DNA-Guided Second Line Adjuvant Therapy For High Residual Risk, Stage II-III, Hormone Receptor Positive, HER2 Negative Breast Cancer

Summary

Objectives

Surveillance population and ctDNA screening (up to 1000 patients): Clinically high risk,
stage II-III, ER positive, HER2-, breast cancer patients who are currently receiving
adjuvant endocrine therapy with an aromatase inhibitor or tamoxifen are eligible for
ctDNA screening if they meet any one of the following criteria for high risk for
recurrence: (i) predicted risk of distant recurrence or death equal to or greater than
15% calculated by PREDICT, RSPC, or CTS5 (for late recurrence), (ii) four or more
positive axillary lymph nodes or ipsilateral supraclavicular involvement regardless of
tumor size, (iii) primary tumor equal to or greater than 5 centimeters regardless of
nodal status, (iv) patients with 1-3 positive nodes, regardless of tumor size are
eligible if at least one of the following is also true: grade 3 histology, greater than
or equal to 3 cm tumor size, high molecular risk score (i.e. Oncotype Dx Recurrence
score(RS) > 26, MammaPrint high risk, EndoPredict > 4, Prosigna score > 60).

In order to start ctDNA surveillance, patients must be currently receiving endocrine
therapy and have completed at least 6 months, but no more than 7 years and with at least
3 more years of planned adjuvant endocrine therapy of treatment without distant
recurrence. Prior adjuvant CDK4/6 therapy is allowed, but at least 12 months must have
elapsed since completing CDK4/6 therapy and enrolling into ctDNA surveillance on this
study. However, participants in the PENELOPE and PALLAS clinical trials are not eligible.

For screening, patients will undergo Signatera testing during routine follow up clinic
visits. The current ASCO/NCCN breast cancer practice guidelines recommend follow up
visits every 4 to 6 months at the treating physician's discretion. The investigators
anticipate that screening positivity rates will be the highest in patients between years
1-5 after initial diagnosis, based on the annual hazard rates of recurrence in ER
positive breast cancer. However, since up to 50% of all recurrences occur after 5 years
of follow-up, the investigators allow starting ctDNA screening up to 7 years after
starting adjuvant endocrine therapy if a patient meets criteria for high risk.