Join Dr. Erica Mayer, medical oncologist at Dana-Farber/Brigham and Women's Cancer Center, to learn about exciting metastatic breast cancer developments from the past year. Dr. Mayer presents an overview on metastatic breast cancer and the subgroups, including Hormone Receptive, HER2+, and Triple Negative, and highlights recent advances for each of these subgroups. She also discusses the importance of clinical trials and what it means to participate in a clinical trial. For more information on the Breast Cancer Treatment Center at Dana-Farber Cancer Institute, please visit: http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/Breast-Cancer-Treatment-Center.aspx

1. Progress Against Metastatic
Breast Cancer: 2012
Erica L. Mayer MD MPH
DFCI Susan F. Smith Center for Women’s Cancers
October 2012

2. We are Making Progress Against
Metastatic Breast Cancer!
• 2 new chemotherapies for breast cancer recently
approved
• 2-3 new biologics for breast cancer approved in 2012
• Greater understanding of the categories of breast
cancer, with identification of new targets
• MULTIPLE trials ongoing for every subtype of breast
cancer
These advances will translate into real
improvements for patients today and in the
future fighting metastatic disease!

3. Clinical Breast Cancer Subsets
Hormone Receptor +
65%-75%
All Breast Cancers
HER2+
15%-20%
Triple
negative
15%
Burstein, Goldhirsch. St Gallen 2007.
3

4. Available Endocrine Medications for ER+
Breast Cancer
Trade Name Generic Name Pre-or Post Form
Novaldex tamoxifen either pill
Arimidex anastrozole post pill
Femara letrozole post pill
Aromasin exemestane post pill
Faslodex fulvestrant post injection
Lupron leuprolide pre injection
Zoladex goserelin pre injection
Megace megestrol acetate post pill

5. A Model of Endocrine Resistance
Estrogen
Receptor
Cell Nucleus

6. A Model of Endocrine Resistance
Estrogen
Receptor
Endocrine
agents
Cell Nucleus

7. A Model of Endocrine Resistance
Estrogen Growth Factor
Receptor Receptor
PI3K
AKT
Endocrine
agents mTOR
Cell Nucleus

8. A Model of Endocrine Resistance
Estrogen Growth Factor
Receptor Receptor
PI3K
AKT Targeted
Inhibitors
Endocrine
agents mTOR
Cell Nucleus

9. A Model of Endocrine Resistance
Estrogen Growth Factor
Receptor Receptor
PI3K
AKT Targeted
Inhibitors
Endocrine
agents mTOR
Cell Nucleus
Resistance to endocrine therapy may be inhibited by
targeting ER and growth factor pathways

10. Everolimus (Affinitor)
• Oral inhibitor of mTOR,
taken daily
• Approved in 2009 for
advanced kidney cancer,
pancreatic cancer
• Side effects include: rash,
diarrhea, mouth sores

11. BOLERO-2: A Trial of Everolimus in
HR+ Breast Cancer
Everolimus 10 mg/day +
724 women with 2 Exemestane 25 mg/day
ER+ HER2- (N = 485)
1 Survival and
metastatic breast
Safety
cancer, with
Placebo + Endpoints
exposure to prior
Exemestane 25 mg/day
AI (N = 239)
Baselga et al, NEJM 2012

12. BOLERO-2: A Trial of Everolimus in
HR+ Breast Cancer
Everolimus 10 mg/day +
724 women with 2 Exemestane 25 mg/day
ER+ HER2- (N = 485)
metastatic breast 1 Survival and
cancer, with Safety
Placebo + Endpoints
exposure to prior
Exemestane 25 mg/day
AI (N = 239)
• Results:
– Improvement in cancer control with combination
– Some increased toxicity
– Preserved quality of life
Baselga et al, NEJM 2012

13. BOLERO-2: A Trial of Everolimus in
HR+ Breast Cancer
Everolimus 10 mg/day +
724 women with 2 Exemestane 25 mg/day
ER+ HER2- (N = 485) Survival and
metastatic breast 1
Safety
cancer, with Endpoints
Placebo +
exposure to prior
Exemestane 25 mg/day
AI (N = 239)
• Results:
– Significant improvement in time on therapy vs AI alone
– Some increased toxicity with combination vs AI alone
– No reported decrease in quality of life
Baselga et al, NEJM 2012

14. Future for Targeted Inhibitors in HR+
Breast Cancer
• Many inhibitors in development targeting
mTOR, PI3K, AKT
• Multiple ongoing trials of new inhibitors
– With endocrine medicines
– With chemotherapy
– With other biologics
• Inhibitors may work even better in tumors with alterations
in PI3K; tumor testing ongoing at DFCI to identify best
candidates for trials

15. HER2-Positive Breast Cancer
Protein
Receptor
HER2
Gene
Normal Cell
HER2+ Cell

16. HER2-Positive Breast Cancer
Protein
Receptor
HER2
Gene
Normal Cell
HER2+ Cell

17. HER2-Positive Breast Cancer
HERCEPTIN
Protein
Receptor
HER2
Gene LAPATINIB
Normal Cell
HER2+ Cell

18. Timeline
1985
HER2 amplification 2001 2005
described in breast 1st trials of Demonstration that Herceptin
cancer lapatinib begun reduces the risk of recurrence
in HER2+ early-stage patients
1998 2007
Herceptin approved by FDA Lapatinib approved by FDA
for treatment of metastatic for treatment of metastatic
HER2+ breast cancer HER2+ breast cancer
1992
following Herceptin
Herceptin developed
1984
HER2 gene
identified

19. Pertuzumab
• Inhibitors HER receptor
interactions
• Prevents activation of
cell growth
• Synergistic with
Herceptin

20. CLEOPATRA: Adding Pertuzumab for
First Line Therapy HER2+ Breast Cancer
Taxotere + herceptin +
HER2+ metastatic placebo
breast cancer, no
prior therapy
Taxotere + herceptin+
N = 808
pertuzumab

21. CLEOPATRA: Adding Pertuzumab for
First Line Therapy HER2+ Breast Cancer
Taxotere + herceptin +
HER2+ metastatic placebo
breast cancer, no
prior therapy
Taxotere + herceptin+
N = 808
pertuzumab
• Results:
– Significant improvements in survival
– No additional toxicity

22. What is TDM-1?
• Antibody-drug Conjugate

23. T-DM1: Mechanism of Action
HER2
T-DM1
Emtansine
release
P
Inhibition of P
microtubule P
polymerization
Lysosome
Internalization
Nucleus
23
Adapted from LoRusso PM, et al. Clin Cancer Res 2011.

24. 2012 Was a Big Year for TDM1!
• 2012: presentation of data from a large trial
comparing TDM1 vs oral regimen of
capecitabine + lapatinib
– Patients who received TDM1 did much better
– TDM1 had remarkably less toxicity (no rash or
diarrhea)
• FDA approval TDM1 expected early 2013
• Multiple other trials of TDM1 ongoing

25. TDM1 at DFCI
• We have had 9 clinical trials offering TDM1 to DFCI patients
– 06-046 - TRASTUZUMAB-MCC-DM1 FOR HER2+ MET BREAST
– 08-058 - TRASTUZUMAB-MCC-DM1 FOR MET HER2+ BREAST
– 08-194 - TRASTUZUMAB-MCC-DM1 FOR HER2+ BREAST
– 09-096 - TRASTUZUMAB-MCC-DM1 EXTENSION STUDY
– 09-130 - T-DM1/PACLITAXEL/PERTUZUMAB FOR HER2+ BREAST
– 09-148 - TRASTUZUMAB-MCC-DM1/GDC-0941 FOR HER2+ BREAST
– 10-305 - T-DM1 W/CT FOR HER2+ BREAST
– 10-442 - EMILIA: T-DM1 VS CAPECITABINE/LAPATINIB FOR BREAST
– 11-309 - THERESA: T-DM1 VS. SOC FOR HER2+ BREAST CANCER
• 109 DFCI patients so far have participated in clinical trials of
TDM1, and have played an important role in development of this
medication

26. Timeline
1985
HER2 amplification 2001 2005 2012:
described in breast 1st trials of Demonstration that Herceptin Pertuzumab
cancer lapatinib begun reduces the risk of recurrence first-line
in HER2+ early-stage patients metastatic
1998 2007 2013:
Herceptin approved by FDA Lapatinib approved by FDA TDM-1 for
for treatment of metastatic for treatment of metastatic metastatic
HER2+ breast cancer HER2+ breast cancer disease
1992
following Herceptin
Herceptin developed
1984
HER2 gene
identified

27. Timeline
1985
HER2 amplification 2001 2005 2012:
described in breast 1st trials of Demonstration that Herceptin Pertuzumab
cancer lapatinib begun reduces the risk of recurrence first-line
in HER2+ early-stage patients metastatic
1998 2007 2013
Herceptin approved by FDA Lapatinib approved by FDA TDM-1 for
for treatment of metastatic for treatment of metastatic metastatic
HER2+ breast cancer HER2+ breast cancer disease
1992
following Herceptin
Herceptin developed
1984
HER2 gene
identified
Many exciting agents in trials!!

28. “Triple Negative” Breast Cancer (TNBC)
• Defined as negative for estrogen, progesterone, and
HER2 receptors
• Represents about 15% of all breast cancer
• Although endocrine and HER2 directed therapies not
used, chemotherapy works the best against TNBC
• Large number of targeted agents in trials

29. Whats New in TNBC? Heterogeneity
• Gene profile
analysis from
over 500 TNBC
tumor samples
• 6 TNBC
subgroups were
identified with
unique profiles
Lehmann et al, JCI 2011

30. Heterogeneity of TNBC
TNBC

31. Heterogeneity of TNBC
EGFR
PARP
VEGF
AR
BRCA1- Src

32. Heterogeneity of TNBC
EGFR
PARP
VEGF
AR
BRCA1- Src
• “A disease defined by negatives is not one disease!”
– Andrew Tutt, MD

33. Many Agents Under Evaluation for TNBC in
Clinical Trials!
Targeted Agent Target
PARP inhibitors DNA repair pathways
Tivozanib VEGFR, angiogenesis
dasatinib Src
CDK inhibitors Cell cycle control
MetMab, ARQ197 Met
Tigatuzumab Death receptor
PI3K inhibitors PI3K
mTOR inhibitors mTOR
FGF inhibitors FGF
Ruxolitinib JAK-1
Bicalutamide AR, androgen receptor

34. TNBC: Conclusions
• Chemotherapy works and has gotten better
• No single best target has been identified; novel
biologic agents may have activity for some
subgroups
• TNBC is an area of very active research; in the past
2 months, 4 new trials opened at DFCI
• Speak to you provider about entering a trial!

35. How Can We Do Better?
Participate in Trials!
• Clinical trials exist for patients at any step of their breast
cancer journey; trials are a part of the continuum of care
• There are benefits to being on a trial!
– a larger treatment team
– possible exposure to cutting edge new medications
– helping other patients with breast cancer
• None of the advances in breast cancer could have happened
without patients volunteering to be in trials

36. What are clinical trial phases?
Clinical trials are conducted in a series of steps (phases) - each phase is designed to
answer a separate research question.
• Phase I: Testing a new treatment in a small group of people to evaluate safety, dose, and side
effects.
• Phase II: Evaluating within a larger group the efficacy and safety of a new treatment
• Phase III: A comparison study in a large group to determine if a new treatment works better
than standard therapy. These trials typically involve randomization and may have a placebo; the
data from a phase 3 trial can be used for FDA drug approval.
nlm.nih.gov/services/ctphases.html

37. How to learn about trials?
Or ask your provider…

38. How Do I Enter a Trial?
• Your provider will discuss with you trials of
interest, review rationale, as well as risks and benefits
• A research RN will review a consent form with
you, which describes the structure and details of the trial
• After a consent is signed, there is a “screening” period to
determine if you are eligible
• When eligibility is confirmed, then you register and can
begin trial therapy

39. FAQs
• If I consent to a trial, do I have to stay on it?
– You can leave a trial at any time if either you or your provider thinks being on
the trial is no longer in your best interest
• Will I have to pay more to be on a trial?
– All normal procedures are billed to insurance; anything beyond normal care
is paid for by the trial. There should be no “upcharge” for being in a trial
• Is being on a trial busy?
– Each trial is different and has a different schedule
• Will I know what medicine I am getting? I don’t want a placebo.
– In most trials, both patient and provider know exactly what treatment is being
given.
– Some larger trials use randomization and placebos, and in some cases
neither patient nor provider know identity of study drug.
– But in almost every trial with placebo, at minimum a patient receives best
standard of care.

40. How Can We Do Better?
“Tissue is the Issue”
• Sources of breast cancer tissue
– Blood samples: Circulating tumor cells
– Archived samples from initial diagnosis
– Biopsies while receiving treatment before surgery
– Biopsies of breast cancer after relapse
• 5 ongoing DFCI breast cancer studies collect and bank
tissue for ongoing and future analyses
• Many recent advances have been developed from tissue
samples; please consider contributing if a biopsy is
needed

41. Conclusions
• 2012 has brought great new advances in the
treatment of metastatic breast cancer
• Many exciting new drugs in the pipeline
• Involvement in clinical trials is encouraged; speak to
your provider about how you can get involved
• Future progress depends on.....Making every
woman count!