To Reduce the Use of Chemotherapy in Postmenopausal Patients With ER-positive and HER2-positive Breast Cancer (TOUCH)

TOUCH is an open label, international, phase II neoadjuvant trial which will assess the treatment of elderly patients with hormone receptor positive / human epidermal growth factor receptor-2 (HER2) positive early breast cancer with neoadjuvant palbociclib in combination with hormonal therapy and HER2 blockade, versus the treatment with paclitaxel in combination with HER2 blockade.

The neo-adjuvant setting was chosen to evaluate these therapy combinations in a short time-frame and to provide access to biomaterial both at baseline and after the end of the treatment, at surgery. Biopsy specimens will be analyzed at the end of the trial by gene-expression profiling to assess RBsig status. This marker may represent a tool to identify the participants who are more likely to benefit from a chemotherapy-free regimen in this population.

Palbociclib is a potent, highly selective, reversible, orally active, inhibitor of cyclin-dependent kinases 4 and 6 (CDK 4/6), therefore inhibiting cell growth and can be safely and effectively administered to older patients without need for dose adjustment based solely on age. Treatment de-escalation, namely harnessing and taking maximum advantage of targeted therapies vs conventional treatment (chemotherapy) in order to limit side effects, is particularly appealing in the older population.

Clinical data from the HR positive /HER2 negative setting show that combinations of palbociclib and letrozole are safe and effective. These combinations have not yet been tested in the HR positive /HER2 positive population that the investigators include in this trial. However, combinations of trastuzumab and endocrine treatment (ET), including letrozole have shown to be safe and to have some additional activity compared to ET alone in the HR positive /HER2 positive population. Therefore, the role of palbociclib in addition to letrozole and trastuzumab plus pertuzumab needs to be further studied.

Current standard of care for treatment of HER2 positive BC incorporates chemotherapy and anti-HER2 agents, with chemotherapy regimens of sequential anthracyclines and taxanes, used as single agents or in combination with other chemotherapy drugs. Trastuzumab is often administered concurrently with a single agent taxane to avoid the possible additive cardiac toxicity of combinations of anthracycline containing regimens and trastuzumab.

A regimen of weekly paclitaxel and trastuzumab plus pertuzumab was chosen as the comparator arm in this trial. More aggressive chemotherapy may not be justified in this population and trial participants may receive additional treatment after surgery, at the discretion of the treating doctor.

Preclinical and clinical rationale exists to support the proposal that palbociclib may represent a valuable option for increasing the activity of ET and anti-HER2 agents, such that a triple combination with these agents could prove superior to a standard treatment with chemotherapy and anti-HER2 agents.

The investigators hypothesize that the combination of palbociclib, letrozole and trastuzumab plus pertuzumab proposed in this trial will be more efficacious compared to the combinations of anti-HER2 agents and ET reported in other trials.

In 2019, it is estimated that of 260,600 newly diagnosed cases of invasive breast cancer in the United States, 82% occurred in women aged 50 or over. Furthermore, of the 41,760 breast cancer-related deaths in the same year, 90% occurred in this predominantly post-menopausal age group. Around 40% of BCs occur in women aged 65 and older. Of these, 10-15% have tumors that overexpress HER2. Elderly patients are generally underrepresented in clinical trials and may benefit from anti-HER2 agents as much as the younger population. Post-menopausal patients with HR positive /HER2 positive BC represent a unique group of patients with an unmet clinical need. This population is the focus of the TOUCH trial.

• Paclitaxel (Drug), also known as Paclitaxel Sandoz: Chemotherapy plus HER2 Blockade
• Trastuzumab (Drug), also known as Herceptin: Chemotherapy plus HER2 Blockade
• Pertuzumab (Drug), also known as Perjeta: Chemotherapy plus HER2 Blockade
• Palbociclib (Drug), also known as Ibrance: CDK Inhibition plus Hormonal Therapy plus HER2 Blockade
• Letrozole (Drug), also known as Femara: CDK Inhibition plus Hormonal Therapy plus HER2 Blockade
• Trastuzumab (Drug), also known as Herceptin: CDK Inhibition plus Hormonal Therapy plus HER2 Blockade
• Pertuzumab (Drug), also known as Perjeta: CDK Inhibition plus Hormonal Therapy plus HER2 Blockade

Primary outcomes

• Pathological Complete Response (pCR) [Assessed within 30 days of the time of breast surgery after completion of a treatment period of up to 16 weeks; up to 21 weeks. If the patient does not undergo surgery, assessment will occur within 30 days after all treatment is stopped; up to 30 weeks.]: Pathological complete response (pCR) is defined as absence of invasive tumour cells in the breast and in the axillary lymph nodes at the time of surgery (ypT0/ypTis ypN0) determined from the local histopathologic evaluation according to the American Joint Committee on Cancer Staging Manual. The presence of in situ cancer after trial treatment in the absence of residual invasive disease constitutes a pCR.

Secondary outcomes

• Pathological Complete Response (pCR) in the Breast [Assessed within 30 days of the time of breast surgery after completion of a treatment period of up to 16 weeks; up to 21 weeks. If the patient does not undergo surgery, assessment will occur within 30 days after all treatment is stopped; up to 30 weeks.]: Defined as the absence of invasive tumour cells in the breast at the time of surgery (ypT0/ypTis) determined from the local histopathologic evaluation according to the American Joint Committee on Cancer Staging Manual..
• Objective Response [Tumor assessments were performed by ultrasound and mammography at screening (prior to treatment start), and before surgery; measurements by caliper were assessed at the same time points and at the end of cycle 2 (28 days/cycle), approximately 56 days.]: The number of patients with partial or complete response measured physically by caliper and by ultrasound and mammography. Response was assessed using World Health Organization tumor measurement and response criteria. Complete response (CR) - The disappearance of all known disease. Partial response (PR) - A 50% or more decrease in total tumor size, i.e., the sum of the products of the maximal diameter (MD) and the corresponding largest perpendicular diameter (LPD) of the lesions which have been measured to determine the effect of therapy. In addition, there can be no appearance of new lesions or progression of any lesion. Stable disease (SD) - Neither a 50% decrease in total tumor size, nor a 25% increase in the size of one or more measurable lesions has been determined. Progressive disease (PD) - An increase of least 25% in total tumor size relative to the smallest size measured during the trial.
• Rate of Breast Conserving Surgery (BCS) [From randomization until completion of study, up to 20 months]: Defined as the number of patients undergoing BCS, divided by the number of patients in the assessable population (subset of the randomized population with RBsig status successfully determined who received at least 1 dose of medication).

Sex: Female, ages: 18 Years to any

Inclusion Criteria:

1. Histologically confirmed invasive breast cancer, with the following characteristics:

   * Early breast cancer with tumor size >1 cm (as measured by at least one of the required examination methods of clinical examination, mammography and ultrasonography);
   * No clinical evidence of regional lymph node metastasis (via physical and/or radiological exam) (cN0) OR
   * Clinical evidence of cN1 status, defined by nodal involvement limited to clinically or radiologically detectable metastasis to movable ipsilateral level I, II axillary lymph node(s)
   * No evidence of metastasis (M0).
2. Postmenopausal, defined by women with:

   * Prior bilateral surgical oophorectomy; OR
   * Amenorrhea and age ≥60 years; OR
   * Age <60 years and amenorrhea for 12 or more consecutive months in the absence of alternative pathological or physiological cause (including chemotherapy, tamoxifen, toremifene, ovarian suppression, or hormonally-based contraception) plus FSH and serum estradiol levels within the laboratory's reference ranges for postmenopausal women
3. Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1
4. Primary tumor must have positive estrogen receptor (ER) ≥10%
5. Primary tumor must be HER2-positive (by IHC and/or ISH)
6. Baseline LVEF ≥55% measured by Echocardiography (preferred) or MUGA scan
7. Normal hematologic status:

   * Absolute neutrophil count ≥1500/mm3 (1.5 × 109/L);
   * Platelets ≥100 × 109/L;
   * Hemoglobin ≥9 g/dL (≥90 g/L).
8. Normal renal function: serum creatinine ≤1.5 ULN
9. Normal liver function:

   * Serum total bilirubin ≤1.5 × upper limit of normal (ULN). In the case of known Gilbert's syndrome, a higher serum total bilirubin (<2 × ULN) is allowed;
   * AST or ALT ≤2.5 × ULN;
   * Alkaline phosphatase ≤2.5 × ULN.
10. Written Informed Consent (IC) must be signed and dated by the patient and the Investigator prior to randomization.
11. The patient has been informed of and agrees to data transfer and handling, in accordance with national data protection guidelines.
12. The patient agrees in writing to make tumor (mandatory diagnostic core biopsy and surgical specimen) available for submission for central pathology review and to conduct translational studies as part of this protocol.

Exclusion Criteria:

1. Tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules) (T4 according to AJCC 8th edition cancer staging TNM)
2. Inflammatory breast cancer
3. Bilateral invasive breast cancer
4. Received any prior treatment for primary invasive breast cancer
5. Any active tumor of non-breast-cancer histology
6. Any of the following in the previous 6 months: myocardial infarction, severe/unstable angina pectoris, ongoing cardiac dysrhythmias of NCI CTCAE grade ≥2, atrial fibrillation of any grade, coronary/peripheral artery bypass graft, symptomatic congestive heart failure (NYHA functional classification ≥II), cerebrovascular accident including transient ischemic attack, or symptomatic pulmonary embolism.
7. Concurrent disease or condition that would make the subject inappropriate for study participation or any serious medical disorder that would interfere with the subject's safety
8. Contraindications or known hypersensitivity to any of the trial medications or excipients
9. Treatment with any investigational agents within 30 days prior to expected start of trial treatment
10. Any GI disorder that may affect absorption of oral medications, such as malabsorption syndrome or status post major bowel resection
11. Evidence via physical and/or radiological exam of cN2 or cN3 nodal involvement defined by: metastasis to ipsilateral level I, II axillary lymph nodes that are clinically fixed or matted, OR involvement of ipsilateral infraclavicular, internal mammary and/or supraclavicular lymph node(s)
12. History of extensive disseminated/bilateral or known presence of interstitial fibrosis or interstitial lung disease, including a history of pneumonitis, hypersensitivity pneumonitis, interstitial pneumonia, obliterative bronchiolitis, and pulmonary fibrosis. A history of prior radiation pneumonitis is not considered an exclusion criterion.

Participant flow

Outcome results

• Pathological Complete Response (pCR) (Primary), Count of participants, Participants: Paclitaxel Plus Trastuzumab and Pertuzumab 24; Palbociclib Plus Letrozole Plus Trastuzumab and Pertuzumab 24
• Pathological Complete Response (pCR) in the Breast (Secondary), Count of participants, Participants: Paclitaxel Plus Trastuzumab and Pertuzumab 26; Palbociclib Plus Letrozole Plus Trastuzumab and Pertuzumab 25
• Objective Response (Secondary), Count of participants, Participants: Paclitaxel Plus Trastuzumab and Pertuzumab 35; Palbociclib Plus Letrozole Plus Trastuzumab and Pertuzumab 38
• Rate of Breast Conserving Surgery (BCS) (Secondary), Count of participants, Participants: Paclitaxel Plus Trastuzumab and Pertuzumab 49; Palbociclib Plus Letrozole Plus Trastuzumab and Pertuzumab 59

Adverse events

Time frame: Assessed at the end of every 4-week cycle until the end of trial treatment prior to surgery; up to 20 weeks. Only serious adverse events were assessed 30 days after end of treatment; up to 21 weeks.

Serious adverse events by term

Other adverse events by term

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• Study Protocol and Statistical Analysis Plan: Protocol Part 2 (PDF, 2020-06-12)
• Study Protocol and Statistical Analysis Plan: Protocol Part 1 (PDF, 2020-06-12)

• Laura Biganzoli, MD, Study chair, USL4 Hospital of Prato, Italy
• Etienne Brain, MD, Study chair, Institut Curie, Paris, France

NIH grants: 2017