Neoadjuvant endocrine therapy with sequential palbociclib and chemotherapy based on Ki67 status in stage II-III breast cancer: An open-label, phase II study

TL;DR

This study shows that combining endocrine therapy with palbociclib can effectively reduce tumor activity in most patients with certain breast cancers, avoiding chemotherapy for many.

Contribution

The study introduces a sequential treatment strategy using Ki67 response to guide adding palbociclib or chemotherapy in hormone receptor-positive breast cancer.

Findings

82% of patients achieved more than 50% Ki67 reduction after sequential endocrine therapy with or without palbociclib.

70% of patients achieved an objective pre-surgical response with the treatment strategy.

61% of patients completed neoadjuvant treatment without needing chemotherapy.

Abstract

While neoadjuvant endocrine therapy (NET), with or without a CDK4/6 inhibitor, is an established treatment option for estrogen receptor-positive breast cancers, optimal patient selection and second-line treatment for non-responders remain uncertain.

In the open-label, phase 2 PETREMAC trial (NCT02624973), pre- and postmenopausal patients with large T2 (>4 cm) or locally advanced ER/PGR>50 %, HER2-, and TP53 wild-type breast cancers received NET (tamoxifen + goserelin for premenopausal and letrozole for postmenopausal patients). Palbociclib was added if the Ki67 reduction was ≤50 % after 14 days. Neoadjuvant chemotherapy (NAC) was introduced if NET ± palbociclib failed to reduce Ki67 sufficiently or if there was no objective response on MRI after 24 weeks. Tumor biopsies underwent targeted sequencing of 360 cancer-related genes and subsequent gene expression profiling.

Among 88 patients, the median tumor size was 48 mm (range 16–140 mm). NET alone reduced Ki67 > 50 % in 49/88 (56 %) of evaluable tumors. Adding palbociclib yielded a Ki67 reduction >50 % in 24/34 (71 %) of tumors where neoadjuvant endocrine therapy alone failed to suppress Ki67, providing a Ki67 reduction of >50 % in a total of 72/88 (82 %) of patients. NAC was administered to 34/88 (39 %) due to inadequate Ki67 response or lack of MRI response. Overall, 70 % achieved a pre-surgical objective response. Pathological complete response was seen in 3/84 patients. Postmenopausal status (p = 0.005) and invasive lobular carcinoma (p = 0.02) predicted Ki67-based response to NET.

Sequential NET with palbociclib, limiting NAC to non-responders, is a feasible strategy for ER/PGR>50 %, HER2-, TP53 wild-type breast cancers.

•Sequential NET with response-guided escalation is feasible in ER+/HER2– BC.•82 % of the patients achieved >50 % Ki67 reduction after NET ± palbociclib.•70 % of patients achieved an objective pre-surgical response.•61 % of patients completed neoadjuvant treatment without need of chemotherapy.

Sequential NET with response-guided escalation is feasible in ER+/HER2– BC.

82 % of the patients achieved >50 % Ki67 reduction after NET ± palbociclib.

70 % of patients achieved an objective pre-surgical response.

61 % of patients completed neoadjuvant treatment without need of chemotherapy.

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