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Ixabepilone and Eribulin Mesylate: Two Novel Agents Approved for the Chemotherapeutic Treatment of Metastatic Breast Cancer

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Ixabepilone and Eribulin Mesylate: Two Novel Agents Approved for the Chemotherapeutic Treatment of Metastatic Breast Cancer Review: Clinical Trial Outcomes Ixabepilone and eribulin mesylate: two novel agents approved for the chemotherapeutic treatment of metastatic breast cancer Clin. Invest. (2013) 3(4), 385–394 While the majority of breast cancer patients present with early stage Yael S Zack & Linda T Vahdat* disease, 40% of these patients will eventually progress to metastatic Division of Hematology and Oncology, disease. Resistance to existing chemotherapeutic agents continues to Department of Medicine, Weill Cornell Medical pose a challenge in the management of these patients. This review College, 425 East 61St, NY, 10065, USA will analyze the two most recently approved chemotherapy drugs for *Author for correspondence: Tel.: +1 212 821 0644 the treatment of breast cancer; ixabepilone and eribulin mesylate. Fax: +1 212 821 0758 Ixabepilone is a semisynthetic analog of epothilone B, and is thought to E-mail: [email protected] overcome taxane resistance via disruption to microtubule homeostasis. Two Phase III studies, one by Rugo et al. and the other by Thomas et al., showed improvement in progression-free survival with the combination of ixabepilone and capecitabine to approximately 6 months compared with 4.2 months in the capecitabine-alone group in both trials. These resulted in ixabepilone being approved for use alone or in combination with capecitabine for the treatment of locally advanced or metastatic breast cancer after failure of an anthracycline and a taxane in either the adjuvant or the metastatic setting. The drug has been shown to have activity even in heavily pretreated patients who have received at least two prior chemotherapy regimens for the treatments of metastatic disease. The main adverse events were noted to be fatigue, cytopenias and peripheral sensory neuropathy, all of which were manageable and reversible. Eribulin mesylate is another novel agent that has been approved for the treatment of metastatic breast cancer. It functions by inhibiting mitotic-spindle formation and has demonstrated efficacy against various taxane-resistant tumor cell lines. Median progression-free survival was approximately 3 months and overall survival ranged from 9 to 13 months amongst the various trials. Eribulin mesylate is approved to treat patients with metastatic breast cancer who have received at least two prior chemotherapy regimens for metastatic disease, including both anthracycline- and taxane-based chemotherapy regimens. The most common toxicities observed were fatigue, nausea, cytopenias and peripheral neuropathy. In conclusion, both drugs provide additional options for patients who have progressed on other agents. Keywords: advanced breast cancer • eribulin • halaven • ixabepilone • ixempra Breast cancer is the most prevalent malignancy among women in the USA and, according to the National Cancer Institute estimates, there were 227,000 new cases and close to 40,000 deaths from breast cancer in 2012 [101] . Approximately half of the women with metastatic breast cancer will succumb to the disease within 10.4155/CLI.13.15 © 2013 Future Science Ltd ISSN 2041-6792 385 Review: Clinical Trial Outcomes Zack & Vahdat 24 months of diagnosis of metastasis. Breast cancer ■ Phase II studies of ixabepilone mortality rates have been declining annually but it is Low et al. evaluated the role of ixabepilone in meta- unclear whether this trend is due to increased rates of static or locally advanced breast cancer patients in a early diagnosis or improvements in treatment [1] . Phase II trial (n = 37). All patients had received at least There have been tremendous advances in the treat- one prior neoadjuvant, adjuvant, or metastatic regimen ment options for metastatic breast cancer that have that contained docetaxel or paclitaxel. The objective improved the survival of these patients over the past response rate (ORR) was 22% (95% CI: 9.8–38.2%), decade; however, resistance to existing chemothera- with one complete response, seven partial responses, peutic agents continues to pose an ongoing challenge and stable disease for 13 patients. The median time in the management of these patients. Anthracyclines to progression was 80 days. In this study, five patients and taxanes have been the mainstay of treatment for also underwent biopsies of their tumors at baseline breast cancer in the adjuvant, as well as in the meta- and then again during the second cycle of ixabepilone. static setting. Nevertheless, their use can be limited While this was a small sample size, it did demonstrate mostly by resistance and, less frequently, by toxicity. increased levels of both Glu-terminated and acetylated Therefore the exploration of new agents is required. a-tubulin after treatment, indicating that ixabepilone In this review we will analyze the two most recently stabilized microtubules in the target tissue. These lev- US FDA-approved drugs for the treatment of breast els were also higher at baseline in the patients who cancer; ixabepilone and eribulin mesylate. responded to treatment, introducing an interesting hypothesis that a tumor with inherent microtubule Epothilones stability might be more likely to respond to a stabi- Epothilones are a novel class of antineoplastic agents, lizing agent with additional microtubule stabilization originating from the myxobacterium Sorangium cel- and decreased proliferation [9]. lulosum. They are cytotoxic macrolides that have a Thomas et al. conducted another Phase II clinical trial mechanism similar to that of the taxanes in that they of ixabepilone in 49 patients with taxane-resistant meta- stabilize microtubules, subsequently leading to mitotic static breast cancer. All the women had received between arrest at the G2–M transition from interference with one and three prior taxane-containing regimens, had the mitotic spindle, resulting ultimately in apoptosis. progressed on a taxane immediately prior to enrollment However, they have been shown in preclinical as well in the study, and were then enrolled to receive ixabepi- as multiple Phase I and II studies to be efficacious even lone 40 mg/m2 every 3 weeks. Time to progression for in tumors that have been previously treated and have all patients was 2.2 months (95% CI: 1.4–3.2 months). developed resistance to the taxanes. The median survival was 7.9 months (95% CI: 6.1– Ixabepilone is a semisynthetic analog of epothilone B. 14.5 months). Of the six patients (12.2%) who achieved It binds to b-tubulin, stabilizes tubulin, disrupts micro- a partial response to ixabepilone, five had not responded tubule homeostasis and induces cell-cycle arrest and to prior taxane treatment, showing that ixabepilone can apoptosis. It is thought to overcome taxane resistance overcome resistance to taxanes [4]. that has developed in tumor cells via changes in tubu- Ixabepilone was shown to have efficacy in patients lin-isotype ratios, tubulin mutations and overexpres- without prior taxane treatment in a trial performed sion of cell membrane transporters. Specifically, there by Denduluri et al. on 23 patients. Patients received are two main pathways that allow the drug to overcome a median of eight cycles of ixabepilone administered taxane resistance: first, the drug is not a substrate for as 6 mg/m2/d for 5 consecutive days every 3 weeks. the p-glycoprotein efflux pump, which is thought to The ORR was 57% (95% CI: 34.5–76.8%) – a partial confer resistance to taxanes in particular [2] and, sec- response was observed in 13 out of 23 patients, with ond, the drug has particular inhibition of the b-III a median duration of response being 5.6 months. Six class of tubulin, which is known to be overexpressed out of 23 patients (26%) experienced stable disease for in taxane-resistant tumors [3]. In fact, in vitro, it was at least 6 weeks [6]. shown to be twice as potent as paclitaxel in induc- This was followed by another single-arm Phase II ing tubulin polymerization [2]. The drug’s efficacy has study looking at the efficacy of ixabepilone in previ- been illustrated in taxane-naive and taxane-resistant ously treated patients with metastatic breast cancer tumors [2–6]. Ixabepilone has been demonstrated to who had developed resistance to anthracyclines, tax- have significant antitumor activity in multiple breast anes and capecitabine. Among 113 response-assess- cancer disease settings. Ixabepilone is cleared via able patients, the overall response rate was 11.5% hepatic metabolism and has a half-life of ranging from (13 patients had a partial response; 95% CI: 6.3– 20–72 h, indicating a variability in metabolism [7,8]. 18.9%). Another 15 patients (13.3%) were observed to have stable disease for 6 months or longer. Median 386 www.future-science.com future science group Ixabepilone & eribulin in metastatic breast cancer Review: Clinical Trial Outcomes progression-free and overall survivals (OS) were nab-paclitaxel, or ixabepilone with or without bevaci- 3.1 months and 8.6 months, respectively [5]. zumab as first-line therapy in the metastatic setting. The Ixabepilone has activity as first-line therapy in patients dosing of ixabepilone in this study was at the nonapproved with metastatic breast cancer, as demonstrated in the weekly dose of 16 mg/m2 as opposed to the FDA-approved Phase II trial conducted by Roche et al. in those previ- dose of 40 mg/m2 every 3 weeks. At the first interim ana- ously treated with anthracycline chemotherapy. Amongst lysis, the comparison of ixabepilone with paclitaxel crossed 65 patients who received ixabepilone 40 mg/m2 as an the futility boundary and there was no further accrual intravenous (iv.) infusion over 3 h every 3 weeks, the over- to the ixabepilone arm. At the second interim ana lysis, all response rate was 41.5% (95% CI: 29.4–54.4%), all accrual was closed to the nab-paclitaxel arm for the same of which were partial responses, with a median duration reason. PFS remained superior in the paclitaxel group of response being 8.2 months. Another 35% of patients compared with the two experimental arms and the toxic- experienced stable disease.
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