Combination anastrozole and fulvestrant in metastatic breast cancer

Rita S. Mehta, William E. Barlow, Kathy S. Albain, Ted A. Vandenberg, Shaker R. Dakhil, Nagendra R. Tirumali, Danika L. Lew, Daniel F. Hayes, Julie R. Gralow, Robert B Livingston, Gabriel N. Hortobagyi

Research output: Contribution to journalArticle

250 Citations (Scopus)

Abstract

BACKGROUND: The aromatase inhibitor anastrozole inhibits estrogen synthesis. Fulvestrant binds and accelerates degradation of estrogen receptors. We hypothesized that these two agents in combination might be more effective than anastrozole alone in patients with hormone-receptor (HR)-positive metastatic breast cancer. METHODS:Postmenopausal women with previously untreated metastatic disease were randomly assigned, in a 1:1 ratio, to receive either 1 mg of anastrozole orally every day (group 1), with crossover to fulvestrant alone strongly encouraged if the disease progressed, or anastrozole and fulvestrant in combination (group 2). Patients were stratified according to prior or no prior receipt of adjuvant tamoxifen therapy. Fulvestrant was administered intramuscularly at a dose of 500 mg on day 1 and 250 mg on days 14 and 28 and monthly thereafter. The primary end point was progressionfree survival, with overall survival designated as a prespecified secondary outcome. RESULTS:The median progression-free survival was 13.5 months in group 1 and 15.0 months in group 2 (hazard ratio for progression or death with combination therapy, 0.80; 95% confidence interval [CI], 0.68 to 0.94; P = 0.007 by the log-rank test). The combination therapy was generally more effective than anastrozole alone in all subgroups, with no significant interactions. Overall survival was also longer with combination therapy (median, 41.3 months in group 1 and 47.7 months in group 2; hazard ratio for death, 0.81; 95% CI, 0.65 to 1.00; P = 0.05 by the log-rank test), despite the fact that 41% of the patients in group 1 crossed over to fulvestrant after progression. Three deaths that were possibly associated with treatment occurred in group 2. The rates of grade 3 to 5 toxic effects did not differ significantly between the two groups. CONCLUSIONS:The combination of anastrozole and fulvestrant was superior to anastrozole alone or sequential anastrozole and fulvestrant for the treatment of HR-positive metastatic breast cancer, despite the use of a dose of fulvestrant that was below the current standard. (Funded by the National Cancer Institute and AstraZeneca; SWOG ClinicalTrials.gov number, NCT00075764.)

Original languageEnglish (US)
Pages (from-to)435-444
Number of pages10
JournalNew England Journal of Medicine
Volume367
Issue number5
DOIs
StatePublished - Aug 2 2012

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Breast Neoplasms
Survival
Therapeutics
Hormones
Confidence Intervals
Aromatase Inhibitors
National Cancer Institute (U.S.)
anastrozole
fulvestrant
Poisons
Tamoxifen
Estrogen Receptors
Disease-Free Survival
Estrogens

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Mehta, R. S., Barlow, W. E., Albain, K. S., Vandenberg, T. A., Dakhil, S. R., Tirumali, N. R., ... Hortobagyi, G. N. (2012). Combination anastrozole and fulvestrant in metastatic breast cancer. New England Journal of Medicine, 367(5), 435-444. https://doi.org/10.1056/NEJMoa1201622

Combination anastrozole and fulvestrant in metastatic breast cancer. / Mehta, Rita S.; Barlow, William E.; Albain, Kathy S.; Vandenberg, Ted A.; Dakhil, Shaker R.; Tirumali, Nagendra R.; Lew, Danika L.; Hayes, Daniel F.; Gralow, Julie R.; Livingston, Robert B; Hortobagyi, Gabriel N.

In: New England Journal of Medicine, Vol. 367, No. 5, 02.08.2012, p. 435-444.

Research output: Contribution to journalArticle

Mehta, RS, Barlow, WE, Albain, KS, Vandenberg, TA, Dakhil, SR, Tirumali, NR, Lew, DL, Hayes, DF, Gralow, JR, Livingston, RB & Hortobagyi, GN 2012, 'Combination anastrozole and fulvestrant in metastatic breast cancer', New England Journal of Medicine, vol. 367, no. 5, pp. 435-444. https://doi.org/10.1056/NEJMoa1201622
Mehta RS, Barlow WE, Albain KS, Vandenberg TA, Dakhil SR, Tirumali NR et al. Combination anastrozole and fulvestrant in metastatic breast cancer. New England Journal of Medicine. 2012 Aug 2;367(5):435-444. https://doi.org/10.1056/NEJMoa1201622
Mehta, Rita S. ; Barlow, William E. ; Albain, Kathy S. ; Vandenberg, Ted A. ; Dakhil, Shaker R. ; Tirumali, Nagendra R. ; Lew, Danika L. ; Hayes, Daniel F. ; Gralow, Julie R. ; Livingston, Robert B ; Hortobagyi, Gabriel N. / Combination anastrozole and fulvestrant in metastatic breast cancer. In: New England Journal of Medicine. 2012 ; Vol. 367, No. 5. pp. 435-444.
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AU - Tirumali, Nagendra R.

AU - Lew, Danika L.

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N2 - BACKGROUND: The aromatase inhibitor anastrozole inhibits estrogen synthesis. Fulvestrant binds and accelerates degradation of estrogen receptors. We hypothesized that these two agents in combination might be more effective than anastrozole alone in patients with hormone-receptor (HR)-positive metastatic breast cancer. METHODS:Postmenopausal women with previously untreated metastatic disease were randomly assigned, in a 1:1 ratio, to receive either 1 mg of anastrozole orally every day (group 1), with crossover to fulvestrant alone strongly encouraged if the disease progressed, or anastrozole and fulvestrant in combination (group 2). Patients were stratified according to prior or no prior receipt of adjuvant tamoxifen therapy. Fulvestrant was administered intramuscularly at a dose of 500 mg on day 1 and 250 mg on days 14 and 28 and monthly thereafter. The primary end point was progressionfree survival, with overall survival designated as a prespecified secondary outcome. RESULTS:The median progression-free survival was 13.5 months in group 1 and 15.0 months in group 2 (hazard ratio for progression or death with combination therapy, 0.80; 95% confidence interval [CI], 0.68 to 0.94; P = 0.007 by the log-rank test). The combination therapy was generally more effective than anastrozole alone in all subgroups, with no significant interactions. Overall survival was also longer with combination therapy (median, 41.3 months in group 1 and 47.7 months in group 2; hazard ratio for death, 0.81; 95% CI, 0.65 to 1.00; P = 0.05 by the log-rank test), despite the fact that 41% of the patients in group 1 crossed over to fulvestrant after progression. Three deaths that were possibly associated with treatment occurred in group 2. The rates of grade 3 to 5 toxic effects did not differ significantly between the two groups. CONCLUSIONS:The combination of anastrozole and fulvestrant was superior to anastrozole alone or sequential anastrozole and fulvestrant for the treatment of HR-positive metastatic breast cancer, despite the use of a dose of fulvestrant that was below the current standard. (Funded by the National Cancer Institute and AstraZeneca; SWOG ClinicalTrials.gov number, NCT00075764.)

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