T-DXd Yields Responses in HER2+ Breast Cancer with Brain Metastases

Central nervous system progression-free survival appears to be longer with trastuzumab deruxtecan than with comparator treatment in those with HER2-positive metastatic breast cancer and brain metastases.

Treatment with fam-trastuzumab deruxtecan-nxki (T-DXd; Enhertu) produced improvements in intracranial responses vs comparator therapies in patients with HER2-positive metastatic breast cancer with both stable and active brain metastases, according to findings from a retrospective pooled analysis of the DESTINY-Breast trials presented at the 2023 European Society for Medical Oncology Congress (ESMO).

The pooled analysis included data from the phase 2 DESTINY-Breast01 trial (NCT03248492), the phase 3 DESTINY-Breast02 trial (NCT03523585), and the phase 3 DESTINY-Breast03 trial (NCT03529110).

Among a pooled population of patients with brain metastases treated with T-DXd, the intracranial objective response rate (ORR) was 45.2% in those with treated/stable brain metastases and 45.5% in those with untreated/active brain metastases. The median intracranial duration of response (DOR) in each respective group was 12.3 months (95% CI, 9.1-17.9) and 17.5 months (95% CI, 13.6-31.6).

In the comparator treatment brain metastasis population, the intracranial ORR was 27.6% in patients with treated brain metastases and 12.0% in those with untreated brain metastases. Additionally, the intracranial DOR was 11.0 months (95% CI, 5.6-16.0) in patients with treated brain metastases. The DOR data for the untreated brain metastases population were not available.

“Shrinkage of brain metastases in response to T-DXd seemed to be more prominent, whereas, in the comparator pool, brain metastases showed less of a response,” said Sara A. Hurvitz, MD, FACP, senior vice president of the Clinical Research Division at Fred Hutch Cancer Center and head of the Division of Hematology and Oncology at the University of Washington Department of Medicine.

The median central nervous system (CNS) progression-free survival (CNS-PFS) was 12.3 months (95% CI, 11.1-13.8) vs 8.7 months (95% CI, 6.3-11.8) with T-DXd and comparator therapy, respectively, in patients with stable brain metastases (HR, 0.5905; 95% CI, 0.3921-0.8895). Among those with active brain metastases, the median CNS-PFS in each treatment population was 18.5 months (95% CI, 13.6-23.3) vs 4.0 months (95% CI, 2.7-5.7), respectively (HR, 0.1919; 95% CI, 0.1060-0.3473).

Investigators of this exploratory pooled analysis aimed to describe the population of patients enrolled on the DESTINY-Breast trials with brain metastases at baseline and to assess the pooled efficacy and safety of T-DXd vs comparator treatment.

In the DESTINY-Breast01 trial, 253 eligible patients previously treated with trastuzumab emtansine (T-DM1; Kadcyla) were assigned to receive T-DXd, 184 of whom received treatment. Additionally, 608 patients in the DESTINY-Breast02 trial were randomly assigned 2:1 to receive T-DXd (n = 406) or trastuzumab (Herceptin) or lapatinib in combination with capecitabine (n = 202). Those enrolled on the DESTINY-Breast03 trial (n = 524) were randomly assigned 1:1 to receive T-DXd (n = 261) or T-DM1 (n = 263).

Overall, the pooled population included 851 patients treated with T-DXd, 148 of whom had brain metastases. The comparator pool consisted of 465 patients, which included 83 with brain metastases.

The end points of the pooled analysis included intracranial ORR per blinded independent central review (BICR) based on RECIST v1.1 criteria, intracranial DOR, CNS-PFS, and safety.

Patients with asymptomatic and stable brain metastases who received prior local treatment were eligible for enrollment on the DESTINY-Breast01 trial. Following protocol amendments, patients with treated, asymptomatic brain metastases could enroll on the DESTINY-Breast02 and DESTINY-Breast03 trials.

Across the pooled T-DXd and comparator populations with and without brain metastases, anywhere from 49.4% to 68.1% of patients had recurrent breast cancer. Additionally, anywhere from 70.9% to 96.6% of patients in each group had visceral disease.

“Overall, patients with brain metastases were heavily pretreated with a median of 3 prior systemic therapies in the metastatic setting,” Hurvitz said.

Most patients had extracranial sites of first disease progression by BICR, which ranged from 31.8% to 62.0% across the T-DXd and comparator pools. According to Hurvitz, rates of any progressive disease were similar in both brain metastasis pool populations.

Any drug-related treatment-emergent adverse effect (TEAE) affected anywhere from 88.5% to 98.9% of the brain metastasis pool populations. Additionally, the incidence of grade 3 or higher TEAEs was comparable across all patient subgroups, and the frequency of TEAEs leading to treatment discontinuation or dose reductions was consistent in patients regardless of whether they had brain metastases.

“The safety profile of T-DXd in patients with brain metastases was acceptable, generally manageable, and similar to the safety profile in the overall population. Thus, T-DXd is an effective treatment option for patients with HER2-positive metastatic breast cancer with brain metastases,” Hurvitz concluded.

Reference

Hurvitz SA, Modi S, Li W, et al. A pooled analysis of trastuzumab deruxtecan (T-DXd) in patients (pts) with HER2-positive (HER2+) metastatic breast cancer (mBC) with brain metastases (BMs) from DESTINY-Breast (DB) -01, -02, and -03. Presented at the 2023 European Society for Medical Oncology Congress (ESMO); October 20-24, 2023; Madrid, Spain; Abstract 3770.