Selecting the optimal position of CDK4/6 inhibitors in hormone receptor-positive advanced breast cancer - the SONIA study: study protocol for a randomized controlled trial

Abstract

Background: Combining cyclin-dependent kinases 4 and 6 (CDK4/6) inhibitors with endocrine therapy is an effective strategy to improve progression-free survival in hormone receptor-positive (HR+), human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer. There is a lack of comparative data to help clinicians decide if CDK4/6 inhibitors can best be added to first- or second-line endocrine therapy. Improvement in median progression-free survival in first-line studies is larger than in second-line studies, but CDK4/6 inhibitors have not consistently shown to improve overall survival or quality of life. They do come with added toxicity and costs, and many patients have lasting disease remission on endocrine therapy alone. No subgroup has been identified to select patients who are most likely to benefit from the addition of CDK4/6 inhibition in any line of treatment. Altogether, these factors make that the optimal strategy for using CDK4/6 inhibitors in clinical practice is unknown.

Methods: The SONIA study is an investigator-initiated, multicenter, randomized phase III study in patients with HR+/HER2-negative advanced breast cancer. Patients are randomly assigned to receive either strategy A (first-line treatment with a non-steroidal aromatase inhibitor combined with CDK4/6 inhibition, followed on progression by fulvestrant) or strategy B (first-line treatment with a non-steroidal aromatase inhibitor, followed on progression by fulvestrant combined with CDK4/6 inhibition). The primary objective is to test whether strategy A is more effective than strategy B. The primary endpoint is time from randomization to second objective progression (PFS2). Secondary endpoints include overall survival, safety, quality of life, and cost-effectiveness. Five-hundred seventy-four events yield 89% power to show that strategy A has statistically significant, clinically meaningful superior PFS2 (according to ESMO-MCBS) in a log-rank test at the two-sided 95% confidence level. Given an accrual period of 42 months and an additional 18 months follow-up, inclusion of 1050 evaluable patients is required.

Discussion: This study design represents daily clinical practice, and the results will aid clinicians in deciding when adding CDK4/6 inhibitors to endocrine therapy will benefit their patients most. Additional biomarker analyses may help to optimize patient selection.

Trial registration: https://ichgcp.net/clinical-trials-registry/NCT03425838" title="See in ClinicalTrials.gov">NCT03425838 (8 February 2018). EudraCT-number: 2017-002334-23 (29 September 2017).

Keywords: Abemaciclib; Advanced breast cancer; CDK4/6 inhibitors; Fulvestrant; Metastatic breast cancer; Non-steroidal aromatase inhibitors; Palbociclib; Ribociclib.

Conflict of interest statement

Ethics approval and consent to participate

The SONIA study was approved by the accredited Medical Ethics Committee of the Netherlands Cancer Institute – Antoni van Leeuwenhoek (METC AVL) on September 29th, 2017. Ethical approval was obtained for all clinical sites, a list of sites currently open for inclusion can be found on Consent for publication

Not applicable.

Competing interests

GSS is a member of the steering committee of the MONALEESA-2 trial and national principal investigator for the MONALEESA-3 trial. In addition he reports institutional research support form AstraZeneca, Merck, Novartis, and Roche. No other competing interests have been reported.

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Figures

Fig. 1

Schematic overview of study design. Non-steroidal AI: non-steroidal aromatase-inhibitor, either letrozole or anastrozole (at the discretion of the treating physician). CDK4/6 inhibitor: type of CDK4/6 inhibitor according to physician’s choice and reimbursement policies