Baseline characteristics of patients.

Background
Combination of HER2-targeted therapy and endocrine therapy offers a more tolerable alternative to HER2-targeted chemotherapy regimens for estrogen receptor (ER)-positive, HER2-positive advanced breast cancer (ABC), but with compromised efficacy. The addition of cyclin-dependent kinase 4/6 (CDK4/6) inhibition may enhance the durability of anti-tumor responses, offering a potential chemotherapy-sparing alternative, although its role in the frontline setting remains uncertain. We performed a multicenter, single-arm, phase 2 clinical trial (PLEASURABLE) to assess the activity and safety of combining dalpiciclib with pyrotinib and endocrine therapy in patients receiving first- or second-line treatment for ER-positive and HER2-positive ABC.
Methods and findings
We enrolled patients with ER-positive and HER2-positive ABC between August 1, 2019, and November 28, 2022 in this prospective, investigator-initiated trial conducted at six centers in China. Patients received dalpiciclib (125 mg once daily, on days 1–21 of each 28-day cycle) and pyrotinib (320 mg once daily) plus endocrine therapy determined by the physician’s choice (letrozole or fulvestrant). The primary endpoint was the objective response rate (ORR), while secondary endpoints included progression-free survival (PFS), duration of response (DOR), disease control rate (DCR), clinical benefit rate (CBR), safety, plasma pharmacokinetics (PK), and biomarker analysis. Efficacy was analyzed in the modified intention-to-treat population, comprising patients with at least one post-baseline tumor assessment. Safety was assessed in all patients who received at least one dose. A total of 51 patients were screened, and 48 were evaluable (median age was 52.5 years [range, 29–74]); 31 (64.6%) had prior HER2-target therapy, and 37 (77.1%) had received prior endocrine therapy. Thirty (62.5%) and 18 (37.5%) patients received the study treatment as first- and second-line HER2-targeted treatment for ABC, respectively. As of the data cutoff on December 11, 2024, six patients were lost to follow-up, and the median follow-up was 27.3 months (interquartile range, 24.8–30.5). The investigator confirmed ORR was 70.2% (95% CI [55.1, 82.7]), with a DCR of 100% (95% CI [92.5, 100]) and a CBR of 87.2% (95% CI [74.3, 95.2]). The median PFS was 22.0 months (95% CI [16.6, 26.6]), and the median DOR was 22.3 months (95% CI [16.4, 26.9]). No new safety signals were observed, and no treatment-related deaths occurred with only one (2.1%) grade 1 alopecia and no interstitial lung disease. Grade 3 or 4 treatment-related adverse events occurred in 68.8% and 12.5% of patients, respectively, mostly myelosuppression. PK analysis showed no major drug accumulation for dalpiciclib or pyrotinib over the treatment period. Of interest, no objective response was observed in three patients with detected BRCA mutations (n = 2) or increased 68Ga-HER2 affibody uptake over the initial two cycles (n = 2). The findings of this study should be interpreted with caution due to the limited patient cohort and sample size in exploratory analyses.
Conclusions
The non-intravenous, chemotherapy-sparing combination of dalpiciclib, pyrotinib, and endocrine therapy demonstrated anti-tumor activity with a manageable safety profile in the frontline treatment of ER-positive, HER2-positive ABC, supporting its further evaluation as a potential alternative.
Trial registration
ClinicalTrials.gov Identifier: NCT03772353