FACT: An Open-Label Randomized Phase III Study of Fulvestrant and Anastrozole in Combination Compared With Anastrozole Alone as First-Line Therapy for Patients With Receptor-Positive Postmenopausal Breast Cancer.

PURPOSE To compare the effect of therapy with anastrozole versus a combination of fulvestrant and anastrozole in women in first relapse of endocrine-responsive breast cancer. PATIENTS AND METHODS Postmenopausal women, or premenopausal women receiving a gonadotropin-releasing hormone agonist, with estrogen receptor- and/or progesterone receptor-positive disease at first relapse after primary treatment of localized disease were open-label randomly assigned to a fulvestrant loading dose (LD) regimen followed by monthly injection plus 1 mg of anastrozole daily or to 1 mg of anastrozole daily alone. The primary end point was time to progression (TTP). RESULTS: 63 patients (24.6%) versus 35 patients (13.8%) in the standard arm (P = .0023). Death owing to AEs was reported in 11 (4.3%) and five patients (2.0%) in the experimental versus standard arm, respectively. CONCLUSION Fulvestrant (250 mg + LD regimen) in combination with anastrozole offered no clinical efficacy advantage over anastrozole monotherapy in this population of individuals with a relatively high proportion of previous adjuvant antiestrogen exposure

Accurate detection of low prevalence AKT1 E17K mutation in tissue or plasma from advanced cancer patients.

Personalized healthcare relies on accurate companion diagnostic assays that enable the most appropriate treatment decision for cancer patients. Extensive assay validation prior to use in a clinical setting is essential for providing a reliable test result. This poses a challenge for low prevalence mutations with limited availability of appropriate clinical samples harboring the mutation. To enable prospective screening for the low prevalence AKT1 E17K mutation, we have developed and validated a competitive allele-specific TaqMan® PCR (castPCR™) assay for mutation detection in formalin-fixed paraffin-embedded (FFPE) tumor tissue. Analysis parameters of the castPCR™ assay were established using an FFPE DNA reference standard and its analytical performance was assessed using 338 breast cancer and gynecological cancer FFPE samples. With recent technical advances for minimally invasive mutation detection in circulating tumor DNA (ctDNA), we subsequently also evaluated the OncoBEAM™ assay to enable plasma specimens as additional diagnostic opportunity for AKT1 E17K mutation testing. The analysis performance of the OncoBEAM™ test was evaluated using a novel AKT1 E17K ctDNA reference standard consisting of sheared genomic DNA spiked into human plasma. Both assays are employed at centralized testing laboratories operating according to quality standards for prospective identification of the AKT1 E17K mutation in ER+ breast cancer patients in the context of a clinical trial evaluating the AKT inhibitor AZD5363 in combination with endocrine (fulvestrant) therapy

Comparing duration of response and duration of clinical benefit between fulvestrant treatment groups in the CONFIRM trial: application of new methodology.

peer reviewedComparisons of duration of response (DoR) and duration of clinical benefit (DoCB) within clinical trials are prone to biases. To address these biases, we used new methodology to prospectively analyze expected DoR and expected DoCB. Objective response rate and clinical benefit rate were calculated for fulvestrant 500 and 250 mg, and used to calculate expected DoR and expected DoCB for each dose group. The ratios for expected DoR and expected DoCB (expected DoR500/expected DoR250 and expected DoCB500/expected DoCB250) were then calculated, thereby allowing statistical comparisons of these endpoints between each arm of the COmparisoN of Faslodex In Recurrent or Metastatic breast cancer (CONFIRM) trial. Expected DoRs for fulvestrant 500 and 250 mg were 3.2 and 3.6 months, respectively. The expected DoR ratio between fulvestrant 500 and 250 mg was not statistically significant (0.89; 95 % CI, 0.48-1.67, P = 0.724). The expected DoCBs for fulvestrant 500 and 250 mg were 9.8 and 7.2 months, respectively. The expected DoCB ratio showed that the expected DoCB for fulvestrant 500 mg was significantly improved compared with the expected DoCB for fulvestrant 250 mg (1.36; 95 % CI, 1.07-1.73, P = 0.013). Analysis of the expected DoR and expected DoCB showed fulvestrant 500 mg significantly increased expected DoCB compared with fulvestrant 250 mg in the CONFIRM trial

Schematic representation of the CastPCR^TM assay.

<p>(A) Two independent amplification reactions are required for mutation detection: the Mutant Allele Assay, in which the mutant allele is amplified via the mutation-specific primer whilst amplification of the wild-type DNA is suppressed by the blocker containing the minor groove binder (MGB) (left), and the Gene Reference Assay, in which a DNA region located within the same gene but outside the mutant region is amplified (right). Both assays include an internal positive control (IPC) to control for PCR failure. (B) Example of Amplification Plots from a breast cancer sample analysis. The first curve to cross the signal threshold line (green line) represents the signal generated by the IPC reaction (blue line). The second curve (red line) represents the signal generated by the Mutant Allele Assay (left) or Gene Reference Assay (right). In this example, the Ct values for the Gene Reference Assay and the Mutant Allele Assay were 23.5 and 27.5 respectively. The resulting ΔCt is 4, indicating that the castPCR™ assay detected the <i>AKT1</i> E17K mutation in this sample.</p

Ct values of duplicate assays showing intra-assay agreement.

<p>All samples were performed in duplicate, resulting in two Ct values for the Gene Reference Assay (open circle) and two Ct values for the Mutant Allele Assay (closed circle). The blue circles show the Ct values obtained in the first experiment, and the red circles show the Ct values obtained in the second experiment. Absence of a closed circle for a particular sample indicates that no Ct value was detected. The two samples in which the <i>AKT1</i> E17K mutation was detected (samples 7 and 41 with a ΔCt <8.1) are indicated with an arrow.</p

Comparison of <i>AKT1</i> mutation detection data generated by castPCR™, MALDI-TOF MS and BEAMing in 4 <i>AKT1</i> E17K gynecological cancer samples.

<p>Comparison of <i>AKT1</i> mutation detection data generated by castPCR™, MALDI-TOF MS and BEAMing in 4 <i>AKT1</i> E17K gynecological cancer samples.</p

Comparison of <i>AKT1</i> mutation detection by castPCR™, MALDI-TOF MS and BEAMing in 6 <i>AKT1</i> E17K mutation positive breast cancer samples.

<p>Comparison of <i>AKT1</i> mutation detection by castPCR™, MALDI-TOF MS and BEAMing in 6 <i>AKT1</i> E17K mutation positive breast cancer samples.</p

Interpretation of castPCR™ <i>AKT1</i> E17K assay results.

<p>Interpretation of castPCR™ <i>AKT1</i> E17K assay results.</p

Individual and mean ΔCt results of two <i>AKT1</i> E17K DNA reference standards analyzed by castPCR™ to determine analysis parameters.

<p>Individual and mean ΔCt results of two <i>AKT1</i> E17K DNA reference standards analyzed by castPCR™ to determine analysis parameters.</p