRCA1 carriers

82 Nolan et al, Nature Medicine June 20, 2016 online

BRCA-P : A Breast Cancer Prevention Study in BRCA1/2

•  International Study by ABCSG (with collaboration from the ALLIANCE, ANZBCTG, Poland, UK, Spain).

•  Double blind Ph3 with denosumab 120 mg subQ every 6 months x 5 years

•  BRCA1 and BRCA2 carriers

•  Stratified by BRCA 1 vs 2, menopausal status.

•  Powered to study premenopausal BRCA1.

•  2900 patients

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Final Points: A plea for Advocacy and Clinical Trial Participation

•  In other cancers with small populations, targeted therapies have seen rapid approval

•  PARP inhibitors have been slow to become available

•  We need collaboration to do trials and get these drugs where they are most needed – to patients!

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85

Key Ongoing/Upcoming Clinical Trials to Consider

•  Prevention –  BRCA-P

•  Use of Denosumab in BRCA1/2+ patients who have not undergone prophylactic mastectomy

•  Pre-operative chemotherapy –  INFORM

•  Comparing pathologic complete response rate (pCR) of Cisplatin to Adriamycin/Cytoxan in BRCA1/2+ patient with primary cancer >1.5 cm

•  Adjuvant –  OlympiA

•  Comparing 1 year of olaparib vs placebo after completing adjuvant/neoadjuvant therapy in BRCA1/2+ patients with node positive or tumor >2cm

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Key Ongoing/Upcoming Clinical Trials to Consider

•  Advanced Breast Cancer –  PARP inhibitors

•  EMBRACA, BRAVO

–  PARP monotherapy vs standard chemotherapy, phase 3

•  BROACDE

–  PARP+Carbo/Taxol vs Carbo/Taxol, phase 3

–  PM1183 (Lurbinectedin)

•  For BRCA1/2 + who have had prior PARP

–  Immunotherapy

•  Numerous trials ongoing as monotherapy and combinations

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Summary and Conclusions

•  We’ve covered a lot today… •  BRCA1/2 associated breast cancer has similar prognosis to non-

BRCA breast cancer, adjusting for subtype –  May even be better for TNBC due to chemo sensitivity

•  Platinum-based chemotherapy is clearly active in BRCA1/2 associated breast cancer

–  More active than taxanes in advanced disease –  Ongoing trials to assess early stage

•  PARP inhibitors are active in BRCA+ breast cancer –  OlympiAD Phase 3 registration study was positive, hopefully the FDA approval

is coming soon… Other trials ongoing

•  Immunotherapy is an exciting new approach for early and advanced breast cancer

–  Activity in BRCA mutation subgroups is under study

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Summary and Conclusions

•  Key areas of investigation for BRCA+ patients –  Does platinum increase cure rates for early stage disease?

–  How can platinum resistance be overcome?

–  Why are some BRCA positive cancers resistant to PARPi?

–  How does PARPi resistance develop during treatment? Reversion?

–  What novel agents might synergize with PARP inhibitors

–  Are BRCA positive tumors differentially sensitive to immunotherapy?

–  What are the next promising novel therapies beyond PARPi?

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•  On a personal note…Thank You for your attention and to Sue Friedman the FORCE for all of your important work

•  [email protected]

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