TNBC is a heterogeneous disease with distinct pathological, genetic, and clinical features among subtypes. Treatment results for high-risk primary TNBC remain poor compared to other breast cancer subtypes. Preoperative chemotherapy is the standard of care for patients with stage II or III primary TNBC. Multiple lines of clinical evidence demonstrate that TNBC patients who achieve a pCR to NACT, (ypT0/is ypN0), have an excellent long-term prognosis. A meta-analysis of individual patient data confirmed a strong association of pCR after NACT with improved long-term event-free survival (EFS, hazard ratio \[HR\] 0.24) and overall survival (OS, HR 0.16) benefit. Taxane- and anthracycline-based neoadjuvant regimens generally result in pCR rates between 25-50% \[REFs\], whereas the addition of platinum increases pCR rates to approximately 50-55%. The KEYNOTE-522 trial has demonstrated that the addition of the immune-checkpoint inhibitor PEM to anthracycline- (AC), taxane- and platinum-based NACT resulted in a significant increase in pCR rates to nearly 65%, associated with a significant reduction of recurrences (EFS, HR 0.65 at 5 years) and improvement of OS (HR 0.66). Based on these results, the KEYNOTE-522 regimen has been approved by the FDA and EMA and has become the standard of care for patients with stage II or III TNBC. Despite this significant progress, two major questions remain unresolved which will be investigated in the ADAPT-TN-IV trial: 1. Do all patients require the full 6 months of NACT as per KEYNOTE-522 or is there a subgroup of patients who are sufficiently treated with 12 weeks of NACT plus PEM? 2. Can incorporation of ADCs into the KEYNOTE-522 regimen improve response and outcomes in patients without an optimal early response? The outcome of patients with residual disease after 24 weeks of NACT and PEM remains suboptimal and there is an urgent need for more effective strategies. ADCs such as SG have demonstrated superior efficacy compared to standard chemotherapy in metastatic TNBC, resulting in substantially higher response rates and improved progression-free (PFS) and OS. Combination studies of ADCs and immunotherapy in metastatic TNBC have demonstrated significant activity, suggesting possible synergistic activity It is therefore a logical next step to investigate, whether the incorporation of SG in the NACT regimen can improve pCR rates and EFS results in patients who have residual clinical disease after 12 weeks of NACT with CARBO/PAC + PEM.
The trial will have two cohorts. COHORT I - SoC DE-ESCALATION Cohort I will include patients with clinical stage II TNBC who have achieved a cCR to 12 weeks of NACT with CARBO/ PAC, and PEM. The trial will evaluate whether these patients can be safely spared from further chemotherapy (CTx) and directly proceed to surgery. If it is unclear whether patients have a cCR, a tumour biopsy (by ultrasound or mammography/MRI-guided) is required to confirm that there is no evidence of residual invasive disease. After surgery, patients with a pCR (ypT0/is, ypN0) will not receive further chemotherapy, but continue otherwise on SoC treatment. Patients with residual disease should be considered for postoperative SoC treatment, which might include further CTx (e.g., AC or AC x4) plus PEM or OLA (in patients with gBRCA mutations). COHORT II - ADC-INTENSIFICATION (STUDY TREATMENT) vs. SoC Cohort II will include all clinical stage III-patients and stage II patients without a cCR after 12 weeks of NACT with CARBO/ PAC and PEM. If it is unclear whether patients have a cCR, a tumour biopsy (by ultrasound or mammography/MRI-guided) is required to confirm that there is no evidence of residual invasive disease. These patients will be randomized 1:1 to further neoadjuvant treatment in either * Arm 1: neoadjuvant SG+PEM, followed by surgery and pCR-dependent post-neoadjuvant SoC treatment or * Arm 2: SoC CTx+SoC, followed by surgery and pCR-dependent post-neoadjuvant SoC treatment
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
765
SG is administered at 10 mg/kg as an intravenous (i.v.) infusion on Days 1 and 8 of a 21-day cycle. The dose of SG will be calculated based on actual weight at randomization (using weight obtained either at enrolment or on Cycle 1 Day 1) and remains constant throughout the study, unless there is a \> 10% change in body weight from baseline. Modifications to the study drug doses administered should be made for a \> 10% change in body weight from baseline and according to local and regional prescribing standards. Dose modifications for changes in body weight \< 10% may be made according to local institutional guidelines. SG is administered via i.v. infusion as described below with additional information available in the current version of the SmPC.
Pembrolizumab 200 mg will be administered as a 30-minute i.v. infusion every 3 weeks.
Standard of care chemotherapy as per common treatment guidelines and recommendations
SLK-Kliniken Heilbronn GmbH, Klinik für Gynäkologie und Geburtshilfe
Heilbronn, Baden-Wurttemberg, Germany
GRN Gesundheitszentren Rhein-Neckar gGmbH, Brustzentrum Weinheim
Weinheim, Baden-Wurttemberg, Germany
Universitaetsklinikum Augsburg, Klinik für Frauenheilkunde und Geburtsmedizin
Augsburg, Bavaria, Germany
Klinikum der Universitaet Muenchen AöR, Frauenheilkunde und Geburtshilfe
München, Bavaria, Germany
Klinikum der Technischen Universitaet Muenchen (TUM Klinikum), Brustzentrum
München, Bavaria, Germany
Cohort I: 3-year event-free survival (EFS)
EFS after 36 months defined as time from registration to any invasive breast cancer event, death, or secondary malignancy (same definition as iDFS) according to STEEP 2.0 criteria \[103\]
Time frame: EFS 3 years
Cohort II: superiority of neoadjuvant treatment with SG+PEM vs. SoC with regards to event-free survival (EFS)
EFS after 36 months defined as time from registration to any invasive breast cancer event, death, or secondary malignancy or local progress precluding surgery in neoadjuvant treated patients
Time frame: EFS 3 years
Cohort II: superiority of neoadjuvant treatment with SG+PEM vs. SoC with regards to pathological complete response (pCR) rates
pCR defined as no invasive disease in breast and lymph nodes (ypT0/is, ypN0) in patients of both arms
Time frame: EFS 3 years
clinical response after 12 weeks of neoadjuvant chemotherapy treatment (NACT)
Clinical response measured by tumour size in mm by palpation, ultrasound, mammography, or MRI
Time frame: 12 weeks NACT
distant disease-free survival (dDFS)
distant disease-free survival (dDFS)
Time frame: 3 years
relapse-free survival (RFS)
relapse-free survival (RFS)
Time frame: 3 years
locoregional relapse-free survival (LRFS)
locoregional relapse-free survival (LRFS)
Time frame: 3 years
overall survival (OS)
OS defined as time from first diagnosis to death
Time frame: 3 years
Health-related quality of life (HRQoL) via questionnaires EORTC-QLQ-C30, version 3.0,
Change of Health-related quality of life (HRQoL)between baseline, after completion of SoC neoadjuvant treatment, and on following defined timepoints:
Time frame: Cohort I: end of the neoadjuvant treatment, at clinical response assessment, at surgery, at start of post-neoadjuvant treatment, at cycle 3, at cycle 5, at end of post-neoadjuvant treatment, 3-monthly during follow-up
Health-related quality of life (HRQoL)via questionnaires EORTC QLQ-BR42
Change of Health-related quality of life (HRQoL)between baseline, after completion of SoC neoadjuvant treatment, and on following defined timepoints:
Time frame: Cohort I: end of the neoadjuvant treatment, at clinical response assessment, at surgery, at start of post-neoadjuvant treatment, at cycle 3, at cycle 5, at end of post-neoadjuvant treatment, 3-monthly during follow-up
Health-related quality of life (HRQoL)via CANKADO active
Change of Health-related quality of life (HRQoL)between baseline, after completion of SoC neoadjuvant treatment, and on following defined timepoints:
Time frame: Cohort I: end of the neoadjuvant treatment, at clinical response assessment, at surgery, at start of post-neoadjuvant treatment, at cycle 3, at cycle 5, at end of post-neoadjuvant treatment, 3-monthly during follow-up
Health-related quality of life (HRQoL)via questionnaires EORTC-QLQ-C30, version 3.0,
Change of Health-related quality of life (HRQoL)between baseline, after completion of SoC neoadjuvant treatment, and on following defined timepoints:
Time frame: Cohort II: end of the neoadjuvant treatment, at clinical response assessment, at cycle 3 of prolonged neoadjuvant treatment, at surgery, at start of post-neoadjuvant treatment, 3-monthly during follow-up
HRQoL via questionnaires EORTC QLQ-BR42
Change of HRQoL between baseline, after completion of SoC neoadjuvant treatment, and on following defined timepoints:
Time frame: Cohort II: end of the neoadjuvant treatment, at clinical response assessment, at cycle 3 of prolonged neoadjuvant treatment, at surgery, at start of post-neoadjuvant treatment, 3-monthly during follow-up
HRQoL via CANKADO active
Change of HRQoL between baseline, after completion of SoC neoadjuvant treatment, and on following defined timepoints:
Time frame: Cohort II: end of the neoadjuvant treatment, at clinical response assessment, at cycle 3 of prolonged neoadjuvant treatment, at surgery, at start of post-neoadjuvant treatment, 3-monthly during follow-up
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Caritas-Krankenhaus St. Josef, Frauenheilkunde und Geburtshilfe
Regensburg, Bavaria, Germany
Haematologisch Onkologische Schwerpunktpraxis
Würzburg, Bavaria, Germany
Medical University Of Lausitz Carl Thiem, Frauenklinik
Cottbus, Brandenburg, Germany
Gesundheitszentrum Wetterau gGmbH, Gynäkologische Ambulanz
Bad Nauheim, Hesse, Germany
Klinikum Kassel GmbH, Klinik für Frauenheilkunde und Geburtshilfe
Kassel, Hesse, Germany
...and 16 more locations