Neo ALTTO (Neoadjuvant Lapatinib and/or Trastuzumab Treatment Optimisation) Study (Neo ALTTO)

Neo ALTTO (Neoadjuvant Lapatinib and/or Trastuzumab Treatment Optimisation) Study: A Randomised, Multicenter Open-label Phase III Study of Neoadjuvant Lapatinib, Trastuzumab and Their Combination Plus Paclitaxel in Women With HER2/ErbB2 Positive Primary Breast Cancer

This is a randomised, open label multicenter Phase III study comparing the efficacy of neoadjuvant lapatinib plus paclitaxel, versus trastuzumab plus paclitaxel, versus concomitant lapatinib and trastuzumab plus paclitaxel given as neoadjuvant treatment in HER2/ErbB2 over-expressing and/or amplified primary breast cancer.

Patients will be randomised to receive either: lapatinib 1500 mg daily, trastuzumab 4 mg/kg intravenous (IV) load followed by 2 mg/kg IV weekly, or lapatinib 1000 mg daily with trastuzumab 4 mg/kg IV load followed by 2 mg/kg IV weekly for a total of 6 weeks. After this biological window, patients on monotherapy arms will continue on the same targeted therapy plus weekly paclitaxel 80 mg/m^2 for a further 12 weeks, up to definitive surgery. In the combination arm, patients will receive lapatinib 750 mg daily in combination with trastuzumab 2 mg/kg IV plus weekly paclitaxel 80mg/m^2 IV for a further 12 weeks, up to definitive surgery. After surgery, patients will receive three courses of adjuvant chemotherapy with 5-Fluorouracil Epirubicin Cyclophosphamide (FEC) followed by the same targeted therapy as in the biological window of the neoadjuvant setting for a further 34 weeks (in the combination arm, lapatinib dose will be 1000 mg daily in combination with trastuzumab). The planned total duration of the anti-HER2 therapy one year.

Primary objective is to evaluate and compare the rate of pathological complete response (pCR) at the time of surgery in patients with HER2/ErbB2 overexpressing or amplified operable breast cancer randomised to lapatinib followed by lapatinib plus paclitaxel versus trastuzumab followed by trastuzumab plus paclitaxel versus lapatinib in combination with trastuzumab followed by lapatinib, trastuzumab plus paclitaxel.

Study Overview

• Status: Completed
• Conditions: Neoplasms, Breast
• Intervention / Treatment: Drug: Lapatinib; Drug: Paclitaxel; Biological: Trastuzumab

Detailed Description

This was a parallel group, three-arm, randomized, multicenter, open-label phase III study. The study compared the efficacy and tolerability of neoadjuvant lapatinib and paclitaxel, versus trastuzumab and paclitaxel, versus the combination of lapatinib with trastuzumab and paclitaxel given as neoadjuvant treatment in HER2/ErbB2 over-expressing and/or amplified primary breast cancer. Subjects were randomized to receive lapatinib, trastuzumab or lapatinib plus trastuzumab for a total of 6 weeks. After this biological window, subjects continued on the same targeted therapy plus weekly paclitaxel for a further 12 weeks, until definitive surgery (total neoadjuvant therapy duration of 18 weeks). Paclitaxel could be initiated at Week 4 if there is evidence of progressive disease (PD) at that time. Within 6 weeks after surgery, subjects received 3 cycles of adjuvant 5-flourouracil, epirubicin and cyclophosphamide (FEC) followed by the same targeted therapy as in the biological window of the neoadjuvant phase for a further 34 weeks (to complete 52 weeks of anti-HER2 therapy).

After completing 52 weeks of (neo-)/adjuvant anti-HER2 therapy, subjects were scheduled to attend post-treatment follow-up every 3 months during the first year (months 12, 15, 18, 21, and 24), every 6months in Years 3 to 5 inclusive, and annually thereafter up to Year 10. Each subject was to be followed for 10 Years. All subjects were to be followed for EFS and OS up to 10 years from last subject randomized.

• Study Type: Interventional
• Enrollment (Actual): 455
• Phase: Phase 3

Contacts and Locations

Study Locations

• Argentina
  • Quilmes, Argentina, 1878
    • Novartis Investigative Site
  • Santa Fe, Argentina, 3000
    • Novartis Investigative Site
  • Tucuman, Argentina, 4000
    • Novartis Investigative Site
  • Buenos Aires
    • Berazategui, Buenos Aires, Argentina, B1880BBF
      • Novartis Investigative Site
    • Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina, C1125ABD
      • Novartis Investigative Site
    • Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina, C1185AAT
      • Novartis Investigative Site
  • Santa Fe
    • Rosario, Santa Fe, Argentina, S2000KZE
      • Novartis Investigative Site
• Belgium
  • Brussel, Belgium, 1090
    • Novartis Investigative Site
  • Brussels, Belgium, 1000
    • Novartis Investigative Site
  • Bruxelles, Belgium, 1070
    • Novartis Investigative Site
  • Gent, Belgium, 9000
    • Novartis Investigative Site
  • Leuven, Belgium, 3000
    • Novartis Investigative Site
  • Namur, Belgium, 5000
    • Novartis Investigative Site
• Brazil
  • Rio Grande Do Sul
    • Porto Alegre, Rio Grande Do Sul, Brazil, 90430-090
      • Novartis Investigative Site
    • Porto Alegre, Rio Grande Do Sul, Brazil, 90560-030
      • Novartis Investigative Site
  • São Paulo
    • Santo Andre, São Paulo, Brazil, 09060-650
      • Novartis Investigative Site
    • Sao Paulo, São Paulo, Brazil, 03102-002
      • Novartis Investigative Site
• Canada
  • Quebec
    • Montreal, Quebec, Canada, H4J 1C5
      • Novartis Investigative Site
• Czechia
  • Brno, Czechia, 656 53
    • Novartis Investigative Site
  • Novy Jicin, Czechia, 741 01
    • Novartis Investigative Site
  • Praha 10, Czechia, 100 34
    • Novartis Investigative Site
• France
  • Bayonne, France, 64100
    • Novartis Investigative Site
  • Bordeaux, France, 33077
    • Novartis Investigative Site
  • Le Mans, France, 72015
    • Novartis Investigative Site
  • Levallois-Perret, France, 92300
    • Novartis Investigative Site
  • Paris, France, 75010
    • Novartis Investigative Site
  • Reims, France, 51100
    • Novartis Investigative Site
  • Strasbourg, France, 67000
    • Novartis Investigative Site
  • Strasbourg, France, 67085
    • Novartis Investigative Site
  • Toulouse, France, 31076
    • Novartis Investigative Site
  • Villejuif Cedex, France, 94805
    • Novartis Investigative Site
• Germany
  • Berlin, Germany, 13125
    • Novartis Investigative Site
  • Berlin, Germany, 13589
    • Novartis Investigative Site
  • Baden-Wuerttemberg
    • Freiburg, Baden-Wuerttemberg, Germany, 79106
      • Novartis Investigative Site
    • Karlsruhe, Baden-Wuerttemberg, Germany, 76135
      • Novartis Investigative Site
  • Bayern
    • Fuerth, Bayern, Germany, 90766
      • Novartis Investigative Site
    • Nuernberg, Bayern, Germany, 90340
      • Novartis Investigative Site
  • Brandenburg
    • Fuerstenwalde, Brandenburg, Germany, 15517
      • Novartis Investigative Site
  • Hessen
    • Frankfurt am Main, Hessen, Germany, 60590
      • Novartis Investigative Site
  • Mecklenburg-Vorpommern
    • Rostock, Mecklenburg-Vorpommern, Germany, 18059
      • Novartis Investigative Site
    • Stralsund, Mecklenburg-Vorpommern, Germany, 18435
      • Novartis Investigative Site
  • Niedersachsen
    • Celle, Niedersachsen, Germany, 29223
      • Novartis Investigative Site
    • Hannover, Niedersachsen, Germany, 30625
      • Novartis Investigative Site
  • Nordrhein-Westfalen
    • Dortmund, Nordrhein-Westfalen, Germany, 44137
      • Novartis Investigative Site
    • Essen, Nordrhein-Westfalen, Germany, 45122
      • Novartis Investigative Site
    • Koeln, Nordrhein-Westfalen, Germany, 50937
      • Novartis Investigative Site
    • Witten, Nordrhein-Westfalen, Germany, 58452
      • Novartis Investigative Site
  • Sachsen-Anhalt
    • Halle, Sachsen-Anhalt, Germany, 06120
      • Novartis Investigative Site
  • Schleswig-Holstein
    • Kiel, Schleswig-Holstein, Germany, 24105
      • Novartis Investigative Site
• Hong Kong
  • Hong Kong, Hong Kong
    • Novartis Investigative Site
  • Kowloon, Hong Kong
    • Novartis Investigative Site
  • Wanchai, Hong Kong
    • Novartis Investigative Site
• Hungary
  • Budapest, Hungary, H-1122
    • Novartis Investigative Site
• India
  • Bangalore, India, 560029
    • Novartis Investigative Site
  • Hyderabad, India, 500082
    • Novartis Investigative Site
  • Mumbai, India, 400012
    • Novartis Investigative Site
  • Nagpur, India, 440010
    • Novartis Investigative Site
  • New Delhi, India, 110076
    • Novartis Investigative Site
  • New Delhi, India, 110060
    • Novartis Investigative Site
  • Pune, India, 411001
    • Novartis Investigative Site
• Italy
  • Lazio
    • Roma, Lazio, Italy, 00144
      • Novartis Investigative Site
  • Liguria
    • Genova, Liguria, Italy, 16132
      • Novartis Investigative Site
  • Lombardia
    • Lecco, Lombardia, Italy, 23900
      • Novartis Investigative Site
    • Milano, Lombardia, Italy, 20141
      • Novartis Investigative Site
    • Milano, Lombardia, Italy, 20132
      • Novartis Investigative Site
    • Monza, Lombardia, Italy, 20052
      • Novartis Investigative Site
    • Sondrio, Lombardia, Italy, 23100
      • Novartis Investigative Site
  • Trentino-Alto Adige
    • Trento, Trentino-Alto Adige, Italy, 38100
      • Novartis Investigative Site
• Korea, Republic of
  • Seoul, Korea, Republic of, 003722
    • Novartis Investigative Site
  • Seoul, Korea, Republic of, 06351
    • Novartis Investigative Site
  • Seoul, Korea, Republic of, 138-736
    • Novartis Investigative Site
  • Seoul, Korea, Republic of, 135-710
    • Novartis Investigative Site
  • Songpa-gu, Seoul, Korea, Republic of, 138-736
    • Novartis Investigative Site
• Lithuania
  • Vilnius, Lithuania, LT-08660
    • Novartis Investigative Site
• Norway
  • Oslo, Norway, 0310
    • Novartis Investigative Site
  • Oslo, Norway, 0407
    • Novartis Investigative Site
• Pakistan
  • Karachi, Pakistan, 74800
    • Novartis Investigative Site
• Peru
  • Lima, Peru, Lima 11
    • Novartis Investigative Site
  • Lima, Peru, Lima 34
    • Novartis Investigative Site
• Romania
  • Bucharest, Romania, 022328
    • Novartis Investigative Site
  • Bucharest, Romania, 050098
    • Novartis Investigative Site
  • Bucuresti, Romania, 022328
    • Novartis Investigative Site
  • Cluj-Napoca, Romania, 400015
    • Novartis Investigative Site
• Russian Federation
  • Moscow, Russian Federation, 115 478
    • Novartis Investigative Site
  • Ryazan, Russian Federation, 390011
    • Novartis Investigative Site
  • St. Petersburg, Russian Federation, 197758
    • Novartis Investigative Site
  • St. Petersburg, Russian Federation, 197022
    • Novartis Investigative Site
• South Africa
  • Athlone Park, Amanzimtoti, South Africa, 4126
    • Novartis Investigative Site
  • Capital Park, South Africa, 0002
    • Novartis Investigative Site
  • Parktown, South Africa, 2193
    • Novartis Investigative Site
  • Gauteng
    • Pretoria, Gauteng, South Africa, 0181
      • Novartis Investigative Site
• Spain
  • Barcelona, Spain, 08035
    • Novartis Investigative Site
  • Girona, Spain, 17007
    • Novartis Investigative Site
  • Lerida, Spain, 25198
    • Novartis Investigative Site
  • Madrid, Spain, 28041
    • Novartis Investigative Site
  • Madrid, Spain, 28033
    • Novartis Investigative Site
  • Mataro, Spain, 08304
    • Novartis Investigative Site
  • Santiago de Compostela, Spain, 15706
    • Novartis Investigative Site
  • Sevilla, Spain, 41013
    • Novartis Investigative Site
  • Toledo, Spain, 45004
    • Novartis Investigative Site
  • Torrevieja (Alicante), Spain, 03186
    • Novartis Investigative Site
  • Valencia, Spain, 46014
    • Novartis Investigative Site
• Sweden
  • Goteborg, Sweden, SE-413 45
    • Novartis Investigative Site
• Taiwan
  • Changhua, Taiwan, 500
    • Novartis Investigative Site
  • Tainan, Taiwan, 704
    • Novartis Investigative Site
  • Taipei, Taiwan, 100
    • Novartis Investigative Site
  • Taipei, Taiwan, 104
    • Novartis Investigative Site
  • Taipei, Taiwan, 112
    • Novartis Investigative Site
• Ukraine
  • Chernivtsi, Ukraine, 58013
    • Novartis Investigative Site
  • Dnipropetrovsk, Ukraine, 49100
    • Novartis Investigative Site
  • Kharkiv, Ukraine, 61070
    • Novartis Investigative Site
  • Kiev, Ukraine, 03115
    • Novartis Investigative Site
  • Krivoy Rog, Ukraine, 50048
    • Novartis Investigative Site
  • Kyiv, Ukraine, 03022
    • Novartis Investigative Site
  • Lviv, Ukraine, 79031
    • Novartis Investigative Site
  • Odessa, Ukraine, 65055
    • Novartis Investigative Site
  • Simferopol, Ukraine, 95023
    • Novartis Investigative Site
• United Kingdom
  • Bournemouth, United Kingdom, BH7 7DW
    • Novartis Investigative Site
  • London, United Kingdom, SE1 9RT
    • Novartis Investigative Site
  • London, United Kingdom, EC1A 7BE
    • Novartis Investigative Site
  • Nottingham, United Kingdom, NG5 1PB
    • Novartis Investigative Site
  • Essex
    • Epping, Essex, United Kingdom, CM16 6TN
      • Novartis Investigative Site

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

• Female gender;
• Age ≥18 years;
• Performance Status- Eastern Cooperative Oncology Group (ECOG) 0-1
• Histologically confirmed invasive breast cancer:
• Primary tumour greater than 2 cm diameter, measured by clinical examination and mammography or echography,
• Any N,
• No evidence of metastasis (M0) (isolated supraclavicular node involvement allowed);
• Over expression and/or amplification of HER2 in the invasive component of the primary tumour [Wolff et al 2006] and confirmed by a certified laboratory prior to randomisation
• Known hormone receptor status.
• Haematopoietic status:
• Absolute neutrophil count ≥ 1,5 x 10^9/L,
• Platelet count ≥ 100 x 10^9/L,
• Hemoglobin at least 9 g/dl,
• Hepatic status:
• Serum total bilirubin ≤ 1.5 x upper limit of normal (ULN). In the case of known Gilbert's syndrome, a higher serum total bilirubin (< 2 x ULN) is allowed,
• Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT) ≤ 2.5 times ULN,
• Alkaline phosphatase ≤ 2.5 times ULN,
• Renal status:
• Creatinine ≤ 2.0 mg/dL,
• Cardiovascular:
• Baseline left ventricular ejection fraction (LVEF) ³ 50% measured by echocardiography (ECHO) or Multiple Gate Acquisition (MUGA) scan,
• Negative serum pregnancy test, within 2-weeks (preferably 7 days) prior to randomization (For women of childbearing potential)
• Fertile patients must use effective contraception (barrier method - condoms, diaphragm - also in conjunction with spermicidal jelly, or total abstinence. Oral, injectable, or implant hormonal contraceptives are not allowed)
• Signed informed consent form (ICF)
• Patient accepts to make available tumour samples for submission to central laboratory to conduct translational studies as part of this protocol

Exclusion Criteria:

• Received any prior treatment for primary invasive breast cancer;
• Previous (less than 10 years) or current history of malignant neoplasms, except for curatively treated:
• Basal and squamous cell carcinoma of the skin;
• Carcinoma in situ of the cervix.
• Patients with a prior malignancy diagnosed more than 10 years prior to randomisation may enter the study. Patients must have been curatively treated with surgery alone. Radiation therapy or systemic therapy (chemotherapy or endocrine) are NOT permitted. Prior diagnoses of breast cancer or melanoma are excluded.
• Diagnosis of inflammatory breast cancer;
• Bilateral cancer;
• This criterion has been deleted from the protocol Version 1. Patients with multi-focal cancer are no longer excluded.
• Known history of uncontrolled or symptomatic angina, clinically significant arrhythmias, congestive heart failure, transmural myocardial infarction, uncontrolled hypertension (≥180/110), unstable diabetes mellitus, dyspnoea at rest, or chronic therapy with oxygen;
• Concurrent disease or condition that would make the subject inappropriate for study participation or any serious medical disorder that would interfere with the subject's safety;
• Unresolved or unstable, serious adverse events from prior administration of another investigational drug;
• Active or uncontrolled infection;
• Dementia, altered mental status, or any psychiatric condition that would prevent the understanding or rendering of ICF;
• Malabsorption syndrome, disease significantly affecting gastrointestinal function, or resection of the stomach or small bowel. Subjects with ulcerative colitis are also excluded;
• Concurrent neoadjuvant cancer therapy (chemotherapy, radiation therapy, immunotherapy, biologic therapy other than the trial therapies);
• Concurrent treatment with an investigational agent or participation in another therapeutic clinical trial;
• Known immediate or delayed hypersensitivity reaction or idiosyncrasy to drugs chemically related to trastuzumab or lapatinib or their excipients;
• Pregnant or lactating women;
• Concomitant use of CYP3A4 inhibitors or inducers

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Masking: NONE

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: Arm 1 Lapatinib; 1500 mg lapatinib for 6 weeks followed by lapatinib plus weekly paclitaxel for an additional 12 weeks. After definitive surgery, 3 cycles of adjuvant FEC followed by 34 weeks of adjuvant lapatinib.	Drug: Lapatinib; Small molecule receptor tyrosine kinase inhibitor; Drug: Paclitaxel; antimicrotubule agent
ACTIVE_COMPARATOR: Arm 2 Trastuzumab; 4 mg/kg IV loading dose followed by 2 mg/kg IV weekly trastuzumab for 6 weeks followed by 2 mg/kg trastuzumab plus weekly paclitaxel for an additional 12 weeks. After definitive surgery, 3 cycles of adjuvant FEC followed by 34 weeks of adjuvant trastuzumab (8 mg/kg loading dose followed by 6 mg/kg every 3 weeks).	Drug: Paclitaxel; antimicrotubule agent; Biological: Trastuzumab; Therapeutic Monoclonal Antibody
EXPERIMENTAL: Arm 3 Lapatinib plus Trastuzumab; 1000 mg lapatinib plus 4 mg/kg IV loading dose followed by 2 mg/kg IV weekly trastuzumab for 6 weeks, followed by 750 mg lapatinib plus 2 mg/kg IV weekly trastuzumab plus weekly paclitaxel for an additional 12 weeks. After definitive surgery, 3 cycles of adjuvant FEC followed by 34 weeks of adjuvant lapatinib (1000 mg) in combination with trastuzumab (8 mg/kg loading dose followed by 6 mg/kg every 3 weeks).	Drug: Lapatinib; Small molecule receptor tyrosine kinase inhibitor; Drug: Paclitaxel; antimicrotubule agent; Biological: Trastuzumab; Therapeutic Monoclonal Antibody

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants With Pathological Complete Response (pCR) at the Time of Surgery	Pathological complete response is defined as no invasive cancer in the breast or only non-invasive in situ cancer in the breast specimen. Surgical breast and axillary node resection specimens were evaluated for pathologic tumor response according to National Surgical Adjuvant Breast and Bowel Project (NSABP) guidelines, which do not take into account the histological nodal status.	Weeks 20 to 22

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants With Overall Response at Week 6	The number of participants with overall response (complete response and/or partial response) was evaluated using World Health Organization (WHO) criteria by clinical examination and by mammography and breast echography with bi-dimensional measurements at Week 6. As per WHO criteria: complete response is defined as the disappearance of all lesions; partial response is defined as a greater than 50% decrease in the sum of products of the greatest length and width of the largest lesion; progressive disease is defined as a greater than 25% increase in the sum of products of all measurable lesions.	Week 6
Overall Response at the Time of Surgery	The number of participants with overall response (complete response and/or partial response) was evaluated using WHO criteria by clinical examination and mammography and breast echography with bi-dimensional measurements at the time of surgery (Weeks 20 to 22). As per WHO criteria: complete response is defined as the disappearance of all lesions; partial response is defined as a greater than 50% decrease in the sum of products of the greatest length and width of the largest lesion; progressive disease is defined as a greater than 25% increase in the sum of products of all measurable lesions.	Time of surgery (Weeks 20 to 22)
Number of Participants With Negative Lymph Nodes at the Time of Surgery	Participants were assessed for node-negative lymph nodes at the time of surgery. As per the pathological TNM (Tumor, Node, Metastases) classification (pTNM) of malignant tumors: pN, absence or presence and extent of regional lymph node metastasis. Node-negative (pN0) participants had no regional lymph node metastasis. Although not assessed in this measure, pT is the extent of primary tumor, and pM is the absence or presence of distant metastasis.	Time of surgery (Weeks 20 to 22)
Number of Participants With Actual Indicated Surgery	Participants were assessed for the type of surgery they underwent for breast cancer. Non-conservative surgery is defined as a radical or modified radical mastectomy. Conservative surgery is comprised of a lumpectomy, a quadrantectomy/segmentectomy, or a partial mastectomy. Participants who were not assessed as being candidates for non-conservative or conservative surgery were classified as non-operable.	At surgery (Weeks 20 to 22)
Mean Change From Baseline in Tumor Size at Week 6 and at Surgery	Mean change from baseline in tumor in tumor size. Change from baseline in tumor size was defined as tumor size at Week 6/ surgery (Weeks 20 to 22) minus tumor size at baseline. The difference in treatment arms was estimated for Lapatinib 1500 mg versus Trastuzumab 2 mg/kg and for Lapatinib 1000/750 mg + Trastuzumab 2 mg/kg versus Trastuzumab 2 mg/kg.	Week 6 and surgery (Weeks 20 to 22)
Number of Participants Starting Paclitaxel Before Completing 6 Weeks of Treatment With Either Lapatinib or Trastuzumab	Participants with progressive disease at 4 week assessment that were permitted to commence treatment with paclitaxel.	Week 6
Event-free Survival (EFS) - Median Clinical Follow-up	Event free survival (EFS) is defined as the time from randomization to first EFS event. For subjects who had breast cancer surgery, EFS events were post-surgery breast cancer relapse, second primary malignancy or death without recurrence. For subjects who did not have breast cancer surgery, EFS events were death during clinical follow-up or non-completion of any neoadjuvant investigational product due to disease progression.	From randomization up to approximately year 10
Event-free Survival (EFS) - Events and Censoring	Event free survival (EFS) is defined as the time from randomization to first EFS event. For subjects who had breast cancer surgery, EFS events were post-surgery breast cancer relapse, second primary malignancy or death without recurrence. For subjects who did not have breast cancer surgery, EFS events were death during clinical follow-up or non-completion of any neoadjuvant investigational product due to disease progression.	From randomization up to approximately year 10
Overall Survival (OS) - Median Survival Follow-up	Overall survival is defined as the period from randomization until death (from any cause). OS was assessed annually for up to 10 years after the randomization of the last participant into the study.	From randomization up to approximately year 10
Overall Survival (OS) - Deaths and Censoring	Overall survival is defined as the period from randomization until death (from any cause). OS was assessed annually for up to 10 years after the randomization of the last participant into the study.	From randomization up to approximately year 10
Assess Associations Between Locoregional Pathological Complete Response (pCR) and Event-free Survival (EFS) - Median Clinical Follow-up (EFS Landmark Population)	The landmark date is 30 weeks after a subject's randomization. Subjects with missing pCR status were not included in the landmark analysis. Clinical follow-up is the period during which the patient is monitored such that all recurrence or second primary malignancy (SPM) or contralateral breast cancer (CBC) events would be reported. Patients are considered in clinical follow-up from randomisation until one of the following occurs: lost to follow-up, withdrawal of consent, end of follow-up due to completion of year 10 visit, termination of study follow-up, or death.	up to year 10
Assess Associations Between Locoregional Pathological Complete Response (pCR) and Event-free Survival (EFS) - Number of Participants With EFS Events (EFS Landmark Population)	The landmark date is 30 weeks after a subject's randomization. Subjects with missing pCR status were not included in the landmark analysis. For patients who had breast cancer surgery, EFS events are post-surgery breast cancer relapse, second primary malignancy or death without recurrence. For patients who do not undergo breast cancer surgery, EFS events are death during clinical follow-up or non-completion of any neo-adjuvant investigational product due to disease progression or second primary malignancy or contralateral breast cancer.	up to year 10
Assess Associations Between Locoregional Pathological Complete Response (pCR) and and Overall Survival (OS) - Median Clinical Follow-up (OS Landmark Population)	The landmark date is 30 weeks after a subject's randomization. Subjects with missing pCR status were not included in the landmark analysis. Patients are considered in survival follow-up from randomisation until one of the following occurs: lost to follow-up, withdrawal of consent, end of follow-up due to completion of year 10 visit, termination of study follow-up, or death. For subjects with no death recorded in the database, time to death is censored.	up to year 10
Assess Associations Between Locoregional Pathological Complete Response (pCR) and and Overall Survival (OS) - Number of Participants Who Died (OS Landmark Population)	The landmark date is 30 weeks after a subject's randomization. Subjects with missing pCR status were not included in the landmark analysis. Includes deaths due to any cause.	up to year 10
To Assess Safety Via a Comparison of the Three Treatment Arms - to Measure On-treatment Primary Cardiac Endpoints		Adverse events were collected from first dose of study treatment until end of study treatment plus 30 days post treatment, up to maximum duration of 31 weeks.
Metabolic Response Rate Determined by Positron Emission Tomography/Computed Tomography (PET/CT)	Metabolic Response Rate determined by Positron Emission Tomography/Computed Tomography (PET/CT)	Week 2 and Week 6
Percentage of Participants With the Indicated Biomarker Expression - PIK3CA.	Biomarker levels of phosphatidylinositol 3-kinase (PI3K) catalytic subunit (PIK3CA) were assessed in participants at baseline.	Baseline
Percentage of Participants With the Indicated Biomarker Expression - PTEN.	Biomarker levels of phosphate and tensin homolog deleted from chromosome 10 (PTEN) were assessed in participants at baseline.	Baseline
Ratio (95% CI) of Geometric Means in p95HER2 Expression in HR Positive Patients With pCR vs no pCR	Ratio (95% CI) of geometric means in p95 human epidermal growth factor receptor (p95HER2) expression in hormone-receptor (HR) positive patients with pathological complete response (pCR) vs no pCR	Baseline
Percentage of Participants With Circulating Tumor Cells (CTC) in the Bloodstream	Circulating tumor cells (CTCs) are cells that have detached from a primary tumor and circulate in the bloodstream. In the adjuvant phase, after surgery all participants received 3 courses of adjuvant 5-fluorouracil, epirubicin and cyclophosphamide, followed by lapatinib 1500 mg or trastuzumab 2 mg/kg or lapatinib 1000/750 mg plus trastuzumab 2 mg/kg given prior to surgery in the neoadjuvant setting for an additional 34 weeks.	Measurement performed at one or more of the time points: baseline, week 2 or week 18

Collaborators and Investigators

• Sponsor: Novartis Pharmaceuticals
• Collaborators: Breast International Group; SOLTI Breast Cancer Research Group

Publications and helpful links

General Publications

• Baselga J, Piccart M, Gelber R, di CosimoS, Viale G, Koehler M, Rojo F. Neo-ALTTO (Neoadjuvant Lapatinib and/or Trastuzumab Treatment Optimisation) study [BIG 1-06 /solti/EGF106903]: a phase III translational study for HER2-overexpressing early breast cancer. [Lancet]. 2012;S140-6736(11):
• Chumsri S, Li Z, Serie DJ, Norton N, Mashadi-Hossein A, Tenner K, Brauer HA, Warren S, Danaher P, Colon-Otero G, Partridge AH, Carey LA, Hilbers F, Van Dooren V, Holmes E, Di Cosimo S, Werner O, Huober JB, Dueck AC, Sotiriou C, Saura C, Moreno-Aspitia A, Knutson KL, Perez EA, Thompson EA. Adaptive immune signature in HER2-positive breast cancer in NCCTG (Alliance) N9831 and NeoALTTO trials. NPJ Breast Cancer. 2022 May 24;8(1):68. doi: 10.1038/s41523-022-00430-0.
• Pizzamiglio S, Cosentino G, Ciniselli CM, De Cecco L, Cataldo A, Plantamura I, Triulzi T, El-Abed S, Wang Y, Bajji M, Nuciforo P, Huober J, Ellard SL, Rimm DL, Gombos A, Daidone MG, Verderio P, Tagliabue E, Di Cosimo S, Iorio MV. What if the future of HER2-positive breast cancer patients was written in miRNAs? An exploratory analysis from NeoALTTO study. Cancer Med. 2022 Jan;11(2):332-339. doi: 10.1002/cam4.4449. Epub 2021 Dec 17.
• Powles RL, Redmond D, Sotiriou C, Loi S, Fumagalli D, Nuciforo P, Harbeck N, de Azambuja E, Sarp S, Di Cosimo S, Huober J, Baselga J, Piccart-Gebhart M, Elemento O, Pusztai L, Hatzis C. Association of T-Cell Receptor Repertoire Use With Response to Combined Trastuzumab-Lapatinib Treatment of HER2-Positive Breast Cancer: Secondary Analysis of the NeoALTTO Randomized Clinical Trial. JAMA Oncol. 2018 Nov 1;4(11):e181564. doi: 10.1001/jamaoncol.2018.1564. Epub 2018 Nov 8.
• Fumagalli D, Venet D, Ignatiadis M, Azim HA Jr, Maetens M, Rothe F, Salgado R, Bradbury I, Pusztai L, Harbeck N, Gomez H, Chang TW, Coccia-Portugal MA, Di Cosimo S, de Azambuja E, de la Pena L, Nuciforo P, Brase JC, Huober J, Baselga J, Piccart M, Loi S, Sotiriou C. RNA Sequencing to Predict Response to Neoadjuvant Anti-HER2 Therapy: A Secondary Analysis of the NeoALTTO Randomized Clinical Trial. JAMA Oncol. 2017 Feb 1;3(2):227-234. doi: 10.1001/jamaoncol.2016.3824. Erratum In: JAMA Oncol. 2019 Jan 1;5(1):122.
• Salgado R, Denkert C, Campbell C, Savas P, Nuciforo P, Aura C, de Azambuja E, Eidtmann H, Ellis CE, Baselga J, Piccart-Gebhart MJ, Michiels S, Bradbury I, Sotiriou C, Loi S. Tumor-Infiltrating Lymphocytes and Associations With Pathological Complete Response and Event-Free Survival in HER2-Positive Early-Stage Breast Cancer Treated With Lapatinib and Trastuzumab: A Secondary Analysis of the NeoALTTO Trial. JAMA Oncol. 2015 Jul;1(4):448-54. doi: 10.1001/jamaoncol.2015.0830. Erratum In: JAMA Oncol. 2015 Jul;1(4):544. JAMA Oncol. 2015 Nov;1(8):1172. Nucifero, Paolo [corrected to Nuciforo, Paolo]. JAMA Oncol. 2019 Jan 1;5(1):122.
• Nuciforo PG, Aura C, Holmes E, Prudkin L, Jimenez J, Martinez P, Ameels H, de la Pena L, Ellis C, Eidtmann H, Piccart-Gebhart MJ, Scaltriti M, Baselga J. Benefit to neoadjuvant anti-human epidermal growth factor receptor 2 (HER2)-targeted therapies in HER2-positive primary breast cancer is independent of phosphatase and tensin homolog deleted from chromosome 10 (PTEN) status. Ann Oncol. 2015 Jul;26(7):1494-500. doi: 10.1093/annonc/mdv175. Epub 2015 Apr 7.
• de Azambuja E, Holmes AP, Piccart-Gebhart M, Holmes E, Di Cosimo S, Swaby RF, Untch M, Jackisch C, Lang I, Smith I, Boyle F, Xu B, Barrios CH, Perez EA, Azim HA Jr, Kim SB, Kuemmel S, Huang CS, Vuylsteke P, Hsieh RK, Gorbunova V, Eniu A, Dreosti L, Tavartkiladze N, Gelber RD, Eidtmann H, Baselga J. Lapatinib with trastuzumab for HER2-positive early breast cancer (NeoALTTO): survival outcomes of a randomised, open-label, multicentre, phase 3 trial and their association with pathological complete response. Lancet Oncol. 2014 Sep;15(10):1137-46. doi: 10.1016/S1470-2045(14)70320-1. Epub 2014 Aug 14.
• Yarden Y, Pines G. The ERBB network: at last, cancer therapy meets systems biology. Nat Rev Cancer. 2012 Jul 12;12(8):553-63. doi: 10.1038/nrc3309.
• Baselga J, Bradbury I, Eidtmann H, Di Cosimo S, de Azambuja E, Aura C, Gomez H, Dinh P, Fauria K, Van Dooren V, Aktan G, Goldhirsch A, Chang TW, Horvath Z, Coccia-Portugal M, Domont J, Tseng LM, Kunz G, Sohn JH, Semiglazov V, Lerzo G, Palacova M, Probachai V, Pusztai L, Untch M, Gelber RD, Piccart-Gebhart M; NeoALTTO Study Team. Lapatinib with trastuzumab for HER2-positive early breast cancer (NeoALTTO): a randomised, open-label, multicentre, phase 3 trial. Lancet. 2012 Feb 18;379(9816):633-40. doi: 10.1016/S0140-6736(11)61847-3. Epub 2012 Jan 17. Erratum In: Lancet. 2012 Feb 18;379(9816):616. Dosage error in published abstract; MEDLINE/PubMed abstract corrected.

Study record dates

Study Major Dates

• Study Start (ACTUAL): January 5, 2008
• Primary Completion (ACTUAL): May 27, 2010
• Study Completion (ACTUAL): December 23, 2019

Study Registration Dates

• First Submitted: November 1, 2007
• First Submitted That Met QC Criteria: November 1, 2007
• First Posted (ESTIMATE): November 4, 2007

Study Record Updates

• Last Update Posted (ACTUAL): September 21, 2021
• Last Update Submitted That Met QC Criteria: August 24, 2021
• Last Verified: August 1, 2021

More Information

Terms related to this study

• Keywords: breast cancer; Neoadjuvant; breast carcinoma; Lapatinib; Early Breast Cancer; breast lump; HER2 positive metastatic breast cancer; breast cancer progression; breast cancer positive for human epidermal growth factor receptor 2 (HER2) HER2 positive metastatic breast cancer; estrogen-receptor (ER) positive(+) breast cancer; Paget's disease; ErbB2+
• Additional Relevant MeSH Terms: Skin Diseases; Neoplasms; Neoplasms by Site; Breast Diseases; Breast Neoplasms; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Antineoplastic Agents; Tubulin Modulators; Antimitotic Agents; Mitosis Modulators; Antineoplastic Agents, Phytogenic; Antineoplastic Agents, Immunological; Protein Kinase Inhibitors; Paclitaxel; Trastuzumab; Lapatinib
• Other Study ID Numbers: EGF106903; 2006-000564-81 (EUDRACT_NUMBER); CLAP016B2302 (OTHER: Novartis)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES

IPD Plan Description

Novartis is committed to sharing with qualified external researchers, access to patient-level data and supporting clinical documents from eligible studies. These requests are reviewed and approved by an independent review panel on the basis of scientific merit. All data provided is anonymized to respect the privacy of patients who have participated in the trial in line with applicable laws and regulations.

This trial data availability is according to the criteria and process described on www.clinicalstudydatarequest.com.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No