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Original Investigation
November 5, 2020

Efficacy of Circulating Tumor Cell Count–Driven vs Clinician-Driven First-line Therapy Choice in Hormone Receptor–Positive, ERBB2-Negative Metastatic Breast Cancer: The STIC CTC Randomized Clinical Trial

Author Affiliations
  • 1Department of Medical Oncology, Institut Curie, UVSQ and Paris-Saclay University, Saint-Cloud, France
  • 2INSERM Center of Clinical Investigations in Biotherapies of Cancer (CIC-BT) 1428, Paris, France
  • 3Department of Medical Oncology, Institut du Cancer de Montpellier (ICM), Institut de Recherche en Cancérologie de Montpellier, INSERM U1194, Montpellier University, Montpellier, France
  • 4Biometry Unit, Institut Curie, PSL Research University, Paris, France
  • 5Department of Medical Oncology, Centre Léon Bérard, Lyon, France
  • 6Department of Medical Oncology, Victor Hugo Clinic, Le Mans, France
  • 7Department of Medical Oncology, Institut Paoli-Calmettes, CRCM, Aix-Marseille University, Marseille, France
  • 8Department of Medical Oncology, Centre Georges François Leclerc, Dijon, France
  • 9Department of Medical Oncology, Centre Azuréen de Cancérologie, Mougins, France
  • 10Department of Medical Oncology, Institut Claudius Regaud, Toulouse, France
  • 11Department of Medical Oncology, Hôpital Tenon, Sorbonne Université, Paris, France
  • 12Department of Medical Oncology, Hôpital Saint-Louis, Paris, France
  • 13Department of Medical Oncology, Centre François Baclesse, Caen, France
  • 14Department of Medical Oncology, Centre Antoine Lacassagne, Nice, France
  • 15Department of Medical Oncology, Institut Curie, Université de Paris, Paris, France
  • 16Formerly with Department of Medical Oncology, Institut Curie, Paris, France
  • 17Now with Department of Medical Oncology, Centre Eugène Marquis, Rennes, France
  • 18Laboratory of Rare Human Circulating Cells, University Medical Center of Montpellier, EA 2415, Montpellier University, Montpellier, France
  • 19Clinical Research Department, Institut Curie, PSL Research University, Paris, France
JAMA Oncol. 2021;7(1):34-41. doi:10.1001/jamaoncol.2020.5660
Visual Abstract. Efficacy of Circulating Tumor Cell Count–Driven vs Clinician-Driven First-line Therapy Choice in Hormone Receptor–Positive, ERBB2-Negative Metastatic Breast Cancer
Efficacy of Circulating Tumor Cell Count–Driven vs Clinician-Driven First-line Therapy Choice in Hormone Receptor–Positive, ERBB2-Negative Metastatic Breast Cancer
Key Points

Question  Can the circulating tumor cell (CTC) count be used as an alternative to the clinical evaluation as the basis for determining the first-line treatment choice (chemotherapy or endocrine therapy) in hormone receptor–positive, ERBB2 (also known as HER2)-negative metastatic breast cancer?

Findings  In this randomized clinical trial that allocated 778 patients to a clinician-driven choice arm or a CTC-driven choice arm, the CTC arm was noninferior for progression-free survival.

Meaning  The CTC count may be a reliable biomarker for choosing between chemotherapy and single-agent endocrine therapy as the first-line treatment in hormone receptor–positive ERBB2-negative metastatic breast cancer.

Abstract

Importance  The choice between chemotherapy and endocrine therapy as first-line treatment for hormone receptor–positive, ERBB2 (also known as HER2)-negative metastatic breast cancer is usually based on the presence of clinical features associated with a poor prognosis. In this setting, a high circulating tumor cell (CTC) count (≥5 CTCs/7.5 mL) is a strong adverse prognostic factor for overall survival and progression-free survival (PFS).

Objective  To compare the efficacy of a clinician-driven treatment choice vs a CTC-driven choice for first-line treatment.

Interventions  In the CTC arm, patients received chemotherapy or endocrine therapy according to the CTC count (chemotherapy if ≥5 CTCs/7.5 mL; endocrine therapy if <5 CTCs/7.5 mL), whereas in the control arm, the choice was left to the investigator.

Design, Setting, and Participants  In the STIC CTC randomized, open-label, noninferiority phase 3 trial, participants were randomized to a clinician-driven choice of first-line treatment or a CTC count–driven first-line treatment choice. Eligible participants were premenopausal and postmenopausal women 18 years or older diagnosed with hormone receptor–positive, ERBB2-negative metastatic breast cancer. Data were collected at 17 French cancer centers from February 1, 2012, to July 28, 2016, and analyzed June 2019 to October 2019.

Main Outcome and Measures  The primary end point was the investigator-assessed PFS in the per-protocol population, with a noninferiority margin of 1.25 for the 90% CI of the hazard ratio.

Results  Among the 755 women in the per-protocol population, the median (range) age was 63 (30-88) years [64 (30-88) years for the 377 patients allocated to the CTC arm and 63 (31-87) years for the 378 patients allocated to the standard arm]; 138 (37%) and 103 (27%) received chemotherapy, respectively. Median PFS was 15.5 months (95% CI, 12.7-17.3) in the CTC arm and 13.9 months (95% CI, 12.2-16.3) in the standard arm. The primary end point was met, with a hazard ratio of 0.94 (90% CI, 0.81-1.09).

Conclusions and Relevance  This randomized clinical trial found that the CTC count may be a reliable biomarker method for guiding the choice between chemotherapy and endocrine therapy as the first-line treatment in hormone receptor–positive, ERBB2-negative metastatic breast cancer.

Trial Registration  ClinicalTrials.gov Identifier: NCT01710605

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