SUMMARY: The FDA on April 7, 2021, granted regular approval to TRODELVY® (Sacituzumab govitecan) for patients with unresectable locally advanced or metastatic Triple Negative Breast Cancer (mTNBC), who have received two or more prior systemic therapies, at least one of them for metastatic disease. Breast cancer is the most common cancer among women in the US and about 1 in 8 women (12%) will develop invasive breast cancer during their lifetime. Approximately 284,200 new cases of breast cancer will be diagnosed in 2021 and about 44,130 individuals will die of the disease, largely due to metastatic recurrence.
Triple Negative Breast Cancer (TNBC) is a heterogeneous, molecularly diverse group of breast cancers and are ER (Estrogen Receptor), PR (Progesterone Receptor) and HER2 (Human Epidermal Growth Factor Receptor-2) negative. TNBC accounts for 15-20% of invasive breast cancers, with a higher incidence noted in young patients and African American females. It is usually aggressive, and tumors tend to be high grade, and patients with TNBC are at a higher risk of both local and distant recurrence and often develop visceral metastases. Those with metastatic disease have one of the worst prognoses of all cancers with a median Overall Survival of 13 months. The majority of patients with TNBC who develop metastatic disease do so within the first 3 years after diagnosis, whereas those without recurrence during this period of time have survival rates similar to those with ER-positive breast cancers. The lack of known recurrent oncogenic drivers in patients with metastatic TNBC, presents a major therapeutic challenge. Overall survival among patients with pretreated metastatic TNBC has not changed over the past 2 decades and standard chemotherapy is associated with low response rates of 10-15% and a Progression Free Survival of only 2-3 months.
TRODELVY® is an Antibody-Drug Conjugate (ADC) in which SN-38, an active metabolite of Irinotecan, a Topoisomerase I inhibitor, is coupled to the humanized Anti-Trophoblast cell-surface antigen 2 (Trop-2) monoclonal antibody (hRS7 IgG1κ), through the cleavable CL2A linker. SN-38 cannot be given directly to patients because of its toxicity and poor solubility. Trop-2, a transmembrane calcium signal transducer, stimulates cancer-cell growth, and this cell surface receptor is overexpressed in several epithelial cancers including cancers of the breast, colon and lung, and has limited expression in normal human tissues. Trop-2 is expressed in more than 85% of breast tumors including Triple Negative Breast Cancer. Upon binding to Trop-2, the anti-TROP-2 monoclonal antibody is internalized and delivers SN-38 directly into the tumor cell, making it a suitable transporter for the delivery of cytotoxic drugs. Further, the cleavable linker enables SN-38 to be released both intracellularly into the tumor cells, as well as the tumor microenvironment, thereby allowing for the delivery of therapeutic concentrations of the active drug in bystander cells to which the conjugate has not bound. Thus, TRODELVY®-bound tumor cells are killed by intracellular uptake of SN-38, whereas the adjacent tumor cells are killed by the extracellular release of SN-38.
The FDA granted accelerated approval to TRODELVY® in April 2020 based on Objective Response Rate of 33.3% and Duration of Response of 7.7 months in a Phase I/II study. The ASCENT trial served as a confirmatory analysis, expanding the previous TRODELVY® indication to include treatment in adult patients with unresectable locally advanced or metastatic TNBC who have received two or more prior systemic therapies, at least one of them for metastatic disease.
The ASCENT study is an open-label, multicenter, active-controlled, randomized, confirmatory Phase III trial in which 529 patients with unresectable locally advanced or metastatic TNBC patients were enrolled. Eligible patients had relapsed/refractory disease and had received two or more prior systemic therapies (including a taxane), one of which could be in the neoadjuvant or adjuvant setting, if disease progression occurred within 12 months. Patients were randomly assigned 1:1 to receive TRODELVY® 10 mg/kg IV on days 1 and 8 of a 21-day cycle (N=267) or physician’s choice of single-agent chemotherapy (N= 262). The Primary endpoint was Progression Free Survival (PFS) in patients without brain metastases at baseline (N=468), as measured by a blinded Independent Centralized Review. Secondary endpoints included PFS for the total population (with and without brain metastases), Overall Survival (OS), Objective Response Rates (ORR) and Safety.
Among all randomly assigned patients (with and without brain metastases), the median PFS for patients receiving TRODELVY® was 4.8 months, compared with 1.7 months in those receiving chemotherapy (HR=0.43; P <0.0001). This represented a statistically significant and clinically meaningful 57% reduction in the risk of disease progression or death. The median OS was 11.8 months and 6.9 months respectively, in favor of TRODELVY® (HR= 0.51; P<0.0001), representing a 49% reduction in the risk of death. The most common adverse reactions in patients receiving TRODELVY® were fatigue, rash, decreased appetite, nausea, vomiting diarrhea, constipation, alopecia, anemia and abdominal pain.
It was concluded that ASCENT is the first Phase III study of an Antibody Drug Conjugate, with significant PFS and OS improvement over Standard-of-Care chemotherapy, in pretreated patients with metastatic Triple Negative Breast Cancer, fulfilling an unmet medical need.
ASCENT: A randomized phase III study of sacituzumab govitecan (SG) vs treatment of physician’s choice (TPC) in patients (pts) with previously treated metastatic triple-negative breast cancer (mTNBC). Bardia A, Tolaney SM, Loirat D, et al. ESMO Virtual Congress 2020. Abstract LBA17. Presented September 19, 2020.