Background
Main text
The biology of the PI3K/AKT/mTORC1 axis
BOLERO-2 and SOLAR-1 trials: a comparison of efficacy and safety data
Patient/tumor characteristic | Everolimus and exemestane group (N = 485) | Placebo and exemestane group (N = 239) | Alpelisib and fulvestrant group (N = 169) | Placebo and fulvestrant group (N = 172) |
---|---|---|---|---|
Age (years) | ||||
Median | 62 | 61 | 63 | 64 |
Range | 34–93 | 28–90 | 25–87 | 38–92 |
ECOG Performance Statusa (%) | ||||
0 | 60 | 59 | 66.3 | 65.7 |
1 | 36 | 35 | 33.1 | 33.7 |
2 | 2 | 3 | 0 | 0 |
Missing data | NA | NA | 0.6 | 0.6 |
Visceral disease (%) | 56 | 56 | 55 | 58.1 |
Metastatic site (%) | ||||
Lung | 29 | 33 | 33.7 | 39.5 |
Liver | 33 | 30 | 29 | 31.4 |
Bone | 76 | 77 | NA | NA |
No. of metastatic sites (%) | ||||
0–1 | 32 | 29 | 37.3 | 30.2 |
2 | 31 | 34 | 34.3 | 34.9 |
≥ 3 | 36 | 37 | 28.4 | 34.3 |
Previous chemotherapy (%) | ||||
Neoadjuvant or adjuvant only | 44 | 40 | 59.8 | 62.2 |
Treatment of metastatic disease (with or without neoadjuvant or adjuvant therapy) | 26 | 26 | 0 | 0.6 |
Previous CDK 4/6 inhibitorsb (%) | 0 | 0 | 5.3 | 6.4 |
Clinical endpoint | Everolimus and exemestane group (N = 482) | Placebo and exemestane group (N = 238) | Alpelisib and fulvestrant group (N = 169) | Placebo and fulvestrant group (N = 172) |
---|---|---|---|---|
Best overall response (%) | ||||
Complete response CR | 0 | 0 | 0.6 | 1.2 |
Partial response PR | 12.6 | 2.1 | 26.0 | 11.6 |
Stable disease SD | 73.4 | 62.8 | 34.3 | 36.6 |
Neither complete response nor progressive diseasea | / | / | 22.5 | 14.5 |
Progressive disease PD | 5.8 | 23.4 | 9.5 | 30.8 |
Unknown | 8.2 | 11.7 | 7.1 | 5.2 |
Overall response (%) | 12.6 | 2.1 | 26.6 | 12.8 |
Clinical benefit (%) | 49.9 | 22.2 | 61.5 | 45.3 |
Adverse event | Everolimus and exemestane group (N = 482) | Placebo and exemestane group (N = 238) | Alpelisib and fulvestrant group (N = 284) | Placebo and fulvestrant group (N = 287) | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Any grade | Grade 3 | Grade 4 | Any grade | Grade 3 | Grade 4 | Any grade | Grade 3 | Grade 4 | Any grade | Grade 3 | Grade 4 | |
Hyperglicemia | 16 | 6 | < 1 | 3 | 1 | 0 | 63.7 | 32.7 | 3.9 | 9.8 | 0.3 | 0.3 |
Stomatitis | 67 | 8 | 0 | 12 | < 1 | 0 | 24.6 | 2.5 | 0 | 6.3 | 0 | 0 |
Rash | 36 | 1 | 0 | 6 | 0 | 0 | 35.6 | 9.9 | 0 | 5.9 | 0.3 | 0 |
Fatigue | 37 | 4 | < 1 | 27 | 1 | 0 | 24.3 | 3.5 | 0 | 17.1 | 1.0 | 0 |
Diarrhea | 30 | 2 | < 1 | 16 | 1 | 0 | 57.7 | 6.7 | 0 | 15.7 | 0.3 | 0 |
Nausea | 27 | < 1 | < 1 | 27 | 1 | 0 | 44.7 | 2.5 | 0 | 22.3 | 0.3 | 0 |
Decreased appetite | 29 | 1 | 0 | 10 | 0 | 0 | 35.6 | 0.7 | 0 | 10.5 | 0.3 | 0 |
Vomiting | 14 | < 1 | < 1 | 11 | < 1 | 0 | 27.1 | 0.7 | 0 | 9.8 | 0.3 | 0 |
Weight loss | 19 | 1 | 0 | 5 | 0 | 0 | 26.8 | 3.9 | 0 | 2.1 | 0 | 0 |
Dysgeusia | 21 | < 1 | 0 | 5 | 0 | 0 | 16.5 | 0 | 0 | 3.5 | 0 | 0 |
Headache | 19 | < 1 | 0 | 13 | 0 | 0 | 17.6 | 0.7 | 0 | 13.2 | 0 | 0 |
Asthenia | 12 | 2 | 0 | 3 | 0 | 0 | 20.4 | 1.8 | 0 | 12.9 | 0 | 0 |
Pruritus | 11 | < 1 | 0 | 3 | 0 | 0 | 18 | 0.7 | 0 | 5.6 | 0 | 0 |
Arthralgia | 16 | 1 | 0 | 16 | 0 | 0 | 11.3 | 0.4 | 0 | 16.4 | 1.0 | 0 |
Cough | 22 | 1 | 0 | 11 | 0 | 0 | / | / | / | / | / | / |
Dyspnea | 18 | 4 | 0 | 9 | 1 | < 1 | / | / | / | / | / | / |
Pneumonitis | 12 | 3 | 0 | 0 | 0 | 0 | / | / | / | / | / | / |
Anemia | 16 | 5 | 1 | 4 | < 1 | < 1 | / | / | / | / | / | / |
Thrombocytopenia | 12 | 2 | 1 | < 1 | 0 | < 1 | / | / | / | / | / | / |
Epistaxis | 15 | 0 | 0 | 1 | 0 | 0 | / | / | / | / | / | / |
Pyrexia | 14 | < 1 | 0 | 6 | < 1 | 0 | / | / | / | / | / | / |
Peripheral edema | 14 | 1 | 0 | 6 | < 1 | 0 | / | / | / | / | / | / |
AST level increaseda | 13 | 3 | < 1 | 6 | 1 | 0 | / | / | / | / | / | / |
ALT level increasedb | 11 | 3 | < 1 | 3 | 2 | 0 | / | / | / | / | / | / |
Constipation | 13 | < 1 | 0 | 11 | < 1 | 0 | / | / | / | / | / | / |
Insomnia | 11 | < 1 | 0 | 8 | 0 | 0 | / | / | / | / | / | / |
Back pain | 11 | 0 | 0 | 8 | 1 | 0 | / | / | / | / | / | / |
Hyperlipidemia | 14 | 1 | 0 | 2 | 0 | 0 | / | / | / | / | / | / |
Infections and infestations | 50 | 5 | 2 | 25 | 2 | 0 | / | / | / | / | / | / |
Alopecia | / | / | / | / | / | / | 19.7 | 0 | 0 | 2.4 | 0 | 0 |
Mucosal inflammation | / | / | / | / | / | / | 18.3 | 2.1 | 0 | 1.0 | 0 | 0 |
Other prospective studies investigating Eve or Alp
Everolimus | |||||||||||
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Study | Study design | Population | N° of pts. | Previous CT allowed | Median TD (mos)/(R)DIa (mg/d) | ORR | mPFS (mos) | mOS (mos) | Any grade AEs (%) (Eve combination)b | G3/4 AEs (%) (Eve combination) b | Discontinuation ratec |
4EVER [38], phase IIIb, open label, single arm | Eve + Exe (10 + 25 mg/d) | Postmenopausal HR+, HER2− LABC/mBC progressing on or after an NSAI (either adjuvant or for advanced disease) | 299b | Yes, any number of lines for LABC/mBC, prior Exe allowed | TD/RDI, 4.4/0.98 | 8.9% (at 24 weeks) | 5.6 | mOS NR, OS at 48w 66.9% | Overall 98.7% Stomatitis 49.2% Fatigue 36.1% Diarrhea 26.4% Nausea 26.1% | Overall 58.9% Stomatitis 8.4% GPHD 6.7% Dyspnea 4.7% Anemia 4.3% | 24.7% |
BRAWO [39], phase IV, non-interventional | Eve + Exe (5–10 + 25 mg/d) | HR+, HER2− LABC/mBC progressed after a NSAI Eve + Exe as per clinical practice | 2074 | Yes, previous Exe allowed | TD 10 mg/d, 5.1 TD 5 mg/d, 4.6 | 8.2% | 6.6 | NA | Stomatitis 42.6% Fatigue 19.8% | Stomatitis 3.9% Fatigue 1.5% | 26% |
STEPAUT [40], phase IV, non-interventional | Eve + Exe (5–10 + 25 mg/d) | Postmenopausal HR+, HER2− LABC/mBC progressing on/after prior NSAIs in routine clinical practice | 225 | NS | TD/DI, NA/NA | NA | 9.5 | NA | Stomatitis/mucositis 48% Rash/exanthema 22.2% Dyspnea/cough 22.2% | Stomatitis/mucositis 4.4% GPHD/weight loss 2.7% Inappetence /nausea 2.2% | NA |
BALLET [41], phase IIIb, open label, single arm, expanded access trial | Eve + Exe (5–10 + 25 mg/d) | Postmenopausal HR+, HER2− LABC/mBC progressing on/after prior NSAIs | 2133 | Yes, any number of lines for LABC/mBC | TD/RDI, 3.7/0.98 | NA | NA | NA | Overall 94.7% Stomatitis 52.8% Asthenia 22.8% Diarrhea 16.8% Rash 16.5% Inappetence 16% | Overall 42.7% Stomatitis 9.4% Asthenia 3.6% Hyperglycemia 2.9% Dyspnea 2% NIP 1.9% | 17.1% |
EVEREXES [42], phase IIIb, open label, single arm, Asia and Africa | Eve + Exe (10 + 25 mg/d) | Postmenopausal HR+, HER2− LABC/mBC progressing on/after prior NSAI (adjuvant or for LABC/mBC) | 232 | Yes, no more than 1 prior CT line for LABC/mBC | TD/DI, NA/9.2 | 15.8% | 9.5 | NA | Stomatitis 60.4% Skin toxicity 27.8% Hyperglycemia 24.7% Fatigue 17.2% Weight loss 15.4% | Stomatitis 10.6% Hyperglycemia 7% Fatigue 2.2% NIP 1.3% Weight loss 0.9% | NA |
BOLERO-4 [43], phase II, multicenter, open-label, single-arm | First line: Eve + Let (10 + 2.5 mg/d); at PD second line: Eve + Exe (10 + 25 mg/d) | Postmenopausal HR+ HER2− LABC/mBC | 202, 50 | No | TD/DI, 14.8/8.5 and 2.9/8.3 | 45%, 6% | 22, 3.7 | mOS NR, OS at 24 m 78.7% | Eve + Let Overall 100% Stomatitis 68.8% Loss of weight 44% Diarrhea 41% Nausea 37% | Eve + Let Overall 58% Anemia 10% Hypertension 8% Stomatitis 6% Hypertriglyceridemia 6% | Eve + Let 15.8% |
TAMRAD [44], phase II, open-label, randomized | Eve + TAM (10 + 20 mg/d) vs. TAM (20 mg/d) | Postmenopausal HR+, HER2−, LABC/mBC progressing on/after prior NSAI (adjuvant or for LABC/mBC) | 54, 57 | Yes, any number of lines for LABC/mBC | TD/DI, 6.2/NA and 4.8/NA | 14%, 13% | 8.6, 4.5 | NR, 32.9 | Pain 82% Fatigue 72% Anemia 69% Stomatitis 56% Leukopenia 54% | Stomatitis 11% Pain 9% Infections 7% Anorexia 7% Fatigue 6% | Eve + TAM 22% |
PrE0102 [45], phase II, randomized, double-blind, placebo-controlled | Eve + Fulve (10 mg/d)fvs. Fulve | Postmenopausal HR+ HER2− LABC/mBC progressing on/after prior NSAI (adjuvant or for LABC/mBC) | 66, 65 | Yes, no more than 1 prior CT line for LABC/mBC | TD/DI, 5.1/NA and 4.6/NA | 18.2%, 12.3% | 10.3, 5.1 | 28.3, 31.4 | Mucositis 53% Fatigue 42% Rash 38% Anemia 31% Diarrhea 23% | Mucositis 11% NIP 6% Fatigue 6% | Eve + Fulv 20% |
MANTA [46], phase II, open-label, randomized | Eve + Fulve (10 mg/d)f, cVIS + Fulve, (50 mg BID)g, iVIS + Fulve (2 days on, 5 days off; 125 mg BID)h, Fulve | Postmenopausal HR+, LABC/mBC progressing on/after prior NSAI (either adjuvant or for LABC/mBC) | 65, 103, 98, 67 | Yes, no more than 1 prior CT line for LABC/mBC | TD/DI, NA/NA for all arms | 41.2%, 30.4%, 28.6%, 25.0% | 12.3, 7.6, 8.0, 5.4 | NR, 27.1, 24.2, 24.4 | Stomatitis 60% Asthenia 53.3% Rash 50.0% Diarrhea 31.7% Decreased appetite 30.0% | Stomatitis 11.7% Rash 5.0% Asthenia 3.3% Diarrhea 1.7% Decreased appetite 1.7% | 18.8% |
Safra et al. [47], phase II, open-label, single-arm, multicenter trial | Eve + Let (10 + 2.5 mg/d) | Postmenopausal ER+, HER2− LABC/mBC progressing on/after prior ET (either adjuvant or for LABC/mBC) | 72 | No | TD/DI, NA/NA | 23.3% | 8.8 | 22.9 | Fatigue 61.1% Stomatitis 54.2% Rash 33.4% Cough 33.3% Decreased appetite 31.9% | Anemia 9.7% Stomatitis 8.3% Fatigue 5.6% Diarrhea 5.6% Hyperglycemia 4.2% | 12.5% |
BOLERO-6 [48], phase II, open-label, randomized | Eve + Exe (10 + 25 mg/d) vs. Eve (10 mg/d) vs. capecitabine (1250 mg/m2 BID) | Postmenopausal HR+ HER2− LABC/mBC progressing on/after prior NSAI | 104, 103, 102 | Yes, no more than 1 prior CT line for LABC/mBC, prior Exe not allowed | TD/RDI, 6.3/0.92, 4.6/0.98, and 6.1/0.78 | NA | 8.4, 6.8, 9.6 | 23.1, 29.3, 25.6 | Overall 100% Stomatitis 49% Fatigue 38% Diarrhea 35% Anemia 32% GGT elevation 15% AST elevation 15% | Overall 70% Anemia 13% Stomatitis 9% GGT elevation 9% Fatigue 8% AST elevation 7% Pneumonitis 7% | Eve + Exe 8% |
Yardley et al. [49], phase II, open label | Eve (10 mg/d) added to the most recent ET on which a patient progressed | Post/premenopausal HR+, HER2− LABC/mBC refractory to ET (either adjuvant or for LABC/mBC) | 47 | Yes no more than 1 prior CT line for LABC/mBC | TD/DI, 4.1/NA | 6% | 6.6 | 21.1 | Fatigue 38% Stomatitis 32% Mucosal inflammation 28% Rash 28% | Fatigue 4% Stomatitis 6% Mucosal inflammation 4% Rash 4% | 15% |
Alpelisib | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|
Study | Study design | Population | N° of pts. | Previous CT allowed | ORR | mPFS (mos) | mOS (mos) | Any grade AEs (%) | G3/4 AEs (%) | Discontinuation ratea |
Juric et al. [30], phase Ib, open-label, single-arm | Alpelisib + Fulvb (300–350–400 mg/d)d | Postmenopausal PIK3CA-mutated (60%) or PIK3CA-wt (38%) HR+, LABC/mBC progressing on/after prior ET | 87 | NS | PIK3CA-mutated, 29%; PIK3CA-wt, 0% | PIK3CA-mutated, 9.1; PIK3CA-wt, 4.7 | NA | Diarrhea 60% Nausea 53% Hyperglycemia 51% | Hyperglycemia 22% Maculopapular rash 13% Rash 8% | 10% |
Mayer et al. [35], phase Ib, multicenter, open-label | Alpelisib + Let (300–350 + 2.5 mg/d)c | Postmenopausal HR+, HER2− mBC progressing on/after prior ET | 26 | Yes | PIK3CA-mutated, 25%; PIK3CA-wt, 10% | NA | NA | Alpelisib 300 mg/d Diarrhea 80% Nausea 60% Hyperglicemia 55% Rash 45% Fatigue 45% | Diarrhea 10% Hyperglicemia 10% AST/ALT elevation 5% | 11% |
Rugo et al. [51], phase 2, open-label, non-comparative study | Alpelisib + Fulvbd (300 mg/d)c, Alpelisib + Letd (300 + 2.5 mg/d) | Men and women with PIK3CA-mutated HR+, HER2− aBC whose disease progressed on/after CDK4/6i + ET | 21, 18 | Yes | 20%, 18% | NA | NA | NA | Hyperglycemia 38.1% (Fulv)/27.8% (Let) Rash 4.8% (Fulv)/27.8% (Let) | 5%, 5% |