Comparison of prognostic signatures for ER positive breast cancer in TransATAC:

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1 Comparison of prognostic signatures for ER positive breast cancer in TransATAC: EndoPredict, a high performance test in node negative and node positive disease Ivana Sestak, PhD Centre for Cancer Prevention Wolfson Institute of Preventive Medicine Queen Mary University London London, United Kingdom

2 Conflict of interest Lecture fees from and on advisory board of Myriad Genetics Lecture fees from NanoString Techonologies

3 Introduction Traditional clinical and pathological methods used to estimate risk of recurrence Age, nodal status, tumour size, grade, hormone receptor status, HER2, ki67 Used as prognostic and predictive markers to identify patients who are likely to benefit from endocrine therapy or chemotherapy Ultimate goal: Identifying patients at high risk of recurrence and selecting optimal therapy for each patient Avoiding over treatment!

4 Gene expression tests Gene expression profiling enables the identification of gene signatures to predict prognosis Ultimate goal Improve prognostication and risk stratification in ER positive/her2 negative disease Central labs Local pathologist Manufacturer Test Manufacturer Test

5 Gene expression tests Oncotype Dx () Prosigna PAM46 () PROLIFERATION Ki-67 STK15 Survivin Cyclin B1 MYBL2 HER2 GRB7 HER2 GSTM1 ESTROGEN ER PGR Bcl2 SCUBE2 + + Tumour size INVASION Stromelysin 3 Cathepsin L2 CD68 BAG1 Breast Cancer Index () H/I HOXB13 IL17BR MGI BUB1B CENPA NEK2 RACGAP1 RRM2 REFERENCE Beta-actin GAPDH RPLPO GUS TFRC REFERENCE ACTB HMBS SDHA UBC EndoPredict () Reference genes CALM2 OAZ1 RPL37A Member 1 Member 2 Member 3 BIRC5 RBBP8 UBE2C IL6ST AZGP1 DHCR7 EP Tumour size + Nodal status Member 4 MGP STC2

6 Similarities between tests Oncotype Dx PAM46 () BAG1 BCL2 ACTR3B, ANLN, BLVRA, CCNE1, CDC20, CDC6, CDCA1, CDH3, CENPF, CEP55, ESR1 CXXC5, EGFR, EXO1, FGFR4, FOXA1, RRM2 FOXC1, GPR160, UBE2T, KIF2C, KNTC2, KRT14, KRT17, KRT5, MAPT, MDM2, HER2 MELK, MIA, MLPH, MMP11, MYC, NAT1, ORC6L, PHGDH, PTTG1, Ki67 SFRP1, SLC39A6, TMEM45, TYMS PgR SKT15 SCUBE2 Stromelysin 3 Cathespin L2 CD68 GSTM1 UBE2C HOXB13 IL17BR BUB1B CENPA NEK2 RACGAP1 AZGP1 IL6ST DHCR7 RBBP8 MGP STC2 Adapted from Denkert et al., 2015, Pathologe

7 Gene expression tests Oncotype DX Breast Cancer Index Prosigna EndoPredict Genes Development set ER+, LN negative, treated with tamoxifen ER+, LN negative/positive, treated with tamoxifen ER+, LN negative/positive, treated with tamoxifen ER+, HER2, lymph node negative/positive, treated with tamoxifen Type Molecular Molecular Combined with clinical information Combined with clinical information Validation studies NSABP B 14, NSABP B 20, SWOG 8814, TransATAC Stockholm, TransATAC, MA17 TransATAC, ABCSG 8 TransATAC, ABCSG 6, ABCSG 8, GEICAM References Dowsett et al., 2010 Paik et al., 2006 Paik et al., 2004 Sgroi et al., 2013 Zhang et al., 2013 Dowsett et al., 2013 Gnant et al., 2014 Dubsky et al., 2013 Buus et al., 2016 Martin et al., 2014 Endocrine treatment Tamoxifen/Anastrozole Tamoxifen plus chemotherapy Tamoxifen/nothing Tamoxifen/Anastrozole Tamoxifen/Anastrozole Tamoxifen or Tamoxifen AI Tamoxifen/Anastrozole Tamoxifen or Tamoxifen AI Patient population Node negative Node positive Node negative Node negative Node positive Node negative Node positive HER2 negative

8 Gene expression tests Oncotype DX Breast Cancer Index Prosigna EndoPredict Genes Development set ER+, LN negative, treated with tamoxifen ER+, LN negative/positive, treated with tamoxifen ER+, LN negative/positive, treated with tamoxifen ER+, HER2, lymph node negative/positive, treated with tamoxifen Type Molecular Molecular Combined with clinical information Combined with clinical information Validation studies NSABP B 14, NSABP B 20, SWOG 8814, TransATAC Stockholm, TransATAC, MA17 TransATAC, ABCSG 8 TransATAC, ABCSG 6, ABCSG 8, GEICAM References Dowsett et al., 2010 Paik et al., 2006 Paik et al., 2004 Sgroi et al., 2013 Zhang et al., 2013 Dowsett et al., 2013 Gnant et al., 2014 Dubsky et al., 2013 Buus et al., 2016 Martin et al., 2014 Endocrine treatment Tamoxifen/Anastrozole Tamoxifen plus chemotherapy Tamoxifen/nothing Tamoxifen/Anastrozole Tamoxifen/Anastrozole Tamoxifen or Tamoxifen AI Tamoxifen/Anastrozole Tamoxifen or Tamoxifen AI Patient population Node negative Node positive Node negative Node negative Node positive Node negative Node positive HER2 negative

9 Comprehensive comparison TransATAC 1. Performance of prognostic signatures for prediction of distant recurrence in N and N+ separately: In years 0 10 (chemotherapy) In years 5 10 (extended endocrine therapy) 2. Clinically useful risk groups for both treatment periods and sub groups Sestak et al., 2018, JAMA Oncology, 4:

10 TransATAC: All ER positive/her2 negative Node negative (N=591) Node positive (N=227) Mean age, years (SD) 63.4 (7.9) 67.2 (8.2) Mean BMI, kg/m 2 (SD) 27.3 (4.9) 27.1 (5.0) Grade % 18.9% % 61.2% % 19.8% Mean tumour size, mm (SD) 17.6 (8.5) 25.7 (13.6) Distant recurrence 0 10 years 60 (10.2%) 66 (29.1%) 5 10 years 34 (5.7%) 31 (13.7%) Sestak et al., 2018, JAMA Oncology, 4:

11 Prognostic signatures Signature Information included Oncotype Recurrence Score () 21 genes (oestrogen, proliferation, invasion, HER2 genes) Breast Cancer Index () H/I and 5 proliferation genes (Molecular Grade Index) Prosigna () 46 genes, proliferation score, tumour size (EU cut offs from transatac for N and N+) EndoPredict () 12 genes (proliferation, differentiation, oestrogen); nodal status and tumour size Sestak et al., 2018, JAMA Oncology, 4:

12 Years 0 10: Node negative Sensitivity Hazard Ratio (95% CI) 1.69 ( ) 2.46 ( ) 2.56 ( ) 2.14 ( ) Specificity Sestak et al., 2018, JAMA Oncology, 4: Distant recurrence free (%) Follow up time [years] % women 61.8% 24.2% 14.0% 63.3% 26.4% 10.3% 53.8% 30.1% 16.1% 72.6% 27.4% 10 year DR risk (%) 3.9% ( ) 19.3% ( ) 27.3% ( ) 5.9% ( ) 16.7% ( ) 27.2% ( ) 3.0% ( ) 14.1% ( ) 32.4% ( ) 6.6% ( ) 22.1% ( ) Low Intermediate High

13 Years 0 10: Node positive Hazard Ratio (95% CI) 100 % women 10 year DR risk (%) Sensitivity ( ) 1.67 ( ) 1.58 ( ) 1.69 ( ) Specificity Sestak et al., 2018, JAMA Oncology, 4: Distant recurrence free (%) % 32.8% 15.3% 57.4% 31.7% 10.9% 8.2% 31.7% 60.1% 23.5% 76.5% 15.5% ( ) 32.0% ( ) 41.4% ( ) 19.4% ( ) 29.1% ( ) 38.0 % ( ) Follow up time [years] Low Intermediate High 0% 20.7% ( ) 30.7% ( ) 5.6% ( ) 30.3% ( )

14 Years 5 10: Node negative Sensitivity Hazard Ratio (95% CI) 1.46 ( ) 2.30 ( ) 2.77 ( ) 2.19 ( ) Specificity Sestak et al., 2018, JAMA Oncology, 4: Distant recurrence free (%) Follow up time [years] % women 63.6% 2.6% ( ) 23.6% 14.4% ( ) 12.8% 15.9% ( ) 65.6% 4.8% ( ) 25.1% 9.6% ( ) 9.3% 16.1% ( ) 54.6% 1.4% ( ) 30.8% 10.0% ( ) 14.6% 23.2% ( ) 73.5% 10 year DR risk (%) 4.3% ( ) 26.5% 14.6% ( ) Low Intermediate High

15 Years 5 10: Node positive Sensitivity Hazard Ratio (95% CI) 1.24 ( ) 1.60 ( ) 1.65 ( ) 1.87 ( ) Sestak et al., 2018, JAMA Oncology, 4: Specificity Distant recurrence free (%) % women 54.6% 32.5% 13.0% 61.0% 29.2% 9.7% 9.7% 33.1% 57.1% 26.0% 74.0% 10 year DR risk (%) 9.5% ( ) 14.3% ( ) 36.5% ( ) 17.9% ( ) 19.5% ( ) 27.5% ( ) 0% 13.0% ( ) 25.0% ( ) 3.3% ( ) 23.6% ( ) Follow up time [years] Low Intermediate High

16 Conclusions comprehensive analysis Node negative patients: All tests provided meaningful prognostic information does not provide independent prognostic value for late DR Low risk groups very unlikely to benefit from chemotherapy/extended endocrine therapy Node positive patients: shows best risk stratification and independent prognostic value Purely molecular assays not informative in this patient cohort All tests show similar performance for prognosis in first 5 years, but differences for years 5 10 Sestak et al., 2018, JAMA Oncology, 4:

17 Conclusions Molecular analysis of tumours can help in assessing risk of distant recurrence in early breast cancer and guide treatment decisions Reduce extent of over treatment Multigene assays can enable a more accurate identification of patients with low or high risk disease (Level of Evidence 1b; Simon et al., JNCI, 2009)

18 Thank you

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