Breast cancer:

Clinical evidence

of new treatments

Aero™ academy ConferenceInnovation and Safety

•Patients Come FirstJanuary 26 & 27, 2018 Lisbon, Portugal

Disclosure & Disclaimer• An honorarium is provided by Accuray for this

presentation• IEO Accuray Grant• The views expressed in this presentation are those of the

presenters and do not necessarily reflect the views orpolicies of Accuray Incorporated or its subsidiaries. No official endorsement by Accuray Incorporated or any of itssubsidiaries of any vendor, products or services contained in this presentation is intended or should be inferred.

1. Hypofractionation

2. PMRT and RNI

3. Biology

Focus on:

1. Hypofractionation

‟ a parallel standard ”

Review and meta-analysis

Valle LF et al, Breast Cancer Res Treat 2017

• 13 randomized trials• 8189 patients, early stage• pT1‐pT2, pN0• Age > 50 years• No concomitant chemotherapy• No study designd for boost (0‐74%)• Hypofractionation versus standard• High homogeneity in dose distributionstrongly recommended (ASTRO± 7%)

Review and meta-analysisLocal Failure

Locoregional Failure

Breast Cancer Mortality

• No difference in:Local Failure,LocoRegional Failure,and Breast Cancer Specificity Mortality

Acute toxicity

Poor cosmesis

• Hypofractionation better in acute toxicity

• No difference in cosmetic outcomeValle LF et al,

Breast Cancer Res Treat 2017

The winner is:START B (Haviland et al. 2013)

10 y IBR 10 y OS Cosmesis

50 Gy in 25 fr(5 wks)2.0 Gy/fr

5.5% 89% 45.3%

40 Gy in 15 fr(3 wks)2.67 Gy/fr

4.3% 92% 37.9%

Equivalent local control Survival benefit Better cosmesis

Coles CE et al. Lancet 2017

UK IMPORT LOW Trial 2,018 patients, 2007-2010, randomised in 3 arms

1) Control WBI 40Gy

2) Reduced Dose WBI 36 Gy + 4 Gy PBI

3) PBI Only 40 Gy

• 1) IBTR Control 1.1% • 2) IBTR Reduced Dose 0.2%• 3) IBTR PBI only 0.5% • Equivalent or fewer adverse effects in 2)&3)

WBI: Whole Breast IrradiationPBI: Partial Breast IrradiationIBRT: Ipsilateral Breast Tumor Recurrence

HypofractionationOpen question

How can we integrate the boost?

LC better (HR 0.64, Qe low)

OS equal (HR 1.04, Qe moderate)

DFS equal (HR 0.94, Qe low)

Late toxicity equal (Qe very low)

Cosmesis by panel worse (Qe low)

Cosmesis by physicians equal (Qe low)

Subgroup > 40 y HR 0.65 = to ≤40 y

Boost: Cochrane Database, 2017

5 randomised controlled trials of 8325 patients

IMRT: Concomitant Boost & Hypo

Whole breast

2.67 Gy x 15

Boost area only

3.2 Gy x 15

HypofractionationOpen question

How can we integrate hypofractionaction and lymphatic irradiation?

Locoregional hypofractionated EBRT at IEO

3 WEEKS, 2.67 Gy/fractions

DBCCG (40 Gy/15 fx vs 50 Gy/25 fx)

2000 pts, pT1-3, pN0-3, BCS or PMRTendpoints: late effects and tumor control

Other similar trials in USA, France, and Egypt with 15/16 fx of 2.7 Gy each In 2 studies IMN irradiation is also

investigated Sub-study UK FAST-Forward (40 Gy/15 fx/

3 weeks versus 27 Gy/5fx/5days or 26 Gy/5fx/5days)

RNI & hypofractionation: ongoing trials

2. PMRT and RNI

‟ an emerging standard ”

PMRT: Post Mastectomy Radiation TherapyRNI: Regional Nodal Irradiation

Regional Node Irradiation

When?

• More than 4 +ve nodes

• From 1 to 3 +ve nodes

• Internal Mammary Chain

• SLN biopsy +

Well established indication

Emerging indication in HR group

Positive trials in HR group

???

0

x 10

00

10

20

30

40

50

2000 2007

60

2011

26.9% 28.7%40.5%

SEER data 2000-2011, Fraiser LL et al, JAMA Oncol 2016NCDB data 2003-2012, Ohri N et al, Cancer 2017

Poortmans PM et al, N Engl J Med 2015

EORTC phase III

trial 22922/10925

Overall Survival

Distant DiseaseFree Survival

4004 patients 1996 to 2004

No IM-MSIrradiation

R

IM-MS irradiation (50Gy)

5-year results WBI WBI + RNI P value

LR Control 94.5% 96.8% 0.020

DFS 84% 90% 0.003

Distant DFS* 87% 92.4% 0.002

OS 90.7% 92.3% 0.070

Lymphedema 4.1% 7.3% 0.004

>G2 toxicity 0.2% 1.3% 0.010

Whelan TJ et al, N EnglJ Med, 2015

NCIC-CTG - MA-20

Patient Eligibility: 1) 1-3 LN+ or >4+ LN+2) Lumpectomy3) > 10 nodes dissected 4) >1 of the following (with High Risk LN-) Grade 3 histology ER-negative disease LymphoVascular space Invasion (LVI)

Quality Assurance in pathologyCountry Reported Reviewed Reported Reviewed

G 3 (%) G 3 (%) LVI (%) LVI (%)

UK 54.6 42.4 41.2 15.1

Netherlands 52.0 39.6 28.4 19.5

China 26.8 45.0 31.7 28.6

Total 52.7 41.9 39.3 15.1

N negativeG3 Reported G3 Reviewed LVI Reported LVI Reviewed

87.4 64.2 38.2 9.9

Supremo/Big 2.04

Breast Cancer Res Treat 2017

PMRT/RNI versus no RT

The panel found insufficient evidence to endorse any specific model or to unambiguosly define specific patients subgroups to which PMRT

should not be administered The panel recommends treatment generally be administered to both the IMNs and the supraclavicular-axillary apical nodes in addition to the CW

or reconstructed breast when PMRT is used for patients with N+

Volume 34 –Number 36 – December 20, 2016Journal of Clinical Oncology – ASCO Special Article

Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update

Recht A, Comen EA, Fine RE, Fleming GF, Hardenbergh PH, Ho AY, Hudis CA, Hwang ES, Kirshner JJ, Morrow M, Salerno KE, Sledge GW Jr, Solin LJ, Spears PA, Whelan TJ, Somerfield MR, Edge SB.

Post-mastectomyRadiotherapy (PMRT)

*Consider omitting RT in women with pT1-pT2, pN1 (1-3), and favorable biological profile

**PMRT in patients with pT3 or 4 or more positive lymph nodes

Regional NodeIrradiation (RNI)

*Consider omitting RNI in N1 (1-3 positive lymph nodes) in the absence of adverse clinical factors

**RNI in N1 cancers and adverse clinical features (≤ 40 years, low or negative estrogen receptor ,

G3, extensive lympho-vascular invasion) or >3 positive nodes

Curigliano G et al, 28:1700-12, Ann Oncol 2017 *De-escalation; **Escalation

De-escalating and escalating treatments

St.Gallen International Expert Consensus Conference 2017

PMRT and RNIOpen question

Could RT substitute surgery in axillary treatment?

No RT

B/CW only

B/CW + SC + PAB

B/CW + SC

LymphedemaChronic pain, functional impairment, psychological distress, poor QoL

AMAROS (EORTC) trial1425 patients with N+, 744 ALND and 681 ART

Axillary relapse:- 0.54% (4 patients) in the surgery group- 1.03% (7 patients) in the RT group- No differences in OS and DFS

Donker M et al, Lancet Oncol 2014

At 5-years

Lymphedema: ART 13.6% vs ALND 28.0% (p<0.0001)

Arm circumference increase >10%: ART 5.9% vs ALDN 13.1% (p<0.0009)

OTOASOR trial2106 patients with N+, 1054 ALND and 1052 ART

Axillary relapse:

- 2.0% in the surgery group- 1.7% in the RT group- No differences in OS and DFS

Savolt A et al, Eur J Surg Oncol 2017

Any clinical sign of toxicity at 1-year:15.3% ALND

4.7% RNI

PMRT and RNIOpen question

Could avoid to increase toxicity?

0

x 10

00

10

20

30

40

50

2000

60

2011

14.8%

31.9%

SEER data 2000-2011, Fraiser LL et al, JAMA Oncol 2016

Implant Sparing Irradiation (ISI)

CTV “excluding implant”

Deep Inspiration Breath Hold (DIBH) Respiratory gating Prone position (large breast) Partial Breast RT Protontherapy

Goal: “Heart Dose Zero”

IMRT

3DCT For-IMRT Inv-IMRT HT VMAT

HeartDmaxDmean

46.044.39

45.224.38

37.908.36

27.214.13

36.609.24

Comparison of heart dose

Haciislamoglu E et al, Phys Med 2015, modified

LADDmaxDmean

45.0116.42

44.3816.22

39.4915.11

11.103.42

32.7717.99

Heart Ideal mean median range

3D-CRT Dmean < 5 Gy 4.57 4.70 2-11.3

Tomo Direct Dmean < 3,2 Gy 1.4 0.7 0.2 - 14

IEO data, 2016

3. Biology

‟ How can we move to it? ”

Braunstein LZ et al, Breast Cancer Res Treat 2017

BCS. LR and molecular subtype

Something new from biology? • Luminal A

High radiosensivityLow LRR rateLocal pattern of recurrenceTo discuss: omission of RT, dose de-escalation, PBI

• Non-Luminal AIntermediate/low/very low radiosensivityIntermediate/high/very high LRR rateLocal, regional and distant pattern of recurrenceTo discuss: dose escalation, regional node RT,

chemoradiation, new fractionationLeonardi MC ….Orecchia R et al, From technological advances to biological understanding: the main steps toward high-precision RT

in breast cancer. The Breast 2016Orecchia R, Tailoring radiotherapy according to cancer subtypes. The Breast 2017

Highlights•Adjuvant RT maximizes LR control, with positive impact on survival and quality of life•Hypofractionation is becoming a parallel standard•Regional node irradiation and PMRT are extending their indications •Optimization of high precision techniques will allow tomaximize effectiveness, and minimize toxicities•Better understanding of tumour biology, and translationin clinics, will allows to personalize treatment and realizea true adaptive RT to most patients

Thank you very much for your attention !!!!roberto.orecchia@ieo.it