Herceptin Hylecta Drug Information
Generic name: TRASTUZUMAB AND HYALURONIDASE-OYSK
Endoglycosidase [EPC] HER2/neu Receptor Antagonist [EPC]
Uses of Herceptin Hylecta
Adjuvant Breast Cancer
HERCEPTIN HYLECTA is indicated for adjuvant treatment of adults with HER2 overexpressing node positive or node negative (ER/PR negative or with one high risk feature ) breast cancer: as part of a treatment regimen consisting of doxorubicin, cyclophosphamide, and either paclitaxel or docetaxel as part of a treatment regimen with docetaxel and carboplatin as a single agent following multi-modality anthracycline based therapy. Select patients for therapy based on an FDA-authorized companion diagnostic for trastuzumab .
Metastatic Breast Cancer
HERCEPTIN HYLECTA is indicated in adults: In combination with paclitaxel for first-line treatment of HER2-overexpressing metastatic breast cancer As a single agent for treatment of HER2-overexpressing breast cancer in patients who have received one or more chemotherapy regimens for metastatic disease. Select patients for therapy based on an FDA-authorized companion diagnostic for trastuzumab .
Dosage & Administration of Herceptin Hylecta
Evaluation and Testing
Before Initiating HERCEPTIN HYLECTA Verify the pregnancy status of females of reproductive potential prior to the initiation of HERCEPTIN HYLECTA .
Patient Selection Select patients based on
HER2 protein overexpression or HER2 gene amplification in tumor specimens . Assessment of HER2 protein overexpression and HER2 gene amplification should be performed using FDA-authorized tests specific for breast cancer by laboratories with demonstrated proficiency. Information on the FDA-authorized tests for the detection of HER2 protein overexpression and HER2 gene amplification is available at: http://www.fda.gov/CompanionDiagnostics. Improper assay performance, including use of suboptimally fixed tissue, failure to utilize specified reagents, deviation from specific assay instructions, and failure to include appropriate controls for assay validation, can lead to unreliable results.
Recommended Dosage
HERCEPTIN HYLECTA is for subcutaneous use only. HERCEPTIN HYLECTA has different dosage and administration instructions than intravenous trastuzumab products. Do not administer intravenously.
Do not substitute HERCEPTIN HYLECTA for or with ado-trastuzumab emtansine. The recommended dose of HERCEPTIN HYLECTA is 600 mg/10,000 units (600 mg trastuzumab and 10,000 units hyaluronidase) administered subcutaneously over approximately 2-5 minutes once every three weeks. No loading dose is required.
No dose adjustments for patient body weight or for different concomitant chemotherapy regimens are required. Duration of treatment Patients with adjuvant breast cancer should be treated with HERCEPTIN HYLECTA for 52 weeks or until disease recurrence, whichever occurs first; extending treatment in adjuvant breast cancer beyond one year is not recommended. Patients with metastatic breast cancer (MBC) should be treated with HERCEPTIN HYLECTA until progression of disease.
Missed Dose If one dose is missed, it is recommended to administer the next 600 mg/10,000 units dose (i.e. the missed dose) as soon as possible. The interval between subsequent HERCEPTIN HYLECTA doses should not be less than three weeks.
Dosage Modification for Adverse Reactions Cardiomyopathy Assess left ventricular ejection fraction (LVEF)
prior to initiation of HERCEPTIN HYLECTA and at regular intervals during treatment. Withhold HERCEPTIN HYLECTA dosing for at least 4 weeks for either of the following: ≥16% absolute decrease in LVEF from pre-treatment values LVEF below institutional limits of normal and ≥10% absolute decrease in LVEF from pretreatment values. HERCEPTIN HYLECTA may be resumed if, within 4–8 weeks, the LVEF returns to normal limits and the absolute decrease from baseline is ≤15%. Permanently discontinue HERCEPTIN HYLECTA for a persistent (>8 weeks) LVEF decline or for suspension of HERCEPTIN HYLECTA dosing on more than 3 occasions for cardiomyopathy.
Administration and Storage To prevent medication errors, it is important to check
the vial labels to ensure that the drug being prepared and administered is HERCEPTIN HYLECTA and not ado-trastuzumab emtansine or intravenous trastuzumab. HERCEPTIN HYLECTA should be administered by a healthcare professional. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.
Do not use vial if particulates or discoloration is present. Discard any unused portion remaining in the vial. HERCEPTIN HYLECTA is for single use only.
The 600 mg/10,000 units (600 mg trastuzumab and 10,000 units hyaluronidase) solution is a ready to use solution for injection which does not need to be diluted. To avoid needle clogging, attach the hypodermic injection needle to the syringe immediately prior to administration followed by volume adjustment to 5 mL. HERCEPTIN HYLECTA is compatible with polypropylene and polycarbonate syringe material and stainless steel transfer and injection needles. Prepare the dosing syringe in controlled and validated aseptic conditions.
After the solution of HERCEPTIN HYLECTA is withdrawn from the vial and into the syringe, replace the transfer needle with a syringe closing cap. Label the syringe with the peel-off sticker. Administration The injection site should be alternated between the left and right thigh.
New injections should be given at least 2.5 cm from the old previous site on healthy skin and never into areas where the skin is red, bruised, tender, or hard, or areas where there are moles or scars. During the treatment course with HERCEPTIN HYLECTA other medicinal products for subcutaneous administration should preferably be injected at different sites. The dose should be administered subcutaneously over approximately 2 to 5 minutes.
Storage If the syringe containing HERCEPTIN HYLECTA is not used immediately, then the syringe can be stored in the refrigerator (2°C to 8°C) for up to 24 hours and subsequently at room temperature (20°C to 25°C) for up to 4 hours. Protect from light. Do not shake or freeze.
Side Effects of Herceptin Hylecta
Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of HERCEPTIN HYLECTA administered subcutaneously has been established in the HannaH and SafeHER studies conducted in patients with HER2 overexpressing breast cancer. The safety of intravenous trastuzumab has been established in studies H0648g and H0649g conducted in patients with HER2 overexpressing metastatic breast cancer.
Adjuvant Breast Cancer HannaH HannaH was a randomized, open-label study to compare the pharmacokinetics, efficacy, and safety of HERCEPTIN HYLECTA compared to intravenous trastuzumab in women with HER2-positive breast cancer. Patients randomized to the HERCEPTIN HYLECTA arm received a dose of 600 mg HERCEPTIN HYLECTA every 3 weeks throughout the treatment phase. Patients were treated for 8 cycles in combination with chemotherapy (docetaxel followed by 5FU, epirubicin and cyclophosphamide), then underwent surgery, and continued HERCEPTIN HYLECTA to complete 18 cycles of therapy.
The median age of patients was 50 (range: 25-81 years), all patients were female, and a majority of patients were white (67%). The median number of HERCEPTIN HYLECTA cycles received was 18 (range 1-18). The most common adverse reactions of any grade (occurring in ≥10% of patients) with HERCEPTIN HYLECTA were alopecia (63%), nausea (49%), ARRs (48%), neutropenia (44%), diarrhea (34%), asthenia (25%), fatigue (24%), vomiting (23%), myalgia (21%), decreased appetite (20%), stomatitis (19%), arthralgia (18%), headache (17%), rash (16%), constipation (14%), radiation skin injury (14%), pyrexia (12%), cough (12%), anemia (11%), dyspnea (11%), incision site pain (11%), peripheral sensory neuropathy (11%), leukopenia (10%), mucosal inflammation (10%), hot flush (10%), upper respiratory tract infection (10%). The most common Grade ≥3 adverse reactions (occurring in >1% of patients) in the HERCEPTIN HYLECTA arm were neutropenia (30%), febrile neutropenia (6%), leukopenia (4%), diarrhea (3%), hypertension (2%), irregular menstruation (2%), alopecia (1%), nausea (1%), granulocytopenia (1%), vomiting (1%), amenorrhea (1%), and cellulitis (1%). Adverse reactions leading to interruption of any study drug in the HERCEPTIN HYLECTA arm occurred in 34% of patients; 31% of patients had these events during the neoadjuvant phase of the study with concurrent chemotherapy and 9% of patients had these events during the adjuvant phase. Overall, the most common (≥ 1%) were neutropenia (21%), leukopenia (2.4%), ALT increase (1.7%), pyrexia (1.7%), anemia (1%), bronchitis (1%), and left ventricular dysfunction (1%). Adverse reactions that led to discontinuation of any study drug in the HERCEPTIN HYLECTA arm (>1 patient) were left ventricular dysfunction (2%). The incidence of ARRs in the HERCEPTIN HYLECTA arm was 48% and was 37% in the intravenous trastuzumab arm. Five (2%) patients in the HERCEPTIN HYLECTA arm experienced a Grade 3 ARR. Three of the events in the HERCEPTIN HYLECTA arm occurred on the day of study drug administration when docetaxel treatment was administered concurrently.
The most commonly reported ARRs in the HERCEPTIN HYLECTA arm (≥5% of patients) were rash, pruritus, erythema, cough and dyspnea. Grade 1 and 2 injection-site reactions (ISRs) occurred in 10% of patients in the HERCEPTIN HYLECTA arm. The most common ISRs were injection-site pain and injection-site erythema.
The data in Table 3 were obtained from the HannaH trial for adverse reactions that occurred in ≥ 5% of the patients treated with HERCEPTIN HYLECTA. Table 3 Adverse Reactions Contains grouped terms (≥ 5% Incidence) Reported in HannaH Adverse Reactions HERCEPTIN HYLECTA 600 mg n=297 Intravenous Trastuzumab (loading dose: 8 mg/kg; maintenance dose: 6 mg/kg) n=298 All Grades % Grades 3 to 5 % All Grades % Grades 3 to 5 % SKIN AND SUBCUTANEOUS TISSUE DISORDERS Alopecia, The HannaH trial was not designed to demonstrate a statistically significant difference in adverse reaction rates between HERCEPTIN HYLECTA and intravenous trastuzumab. 63 1.3 63
Rash, 26 < 1 26 - Nail Disorder, 14 - 14 <
1 Pruritus, 9 - 9 - Skin Discoloration 9 - 8 - Erythema 7 < 1 3 - GASTROINTESTINAL DISORDERS Nausea 49 1.3 49
Diarrhea, 34 2.7 37 2.7 Vomiting 23 1 23 1.7 Stomatitis 21
< 1 18 < 1 Abdominal Pain, 14 - 14 < 1 Dyspepsia 11 - 10 - GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS Fatigue, 46 < 1 49 2 Edema, 14 - 15 - Pyrexia 13 1 12 < 1 Mucosal Inflammation 10 < 1 13 - Pain, 5 - 8 < 1 Injection Site Reaction, Injection Site Reaction includes terms for injection related reaction and injection site joint pain, bruising, dermatitis, discoloration, discomfort, erythema, extravasation, fibrosis, hematoma, hemorrhage, hypersensitivity, induration, inflammation, irritation, macule, mass, nodule, edema, pallor, paraesthesia, pruritus, rash, reaction, swelling, ulcer, vesicles and warmth. 10 - < 1 - BLOOD AND LYMPHATIC SYSTEM DISORDERS Neutropenia 44 30 47 34 Leukopenia, 11 5 16 8 Anemia, 12 < 1 14 1 Febrile Neutropenia 6 6 4 4 INFECTIONS AND INFESTATIONS Upper Respiratory Tract Infection, 24 1 27 < 1 Urinary Tract Infection, 4 - 8 < 1 MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS Myalgia 21 - 19 < 1 Arthralgia, 18 - 21 < 1 Back Pain 11 1 9 1 Pain in Extremity 10 - 9 < 1 Pain, 8 < 1 9 - Bone Pain 6 < 1 3.4 - NERVOUS SYSTEM DISORDERS Neuropathy Peripheral 20 - 15 - Headache 17 < 1 15 < 1 Dizziness 10 < 1 9 < 1 Dysgeusia 10 - 8 - INJURY, POISONING AND PROCEDURAL COMPLICATIONS Incision Site Complication 11 - 8 < 1 Pain 6 - 5 < 1 RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS Cough 12 < 1 8 - Dyspnea, 7 - 8 - Epistaxis 6 - 6 - Nasal Inflammation / Discomfort, 5 - 7 - VASCULAR DISORDERS Flushing 14 < 1 13 < 1 Hypertension 8 2.4 5 < 1 METABOLISM AND NUTRITION DISORDERS Decreased Appetite 20 < 1 20 < 1 INVESTIGATIONS Liver Function Analysis Abnormal, 6 1 9
CARDIAC
DISORDERS Arrhythmia 5 - 5 < 1 IMMUNE SYSTEM DISORDERS Hypersensitivity, 7 1 7
SafeHER SafeHER was a prospective, two-cohort, non-randomized, multi-center, multinational, open-label study to
assess the safety of HERCEPTIN HYLECTA in patients with operable HER2-positive breast cancer. In SafeHER, 1864 patients were enrolled and treated with 600 mg of HERCEPTIN HYLECTA administered subcutaneously once every three weeks for 18 cycles. The median age of patients was 54 (range: 20-88 years), 99.8% were female, and a majority were white (76%). A majority of the patients received HERCEPTIN HYLECTA concurrently with a chemotherapy regimen (58%). The median number of HERCEPTIN HYLECTA cycles administered was 18 and the median duration of HERCEPTIN HYLECTA exposure was 11.8 months.
The median duration of follow-up was 23.7 months. During the treatment period, the most common adverse reactions of any grade (occurring in ≥10% of patients) were ARRs (39%), diarrhea (21%), fatigue (21%), arthralgia (21%), nausea (15%), myalgia (14%), headache (13%), asthenia (12%), pain in extremity (11%), cough (11%), pyrexia (11%), hot flush (10%), and rash (10%). The most common Grade ≥3 adverse reactions (occurring in >1% of patients) were neutropenia (4%), febrile neutropenia (2%), hypertension (2%), leukopenia (1%), and diarrhea (1%). Adverse reactions that led to study drug discontinuation (≥0.5% of patients) were ejection fraction decreased (2%) and left ventricular dysfunction (1%). The incidence of ARRs was 39%, with Grade ≥3 ARRs reported in 1% of patients treated with HERCEPTIN HYLECTA. The most frequently reported Grade ≥3 ARRs were dyspnea (<1%), cough (<1%), erythema (<1%), rash (<1%), and drug hypersensitivity (<1%). ISRs were reported in 20% of patients treated with HERCEPTIN HYLECTA. The most common ISRs were injection-site erythema (7%) and injection-site pain (6%). All ISRs were Grade 1 or 2, except for one (<1%) Grade 3 injection site discomfort. The data in Table 4 were obtained from the SafeHER trial for adverse reactions that occurred in ≥5% of the patients treated with HERCEPTIN HYLECTA. Table 4 Adverse Reactions Contains grouped terms (≥ 5% Incidence) Reported in SafeHER Adverse Reactions, Includes adverse reactions reported throughout study treatment and follow-up.
HERCEPTIN HYLECTA 600 mg (once every 3 weeks) n=1864 All Grades % Grades 3 to 5 % GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS Fatigue 33 < 1 Injection Site Reaction, ISR includes injection related reaction and injection site joint pain, bruising, dermatitis, discoloration, discomfort, erythema, extravasation, fibrosis, hematoma, hemorrhage, hypersensitivity, induration, inflammation, irritation, macule, mass, nodule, edema, pallor, paresthesia, pruritus, rash, reaction, swelling, ulcer, vesicles and warmth. 20 < 1 Edema 12 < 1 Pyrexia 11 < 1 Pain 8 < 1 Mucosal Inflammation 6 < 1 MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS Arthralgia 21 < 1 Myalgia 17 < 1 Pain in Extremity 11 < 1 Back Pain 8 < 1 Pain 7 < 1 GASTROINTESTINAL DISORDERS Diarrhea 21 1 Nausea 15 < 1 Abdominal Pain 10 < 1 Constipation 9 < 1 Stomatitis 8 < 1 Vomiting 7 < 1 SKIN AND SUBCUTANEOUS TISSUE DISORDERS Rash 17 < 1 Nail Disorder 10 < 1 Alopecia 9 < 1 Erythema 9 < 1 Pruritus 6 - INFECTIONS AND INFESTATIONS Upper Respiratory Tract Infection 19 < 1 Urinary Tract Infection 6 < 1 Viral Infection 5 - NERVOUS SYSTEM DISORDERS Neuropathy Peripheral 14 < 1 Headache 13 < 1 Dizziness 6 < 1 Paresthesia 6 < 1 RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS Cough 11 < 1 Dyspnea 8 < 1 Epistaxis 6 - Nasal Inflammation/Discomfort 6 - VASCULAR DISORDERS Flushing 12 < 1 Hypertension 8 2 BLOOD AND LYMPHATIC SYSTEM DISORDERS Anemia 8 < 1 Neutropenia 6 4 PSYCHIATRIC DISORDERS Insomnia 7 < 1 Metastatic Breast Cancer (based on intravenous trastuzumab) The data below reflect exposure to intravenous trastuzumab in one randomized, open-label study, H0648g, of chemotherapy with (n=235) or without (n=234) intravenous trastuzumab in patients with metastatic breast cancer, and one single-arm study (H0649g; n=222) in patients with metastatic breast cancer. Data in Table 5 are based on H0648g and H0649g. Among the 464 patients treated in H0648g, the median age was 52 years (range: 25–77 years). Eighty-nine percent were white, 5% black, 1% Asian, and 5% other racial/ethnic groups.
All patients received 4 mg/kg initial dose of intravenous trastuzumab followed by 2 mg/kg weekly. The percentages of patients who received intravenous trastuzumab treatment for ≥ 6 months and ≥ 12 months were 58% and 9%, respectively. Among the 352 patients treated in single agent studies (213 patients from H0649g), the median age was 50 years (range 28–86 years), 86% were white, 3% were black, 3% were Asian, and 8% in other racial/ethnic groups.
Most of the patients received 4 mg/kg initial dose of intravenous trastuzumab followed by 2 mg/kg weekly. The percentages of patients who received intravenous trastuzumab treatment for ≥ 6 months and ≥ 12 months were 31% and 16%, respectively. Table 5 Adverse Reactions ( ≥ 5%) in the Intravenous Trastuzumab Arm (H0648g and H0649g) Intravenous trastuzumab Data for Herceptin single agent were from 4 studies, including 213 patients from H0649g. n = 352 % Intravenous trastuzumab + Paclitaxel n = 91 % Paclitaxel n = 95 % Intravenous trastuzumab + AC Anthracycline (doxorubicin or epirubicin) and cyclophosphamide. n = 143 % AC n = 135 % General Pain 47 61 62 57 42 Asthenia 42 62 57 54 55 Fever 36 49 23 56 34 Chills 32 41 4 35 11 Headache 26 36 28 44 31 Abdominal pain 22 34 22 23 18 Back pain 22 34 30 27 15 Infection 20 47 27 47 31 Flu syndrome 10 12 5 12 6 Accidental injury 6 13 3 9 4 Allergic reaction 3 8 2 4 2 Gastrointestinal Nausea 33 51 9 76 77 Diarrhea 25 45 29 45 26 Vomiting 23 37 28 53 49 Anorexia 14 24 16 31 26 Nausea and vomiting 8 14 11 18 9 Respiratory Cough increased 26 41 22 43 29 Dyspnea 22 27 26 42 25 Rhinitis 14 22 5 22 16 Pharyngitis 12 22 14 30 18 Sinusitis 9 21 7 13 6 Skin Rash 18 38 18 27 17 Herpes simplex 2 12 3 7 9 Acne 2 11 3 3 < 1 Nervous Insomnia 14 25 13 29 15 Dizziness 13 22 24 24 18 Paresthesia 9 48 39 17 11 Depression 6 12 13 20 12 Peripheral neuritis 2 23 16 2 2 Neuropathy 1 13 5 4 4 Metabolic Peripheral edema 10 22 20 20 17 Edema 8 10 8 11 5 Cardiovascular Congestive heart failure 7 11 1 28 7 Tachycardia 5 12 4 10 5 Musculoskeletal Bone pain 7 24 18 7 7 Arthralgia 6 37 21 8 9 Urogenital Urinary tract infection 5 18 14 13 7 Blood and Lymphatic Anemia 4 14 9 36 26 Leukopenia 3 24 17 52 34
Postmarketing Experience
The following adverse reactions have been identified during post-approval use of trastuzumab. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Administration-related reaction Oligohydramnios or oligohydramnios sequence, including pulmonary hypoplasia, skeletal abnormalities, and neonatal death Glomerulopathy Immune thrombocytopenia Tumor lysis syndrome (TLS): Cases of possible TLS have been reported in patients treated with trastuzumab.
Patients with significant tumor burden (e.g. bulky metastases) may be at a higher risk. Patients could present with hyperuricemia, hyperphosphatemia, and acute renal failure which may represent possible TLS. Providers should consider additional monitoring and/or treatment as clinically indicated.
Warnings & Cautions for Herceptin Hylecta
Cardiomyopathy
HERCEPTIN HYLECTA can cause left ventricular cardiac dysfunction, arrhythmias, hypertension, disabling cardiac failure, cardiomyopathy, and cardiac death . HERCEPTIN HYLECTA can also cause asymptomatic decline in LVEF. There is a 4–6 fold increase in the incidence of symptomatic myocardial dysfunction among patients receiving trastuzumab as a single agent or in combination therapy compared with those not receiving trastuzumab. The highest absolute incidence occurs when trastuzumab is administered with an anthracycline. The incidence of symptomatic myocardial dysfunction for intravenous trastuzumab and HERCEPTIN HYLECTA was similar in clinical trials.
Withhold HERCEPTIN HYLECTA for ≥16% absolute decrease in LVEF from pre-treatment values or an LVEF value below institutional limits of normal and ≥10% absolute decrease in LVEF from pretreatment values . The safety of continuation or resumption of HERCEPTIN HYLECTA in patients with HERCEPTIN HYLECTA induced left ventricular cardiac dysfunction has not been studied. Patients who receive anthracycline after stopping HERCEPTIN HYLECTA may also be at increased risk of cardiac dysfunction . Cardiac Monitoring Conduct thorough cardiac assessment, including history, physical examination, and determination of LVEF by echocardiogram or MUGA scan. The following schedule is recommended: Baseline LVEF measurement immediately prior to initiation of HERCEPTIN HYLECTA LVEF measurements every 3 months during and upon completion of HERCEPTIN HYLECTA Repeat LVEF measurement at 4 week intervals if HERCEPTIN HYLECTA is withheld for significant left ventricular cardiac dysfunction LVEF measurements every 6 months for at least 2 years following completion of HERCEPTIN HYLECTA as a component of adjuvant therapy.
HERCEPTIN HYLECTA In the HannaH study, the overall percentage of patients with at least one cardiac disorder was similar in both study arms: 15% (44/297) of patients in the HERCEPTIN HYLECTA arm and 14% (42/298) of patients in the intravenous trastuzumab arm. The most frequent cardiac adverse reactions were left ventricular dysfunction, tachycardia and palpitations in the HERCEPTIN HYLECTA arm and the intravenous trastuzumab arm, respectively. The incidence of cardiac failure and congestive cardiac failure was 1% (3/297) in the HERCEPTIN HYLECTA arm and <1% (1/298) in the intravenous trastuzumab arm.
The proportion of patients in each treatment arm with a significant decrease in LVEF defined as a drop of ≥10% points to an LVEF of <50% was comparable between treatment arms. In patients with lower body weights (<59 kg, the lowest body weight quartile) the fixed-dose used in the HERCEPTIN HYLECTA arm was not associated with an increased risk of cardiac events or significant drop in LVEF. In the SafeHER study, in patients treated with HERCEPTIN HYLECTA, 17% (323/1864) reported a cardiac disorder during the treatment period. Decreased ejection fraction, reported in 4.5% (84/1864) of the patients was the most frequently reported cardiac disorder.
Congestive cardiac failure was reported in <1% (10/1864) of patients and <1% (4/1864) of patients reported cardiac failure during the treatment period. One patient reported congestive cardiac failure during the follow-up period. Six percent (111/1864) of the patients treated with HERCEPTIN HYLECTA had an LVEF <50% with a decrease of ≥10 points in LVEF from baseline.
Trastuzumab (intravenous formulation): In study NSABP B31 (NCT00004067), 15% (158/1031) of patients discontinued intravenous trastuzumab due to clinical evidence of myocardial dysfunction or significant decline in LVEF after a median follow-up duration of 8.7 years in the AC-TH arm. In the HERA study (one-year intravenous trastuzumab treatment; NCT00045032), the number of patients who discontinued intravenous trastuzumab due to cardiac toxicity at 12.6 months median duration of follow-up was 2.6% (44/1678). In the BCIRG006 study (NCT00021255), a total of 2.9% (31/1056) of patients in the TCH arm (1.5% during the chemotherapy phase and 1.4% during the monotherapy phase) and 5.7% (61/1068) of patients in the AC-TH arm (1.5% during the chemotherapy phase and 4.2% during the monotherapy phase) discontinued intravenous trastuzumab due to cardiac toxicity. Among 64 patients receiving adjuvant chemotherapy (studies NSABP B31 and NCCTG N9831; NCT00005970) who developed congestive heart failure (CHF), one patient died of cardiomyopathy, one patient died suddenly without documented etiology, and 33 patients were receiving cardiac medication at last follow-up.
Approximately 24% of the surviving patients had recovery to a normal LVEF (defined as ≥ 50%) and no symptoms on continuing medical management at the time of last follow-up. Incidence of CHF is presented in Table 1. The safety of continuation or resumption of intravenous trastuzumab in patients with trastuzumab-induced left ventricular cardiac dysfunction has not been studied. Table 1 Incidence of Congestive Heart Failure in Adjuvant Breast Cancer Studies Incidence of Congestive Heart Failure % (n) Study Regimen Intravenous Trastuzumab Control NSABP B31 & NCCTG N9831 Median follow-up duration for studies NSABP B31 and NCCTG N9831 combined was 8.3 years in the AC→ paclitaxel+Herceptin arm.
AC Anthracycline (doxorubicin) and cyclophosphamide. →paclitaxel + intravenous trastuzumab 3.2% (64/2000) Includes 1 patient with fatal cardiomyopathy and 1 patient with sudden death without documented etiology. 1.3% (21/1655) HERA Includes NYHA II-IV and cardiac death at 12.6 months median duration of follow-up in the one-year intravenous trastuzumab arm. Chemotherapy → intravenous trastuzumab 2% (30/1678) 0.3% (5/1708) BCIRG006 AC →docetaxel + intravenous trastuzumab 2% (20/1068) 0.3% (3/1050) BCIRG006 Docetaxel + carboplatin + intravenous trastuzumab 0.4% (4/1056) 0.3% (3/1050) In the HERA study (one-year intravenous trastuzumab treatment), at a median follow-up duration of 8 years, the incidence of severe CHF (NYHA III & IV) was 0.8%, and the rate of mild symptomatic and asymptomatic left ventricular dysfunction was 4.6%. Table 2 Incidence of Cardiac Dysfunction Congestive heart failure or significant asymptomatic decrease in LVEF. in Metastatic Breast Cancer Studies Incidence NYHA I–IV NYHA III–IV Study Event Intravenous Trastuzumab Control Intravenous Trastuzumab Control H0648g (AC) Anthracycline (doxorubicin or epirubicin) and cyclophosphamide. Cardiac Dysfunction 28% 7% 19% 3% H0648g (paclitaxel) Cardiac Dysfunction 11% 1% 4% 1% H0649g Cardiac Dysfunction Includes 1 patient with fatal cardiomyopathy. 7% N/A 5% N/A In the BCIRG006 study, the incidence of NCI-CTC Grade 3/4 cardiac ischemia/infarction was higher in the intravenous trastuzumab containing regimens as compared to none in AC-T.
Embryo-Fetal Toxicity
HERCEPTIN HYLECTA can cause fetal harm when administered to a pregnant woman. In post-marketing reports, use of trastuzumab during pregnancy resulted in cases of oligohydramnios and oligohydramnios sequence manifesting as pulmonary hypoplasia, skeletal abnormalities, and neonatal death. Verify the pregnancy status of females of reproductive potential prior to the initiation of HERCEPTIN HYLECTA. Advise pregnant women and females of reproductive potential that exposure to HERCEPTIN HYLECTA during pregnancy or within 7 months prior to conception can result in fetal harm.
Advise females of reproductive potential to use effective contraception during treatment and for 7 months following the last dose of HERCEPTIN HYLECTA.
Pulmonary Toxicity
HERCEPTIN HYLECTA can result in serious and fatal pulmonary toxicity. Pulmonary toxicity includes dyspnea, interstitial pneumonitis, pulmonary infiltrates, pleural effusions, non-cardiogenic pulmonary edema, pulmonary insufficiency and hypoxia, acute respiratory distress syndrome, and pulmonary fibrosis. Patients with symptomatic intrinsic lung disease or with extensive tumor involvement of the lungs, resulting in dyspnea at rest, appear to have more severe toxicity.
Exacerbation of Chemotherapy-Induced Neutropenia
HERCEPTIN HYLECTA may exacerbate chemotherapy-induced neutropenia. In randomized, controlled clinical trials with intravenous trastuzumab, the per-patient incidences of NCI-CTC Grade 3–4 neutropenia and of febrile neutropenia were higher in patients receiving trastuzumab in combination with myelosuppressive chemotherapy as compared to those who received chemotherapy alone. The incidence of septic death was similar among patients who received trastuzumab and those who did not.
Hypersensitivity and Administration-Related Reactions Severe administration-related reactions (ARRs), including hypersensitivity and anaphylaxis
have been reported with HERCEPTIN HYLECTA. Patients experiencing dyspnea at rest due to complications of advanced malignancy and comorbidities may be at increased risk of a severe or of a fatal ARR. In the HannaH and SafeHER trials, 9% and 4.2% of patients experienced Grade 1-4 hypersensitivity and anaphylaxis, respectively. Grade 3-4 hypersensitivity and anaphylactic reactions occurred in 1% and <1% of the patients treated with HERCEPTIN HYLECTA, respectively. In the SafeHER trial, 2 patients required permanent treatment discontinuation with HERCEPTIN HYLECTA (1 patient due to a hypersensitivity reaction and 1 patient due to anaphylaxis). Serious and fatal reactions have been reported after treatment with intravenous trastuzumab products.
Closely monitor patients for systemic hypersensitivity reactions, especially during the first administration. Permanently discontinue HERCEPTIN HYLECTA in patients who experience anaphylaxis or severe hypersensitivity reactions. Medications to treat such reactions, as well as emergency equipment, should be available for immediate use.
For patients experiencing reversible Grade 1 or 2 hypersensitivity reactions, consider pre-medication with an analgesic, antipyretic, or an antihistamine prior to readministration of HERCEPTIN HYLECTA.
Drug Interactions with Herceptin Hylecta
Anthracyclines Patients who receive anthracycline after stopping HERCEPTIN HYLECTA may be at increased risk of cardiac dysfunction because of HERCEPTIN HYLECTA's estimated long washout period . If possible, avoid anthracycline-based therapy for up to 7 months after stopping HERCEPTIN HYLECTA. If anthracyclines are used, closely monitor the patient's cardiac function.
Pregnancy Safety for Herceptin Hylecta
Pregnancy If HERCEPTIN HYLECTA is administered during pregnancy, or if a patient becomes pregnant while receiving HERCEPTIN HYLECTA or within 7 months following the last dose of HERCEPTIN HYLECTA, health care providers and patients should immediately report HERCEPTIN HYLECTA exposure to Genentech at 1-888-835-2555. Risk Summary HERCEPTIN HYLECTA can cause fetal harm when administered to a pregnant woman. In post-marketing reports and published literature, use of trastuzumab during pregnancy resulted in cases of oligohydramnios and of oligohydramnios sequence, manifesting as pulmonary hypoplasia, skeletal abnormalities, and neonatal death. Apprise the patient of the potential risks to a fetus.
There are clinical considerations if HERCEPTIN HYLECTA is used in a pregnant woman or if a patient becomes pregnant within 7 months following the last dose of HERCEPTIN HYLECTA. The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively. Clinical Considerations Fetal/Neonatal Adverse Reactions Monitor women who received HERCEPTIN HYLECTA during pregnancy or within 7 months prior to conception for oligohydramnios.
If oligohydramnios occurs, perform fetal/neonatal testing that is appropriate for gestational age and consistent with community standards of care. Data Human Data In post-marketing reports and published literature, use of trastuzumab during pregnancy resulted in cases of oligohydramnios and of oligohydramnios sequence. Fetal manifestations included pulmonary hypoplasia, skeletal abnormalities, and neonatal death.
These case reports described oligohydramnios in pregnant women who received trastuzumab either alone or in combination with chemotherapy. In most reported cases, amniotic fluid index increased after use of trastuzumab was stopped. In reported cases where Herceptin therapy was resumed after amniotic index improved, oligohydramnios recurred.
Animal Data HERCEPTIN HYLECTA for subcutaneous injection contains trastuzumab and hyaluronidase . Trastuzumab : In studies where intravenous trastuzumab was administered to pregnant cynomolgus monkeys during the period of organogenesis at doses up to 25 mg/kg given twice weekly (up to 25 times the recommended weekly human dose of 2 mg/kg), trastuzumab crossed the placental barrier during the early (Gestation Days 20 to 50) and late (Gestation Days 120 to 150) phases of gestation. The resulting concentrations of trastuzumab in fetal serum and amniotic fluid were approximately 33% and 25%, respectively, of those present in the maternal serum but were not associated with adverse developmental effects. Hyaluronidase: In an embryo-fetal study, mice have been dosed daily by subcutaneous injection during the period of organogenesis with hyaluronidase (recombinant human) at dose levels up to 2,200,000 U/kg, which is >7,200 times higher than the human dose.
The study found no evidence of teratogenicity. Reduced fetal weight and increased numbers of fetal resorptions were observed, with no effects found at a daily dose of 360,000 U/kg, which is >1,200 times higher than the human dose. In a peri-and post-natal reproduction study, mice have been dosed daily by subcutaneous injection, with hyaluronidase (recombinant human) from implantation through lactation and weaning at dose levels up to 1,100,000 U/kg, which is >3,600 times higher than the human dose.
The study found no adverse effects on sexual maturation, learning and memory or fertility of the offspring.
Pediatric Use of Herceptin Hylecta
Pediatric Use The safety and effectiveness of HERCEPTIN HYLECTA in pediatric patients have not been established.
Clinical Studies of Herceptin Hylecta
Adjuvant Breast Cancer
HERCEPTIN HYLECTA HannaH The HannaH study (NCT00950300) was a randomized, multicenter, open-label, clinical trial in 596 patients with HER2-positive operable or locally advanced breast cancer (LABC), including inflammatory breast cancer. HER2-positivity was defined as IHC 3+ or ISH+. Patients were randomized to receive 8 cycles of either HERCEPTIN HYLECTA or intravenous trastuzumab concurrently with chemotherapy (docetaxel followed by 5FU, epirubicin and cyclophosphamide), followed by surgery and continued therapy with HERCEPTIN HYLECTA or intravenous trastuzumab as treated prior to surgery, for an additional 10 cycles, to complete 18 cycles of therapy. HannaH was designed to demonstrate non-inferiority of treatment with HERCEPTIN HYLECTA versus intravenous trastuzumab based on co-primary PK and efficacy outcomes (trastuzumab C trough at pre-dose Cycle 8, and pCR rate at definitive surgery, respectively) . EFS and OS were among other outcomes evaluated in this study.
The majority of patients were white (69%) and the median age was 50 years (range: 24-81). The analysis of the efficacy co-primary outcome, pCR, defined as absence of invasive neoplastic cells in the breast, resulted in rates of 45.4% (95% CI: 39.2, 51.7) in the HERCEPTIN HYLECTA arm and 40.7% (95% CI: 34.7, 46.9) in the intravenous trastuzumab arm. Table 8: Summary of Pathological Complete Response (pCR) (HannaH) HERCEPTIN HYLECTA (n=260) Intravenous Trastuzumab (n=263) pCR (absence of invasive neoplastic cells in breast ) 118 (45.4%) 107 (40.7%) Exact 95% CI for pCR Rate CI for one sample binomial using Pearson-Clopper method (39.2; 51.7) (34.7; 46.9) Difference in pCR (SC minus IV arm) 4.70 95% CI for Difference in pCR Approximate 95% CI for difference of two rates using Hauck-Anderson method (-4.0; 13.4) With a median follow-up exceeding 70 months, no difference in EFS and OS was observed in the final analysis between patients who received intravenous trastuzumab and those who received HERCEPTIN HYLECTA. SafeHER The SafeHER study (NCT01566721) was a prospective, two-cohort, non-randomized, multinational, open-label study designed to assess the overall safety and tolerability of HERCEPTIN HYLECTA with chemotherapy in 1864 patients with HER2-positive breast cancer. The secondary objectives include the evaluation of DFS and OS. HER2-positivity was defined as IHC 3+ or ISH+. Patients received a fixed dose of 600 mg HERCEPTIN HYLECTA every 3 weeks for a total of 18 cycles throughout the study.
HERCEPTIN HYLECTA treatment was initiated either sequentially with chemotherapy, concurrently with chemotherapy, or without adjuvant chemotherapy, or in combination with neoadjuvant chemotherapy followed by trastuzumab therapy. The majority of treated patients were white (76%) and the median age was 54 years (range: 20-88). In the primary safety analysis (median follow-up 23.7 months), no new safety signals were identified for HERCEPTIN HYLECTA. Safety and tolerability results, including in lower weight patients, were consistent with the known safety profile for HERCEPTIN HYLECTA and intravenous trastuzumab. In the ITT population (n=1867), 126 patients (7%) had a DFS event (recurrence, contralateral invasive breast cancer or death) and 28 patients (1.5%) had an OS event at the time of clinical cut-off.
Intravenous Trastuzumab The safety and efficacy of intravenous trastuzumab in women receiving adjuvant chemotherapy for HER2 overexpressing breast cancer were evaluated in an integrated analysis of two randomized, open-label, clinical trials (Studies NSABP B31 and NCCTG N9831) with a total of 4063 women at the protocol-specified final overall survival analysis, a third randomized, open-label, clinical trial (HERA Study) with a total of 3386 women at definitive DFS analysis for 1-year intravenous trastuzumab treatment versus observation, and a fourth randomized, open-label clinical trial with a total of 3222 patients (Study BCIRG006). Studies NSABP B31 and NCCTG N9831 In Studies NSABP B31 and NCCTG N9831, breast tumor specimens were required to show HER2 overexpression (3+ by IHC) or gene amplification (by FISH). HER2 testing was verified by a central laboratory prior to randomization (Study NCCTG N9831) or was required to be performed at a reference laboratory (Study NSABP B31). Patients with a history of active cardiac disease based on symptoms, abnormal electrocardiographic, radiologic, or left ventricular ejection fraction findings or uncontrolled hypertension (diastolic > 100 mm Hg or systolic > 200 mm Hg) were not eligible. Patients were randomized (1:1) to receive doxorubicin and cyclophosphamide followed by paclitaxel (AC→paclitaxel) alone or paclitaxel plus intravenous trastuzumab (AC→paclitaxel + intravenous trastuzumab). In both trials, patients received four 21-day cycles of doxorubicin 60 mg/m 2 and cyclophosphamide 600 mg/m 2. Paclitaxel was administered either weekly (80 mg/m 2 ) or every 3 weeks (175 mg/m 2 ) for a total of 12 weeks in Study NSABP B31; paclitaxel was administered only by the weekly schedule in Study NCCTG N9831. Intravenous trastuzumab was administered at 4 mg/kg on the day of initiation of paclitaxel and then at a dose of 2 mg/kg weekly for a total of 52 weeks. Intravenous trastuzumab treatment was permanently discontinued in patients who developed congestive heart failure, or persistent/recurrent LVEF decline . Radiation therapy, if administered, was initiated after the completion of chemotherapy.
Patients with ER+ and/or PR+ tumors received hormonal therapy. The major efficacy outcome of the combined efficacy analysis was DFS, defined as the time from randomization to recurrence, occurrence of contralateral breast cancer, other second primary cancer, or death. An additional efficacy outcome measure was OS. A total of 3752 patients were included in the joint efficacy analysis of DFS following a median follow-up of 2.0 years in the AC→paclitaxel + intravenous trastuzumab arm.
The pre-planned final OS analysis from the joint analysis included 4063 patients and was performed when 707 deaths had occurred after a median follow-up of 8.3 years in the AC→paclitaxel + intravenous trastuzumab arm. The data from both arms in Study NSABP B31 and two of the three study arms in Study NCCTG N9831 were pooled for efficacy analyses. The patients included in the DFS analysis had a median age of 49 years (range, 22–80 years; 6% > 65 years), 84% were White, 7% Black, 4% Hispanic, and 4% Asian/Pacific Islander.
Disease characteristics included 90% infiltrating ductal histology, 38% T1, 91% nodal involvement, 27% intermediate and 66% high grade pathology, and 53% ER+ and/or PR+ tumors. HERA Study In the HERA Study, breast tumor specimens were required to show HER2 overexpression (3+ by IHC) or gene amplification (by FISH) as determined at a central laboratory. Patients with node-negative disease were required to have ≥ T1c primary tumor.
Patients with a history of congestive heart failure or LVEF < 55%, uncontrolled arrhythmias, angina requiring medication, clinically significant valvular heart disease, evidence of transmural infarction on ECG, poorly controlled hypertension (systolic > 180 mm Hg or diastolic > 100 mm Hg) were not eligible. Patients were randomized (1:1:1) upon completion of definitive surgery, and at least 4 cycles of chemotherapy to receive no additional treatment, or 1 year of intravenous trastuzumab treatment or 2 years of intravenous trastuzumab treatment. Patients undergoing a lumpectomy had also completed standard radiotherapy.
Patients with ER+ and/or PgR+ disease received systemic adjuvant hormonal therapy at investigator discretion. Intravenous trastuzumab was administered with an initial dose of 8 mg/kg followed by subsequent doses of 6 mg/kg once every 3 weeks. The major efficacy outcome measure was DFS, defined as in Studies NSABP B31 and NCCTG N9831. HERA was designed to compare 1 and 2 years of three-weekly intravenous trastuzumab treatment versus observation in patients with HER2 positive EBC following surgery, established chemotherapy and radiotherapy (if applicable). A protocol specified interim efficacy analysis comparing one-year intravenous trastuzumab treatment to observation was performed at a median follow-up duration of 12.6 months in the intravenous trastuzumab.
Among the 3386 patients randomized to the observation (n = 1693) and intravenous trastuzumab one-year (n = 1693) treatment arms, the median age was 49 years (range 21–80), 83% were White, and 13% were Asian. Disease characteristics: 94% infiltrating ductal carcinoma, 50% ER+ and/or PgR+, 57% node positive, 32% node negative, and in 11% of patients, nodal status was not assessable due to prior neo-adjuvant chemotherapy. Ninety-six percent (1055/1098) of patients with node-negative disease had high-risk features: among the 1098 patients with node-negative disease, 49% were ER– and PgR–, and 47% were ER+ and/or PgR+ and had at least one of the following high-risk features: pathological tumor size > 2 cm, Grade 2–3, or age < 35 years.
Prior to randomization, 94% of patients had received anthracycline-based chemotherapy regimens. After the DFS results comparing observation to one-year intravenous trastuzumab treatment were disclosed, a prospectively planned analysis that included comparison of one year versus two years of intravenous trastuzumab treatment at a median follow-up duration of 8 years was performed. Based on this analysis, extending intravenous trastuzumab treatment for a duration of two years did not show additional benefit over treatment for one year.
BCIRG006 Study In the BCIRG006 Study, breast tumor specimens were required to show HER2 gene amplification (FISH+ only) as determined at a central laboratory. Patients were required to have either node-positive disease, or node-negative disease with at least one of the following high-risk features: ER/PR-negative, tumor size > 2 cm, age < 35 years, or histologic and/or nuclear Grade 2 or 3. Patients with a history of CHF, myocardial infarction, Grade 3 or 4 cardiac arrhythmia, angina requiring medication, clinically significant valvular heart disease, poorly controlled hypertension (diastolic > 100 mm Hg), any T4 or N2, or known N3 or M1 breast cancer were not eligible. Patients were randomized (1:1:1) to receive doxorubicin and cyclophosphamide followed by docetaxel (AC-T), doxorubicin and cyclophosphamide followed by docetaxel plus intravenous trastuzumab (AC-TH), or docetaxel and carboplatin plus intravenous trastuzumab (TCH). In both the AC-T and AC-TH arms, doxorubicin 60 mg/m 2 and cyclophosphamide 600 mg/m 2 were administered every 3 weeks for four cycles; docetaxel 100 mg/m 2 was administered every 3 weeks for four cycles.
In the TCH arm, docetaxel 75 mg/m 2 and carboplatin (at a target AUC of 6 mg/mL/min as a 30- to 60-minute infusion) were administered every 3 weeks for six cycles. Intravenous trastuzumab was administered weekly (initial dose of 4 mg/kg followed by weekly dose of 2 mg/kg) concurrently with either T or TC, and then every 3 weeks (6 mg/kg) as monotherapy for a total of 52 weeks. Radiation therapy, if administered, was initiated after completion of chemotherapy.
Patients with ER+ and/or PR+ tumors received hormonal therapy. DFS was the major efficacy outcome measure. Among 3222 patients, the median age was 49 (range 22 to 74 years; 6% ≥ 65 years). Disease characteristics included 54% ER+ and/or PR+ and 71% node positive.
Prior to randomization, all patients underwent primary surgery for breast cancer. The results for DFS for the integrated analysis of Studies NSABP B31 and NCCTG N9831, HERA, and BCIRG006 and OS results for the integrated analysis of Studies NSABP B31 and NCCTG N9831, and HERA are presented in Table 9. For Studies NSABP B31 and NCCTG N9831, the duration of DFS following a median follow-up of 2.0 years in the AC→TH arm is presented in Figure 1, and the duration of OS after a median follow-up of 8.3 years in the AC→TH arm is presented in Figure 2. The duration of DFS for BCIRG006 is presented in Figure 3. For Studies NSABP B31 and NCCTG N9831, the OS hazard ratio was 0.64 (95% CI: 0.55, 0.74). At 8.3 years of median follow-up, the survival rate was estimated to be 86.9% in the AC→TH arm and 79.4% in the AC→T arm. The final OS analysis results from Studies NSABP B31 and NCCTG N9831 indicate that OS benefit by age, hormone receptor status, number of positive lymph nodes, tumor size and grade, and surgery/radiation therapy was consistent with the treatment effect in the overall population.
In patients ≤ 50 years of age (n = 2197), the OS hazard ratio was 0.65 (95% CI: 0.52, 0.81) and in patients > 50 years of age (n = 1866), the OS hazard ratio was 0.63 (95% CI: 0.51, 0.78). In the subgroup of patients with hormone receptor-positive disease (ER-positive and/or PR-positive) (n = 2223), the hazard ratio for OS was 0.63 (95% CI: 0.51, 0.78). In the subgroup of patients with hormone receptor-negative disease (ER-negative and PR-negative) (n = 1830), the hazard ratio for OS was 0.64 (95% CI: 0.52, 0.80). In the subgroup of patients with tumor size ≤ 2 cm (n = 1604), the hazard ratio for OS was 0.52 (95% CI: 0.39, 0.71). In the subgroup of patients with tumor size > 2 cm (n = 2448), the hazard ratio for OS was 0.67 (95% CI: 0.56, 0.80). Table 9 Efficacy Results from Adjuvant Treatment of Breast Cancer (Studies NSABP B31, NCCTG N9831, HERA, and BCIRG006) DFS events DFS Hazard ratio (95% CI) p-value Deaths (OS events) OS Hazard ratio p-value CI = confidence interval. Studies NSABP B31 and NCCTG N9831 Studies NSABP B31 and NCCTG N9831 regimens: doxorubicin and cyclophosphamide followed by paclitaxel (AC→T) or paclitaxel plus intravenous trastuzumab (AC→TH). AC→TH (n = 1872) Efficacy evaluable population, for the primary DFS analysis, following a median follow-up of 2.0 years in the AC→TH arm. (n = 2031) Efficacy evaluable population, for the final OS analysis, following 707 deaths (8.3 years of median follow-up in the AC→TH arm). 133 0.48, Hazard ratio estimated by Cox regression stratified by clinical trial, intended paclitaxel schedule, number of positive nodes, and hormone receptor status. p< 0.0001 stratified log-rank test. 289 0.64, p< 0.0001 AC→T (n = 1880) (n = 2032) 261 418 HERA At definitive DFS analysis with median duration of follow-up of 12.6 months in the one-year intravenous trastuzumab treatment arm. Chemo→ Intravenous trastuzumab (n = 1693) 127 0.54 p< 0.0001 log-rank test. 31 0.75 p = NS NS = non-significant.
Chemo→ Observation (n = 1693) 219 40 BCIRG006 BCIRG006 regimens: doxorubicin and cyclophosphamide followed by docetaxel (AC→T) or docetaxel plus intravenous trastuzumab (AC→TH); docetaxel and carboplatin plus intravenous trastuzumab (TCH). TCH (n = 1075) 134 0.67 (0.54 – 0.84) p=0.0006, A two-sided alpha level of 0.025 for each comparison. 56 AC→TH (n = 1074) 121 0.60 (0.48 – 0.76) p< 0.0001, 49 AC→T (n = 1073) 180 80 Figure 1 Duration of Disease-Free Survival in Patients with Adjuvant Treatment of Breast Cancer (Studies NSABP B31 and NCCTG N9831) Figure 2 Duration of Overall Survival in Patients with Adjuvant Treatment of Breast Cancer (Studies NSABP B31 and NCCTG N9831) Figure 3 Duration of Disease-Free Survival in Patients with Adjuvant Treatment of Breast Cancer (BCIRG006) Exploratory analyses of DFS as a function of HER2 overexpression or gene amplification were conducted for patients in Study NCCTG N9831 and HERA, where central laboratory testing data were available. The results are shown in Table 10. The number of events in Study NCCTG N9831 was small with the exception of the IHC 3+/FISH+ subgroup, which constituted 81% of those with data. Definitive conclusions cannot be drawn regarding efficacy within other subgroups due to the small number of events.
The number of events in HERA was adequate to demonstrate significant effects on DFS in the IHC 3+/FISH unknown and the FISH+/IHC unknown subgroups. Table 10 Treatment Outcomes in Study NCCTG N9831 and HERA for Patients with HER2 Overexpression or Amplification Study NCCTG N9831 HERA Median follow-up duration of 12.6 months in the one-year intravenous trastuzumab treatment arm. HER2 Assay Result IHC by HercepTest, FISH by PathVysion (HER2/CEP17 ratio ≥ 2.0) as performed at a central laboratory.
Number of Patients Hazard Ratio DFS (95% CI) Number of Patients Hazard Ratio DFS (95% CI) IHC 3+ FISH (+) 1170 0.42 91 0.56 FISH (−) 51 0.71 8 — FISH Unknown 51 0.69 2258 0.53 IHC < 3+ / FISH (+) 174 1.01 299 All cases in this category in HERA were IHC 2+. 0.53 IHC unknown / FISH (+) — — 724 0.59 Figure 1 Figure 2 Figure 3
Metastatic Breast Cancer Intravenous Trastuzumab
The safety and efficacy of intravenous trastuzumab in the treatment of women with metastatic breast cancer were studied in a randomized, controlled clinical trial in combination with chemotherapy (H0648g, n=469 patients) and an open-label single agent clinical trial (H0649g, n=222 patients). Both trials studied patients with metastatic breast cancer whose tumors overexpress the HER2 protein. Patients were eligible if they had level 2 or 3 overexpression (based on a 0 to 3 scale) by immunohistochemical assessment of tumor tissue performed by a central testing lab. Previously Untreated Metastatic Breast Cancer (H0648g) H0648g was a multicenter, randomized, open-label clinical trial conducted in 469 women with metastatic breast cancer who had not been previously treated with chemotherapy for metastatic disease.
Patients were randomized to receive chemotherapy alone or in combination with trastuzumab given intravenously as a 4 mg/kg loading dose followed by weekly doses of intravenous trastuzumab at 2 mg/kg. For those who had received prior anthracycline therapy in the adjuvant setting, chemotherapy consisted of paclitaxel (175 mg/m 2 over 3 hours every 21 days for at least six cycles); for all other patients, chemotherapy consisted of anthracycline plus cyclophosphamide (AC: doxorubicin 60 mg/m 2 or epirubicin 75 mg/m 2 plus 600 mg/m 2 cyclophosphamide every 21 days for six cycles). Sixty-five percent of patients randomized to receive chemotherapy alone in this study received intravenous trastuzumab at the time of disease progression as part of a separate extension study. Based upon the determination by an Independent Response Evaluation Committee, the patients randomized to intravenous trastuzumab and chemotherapy experienced a significantly longer time to disease progression (TTP), a higher overall response rate (ORR), and a longer median duration of response as compared with patients randomized to chemotherapy alone.
Patients randomized to intravenous trastuzumab and chemotherapy also had a longer median overall survival (OS) (see Table 11 ). These treatment effects were observed both in patients who received intravenous trastuzumab plus paclitaxel and in those who received intravenous trastuzumab plus AC; however the magnitude of the effects was greater in the paclitaxel subgroup. Table 11: H0648g: Efficacy Results in First-Line Treatment for Metastatic Breast Cancer Combined Results Paclitaxel Subgroup AC Subgroup Intravenous Trastuzumab + All Chemotherapy (n=235) All Chemotherapy (n=234) Intravenous Trastuzumab + Paclitaxel (n=92) Paclitaxel (n=96) Intravenous Trastuzumab + AC AC=Anthracycline (doxorubicin or epirubicin) and cyclophosphamide. (n=143) AC (n=138) Time to Disease Progression (TTP) Median (months) Assessed by an independent Response Evaluation Committee., Kaplan-Meier Estimate. 7.2 4.5 6.7 2.5 7.6 5.7 95% CI 7, 8 4, 5 5, 10 2, 4 7, 9 5, 7 p -value log-rank test. < 0.0001 < 0.0001 0.002 Overall Response Rate (ORR) Events (n) 45 29 38 15 50 38 95% CI 39, 51 23, 35 28, 48 8, 22 42, 58 30, 46 p -value χ2-test. < 0.001 < 0.001 0.10 Duration of Response (DoR) Median (months), 8.3 5.8 8.3 4.3 8.4 6.4 25%, 75% Quartile 6, 15 4, 8 5, 11 4, 7 6, 15 4, 8 Overall Survival (OS) Median (months) 25.1 20.3 22.1 18.4 26.8 21.4 95% CI 22, 30 17, 24 17, 29 13, 24 23, 33 18, 27 p -value 0.05 0.17 0.16 Data from H0648g suggest that the beneficial treatment effects were largely limited to patients with the highest level of HER2 protein overexpression (3+) (see Table 12 ). Table 12: Treatment Effects in H0648g as a Function of HER2 Overexpression or Amplification HER2 Assay Result Number of Patients (N) Relative Risk The relative risk represents the risk of progression or death in the trastuzumab plus chemotherapy arm versus the chemotherapy arm. for Time to Disease Progression (95% CI) Relative Risk for Mortality (95% CI) CTA 2+ or 3+ 469 0.49 0.80 FISH (+) FISH testing results were available for 451 of the 469 patients enrolled on study. 325 0.44 0.70 FISH (−) 126 0.62 1.06 CTA 2+ 120 0.76 1.26 FISH (+) 32 0.54 1.31 FISH (−) 83 0.77 1.11 CTA 3+ 349 0.42 0.70 FISH (+) 293 0.42 0.67 FISH (−) 43 0.43 0.88 Previously Treated Metastatic Breast Cancer (Study H0649g) Intravenous trastuzumab was studied as a single agent in a multicenter, open-label, single-arm clinical trial (Study H0649g) in patients with HER2 overexpressing MBC who had relapsed following one or two prior chemotherapy regimens for metastatic disease. Of 222 patients enrolled, 66% had received prior adjuvant chemotherapy, 68% had received two prior chemotherapy regimens for metastatic disease, and 25% had received prior myeloablative treatment with hematopoietic rescue.
Patients were treated with a loading dose of 4 mg/kg IV followed by weekly doses of trastuzumab at 2 mg/kg IV. The ORR (complete response + partial response), as determined by an independent Response Evaluation Committee, was 14%, with a 2% complete response rate and a 12% partial response rate. Complete responses were observed only in patients with disease limited to skin and lymph nodes. The overall response rate in patients whose tumors tested as CTA 3+ was 18% while in those that tested as CTA 2+, it was 6%.
Patient Experience
The PrefHER study (NCT01401166) was a randomized, multi-center, two-arm, cross-over trial conducted in 240 patients with HER2-positive breast cancer undergoing neoadjuvant or adjuvant treatment. One hundred twenty-one patients in arm A received 4 cycles of HERCEPTIN HYLECTA followed by 4 cycles of intravenous trastuzumab and 119 patients in arm B received 4 cycles of intravenous trastuzumab followed by 4 cycles of HERCEPTIN HYLECTA. Both arms received a total of 18 cycles. After Cycle 8, 199 of 231 patients (86%) reported preferring subcutaneous administration of HERCEPTIN HYLECTA over intravenous trastuzumab and the most common reason cited was administration required less time (179/231) in the clinic.
After Cycle 8, 29 out of 231 patients (13%) reported preferring intravenous trastuzumab over HERCEPTIN HYLECTA and the most common reason was fewer local injection reactions. Three out of 231 patients (1%) had no preference for the route of administration. Nine out of 240 (3.8%) withdrew from treatment prior to completion of Cycle 8 and did not complete the post-study preference questionnaire.
Drug information sourced from the FDA. This content is for informational purposes only and does not constitute medical advice. Consult a healthcare professional before making any medication decisions.
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