Feasibility of Serial Multisite Image-guided Biopsy to Study Breast Cancer Evolution

Breast cancer is the most frequently diagnosed cancer in women and is the second leading cause of female cancer death in the UK. Metastatic breast cancer has a historical five-year survival of 26% in England, although there is considerable variation by histology, with the poorest outcomes observed in patients with triple negative breast cancer (TNBC). Therapeutic approaches are chosen based on tumour clinical and pathological features, including oestrogen hormone receptor (ER) and human epidermal growth factor receptor 2 (HER2) status, however, patients with advanced disease almost inevitably develop therapy resistance and disease progression.

Next generation sequencing technologies have allowed us to understand the biology of breast cancer at a previously unprecedented depth. While the molecular landscape of early breast cancer has been extensively investigated, our understanding of the molecular basis of metastatic breast cancer remains more limited. In the clinic, metastatic breast cancer tissue is often biopsied once, from a single site, at the time of diagnosis. This biopsy sampling method is under-representative of the total disease burden and does not take into consideration the fact that metastatic disease is heterogeneous and evolves during the course of the disease.

The development of a method to serially sample multiple disease sites that is acceptable to patients will allow comprehensive evaluation of the heterogeneity of their disease and allow a deeper understanding of tumour heterogeneity, the mechanisms underlying treatment resistance as well as the biological processes governing metastatic behaviour. This will enable us to develop new cancer treatments and new ways of monitoring response to cancer therapies.

FORTITUDE will evaluate established standard of care biopsy techniques (fine needle biopsy and core needle biopsy) in a serial and multisite approach in patients with metastatic breast cancer or with locally advanced but inoperable breast cancer. Tumour tissue will be acquired at:

1. Baseline (mandatory), defined as:

1. At diagnosis of locally advanced but inoperable breast cancer or metastatic disease OR 2. In patients with established locally advanced but inoperable breast cancer or metastatic disease who require re-biopsy for clinical reasons 2. At every diagnosis of disease progression (optional)

No more than a total of four lesions will be biopsied in one sitting, with a maximum of three anatomical sites targeted (and no more than two solid organs). When tissue sampling is required as part of clinical care, patients will be invited to undergo additional serial multisite sampling. The sampling scheme will be repeated at subsequent relevant time points. This will be coupled with blood sampling when clinically indicated, including prior to each cycle of systemic therapy, and on disease progression. Furthermore, any cerebrospinal, ascitic and pleural fluid drained as part of clinical care can also be collected and profiled within this study.

• Quantification of procedural complication rates [Time frame: Through study completion, 15 years]
• Quantification of duration of biopsy procedures [Time frame: Through study completion, 15 years]
• Accuracy of tumour biopsies [Time frame: Through study completion, 15 years]
• Quantification of proportion of samples adequate for molecular profiling [Time frame: Through study completion, 15 years]
• Number of clinically relevant molecular alterations detected using multisite, multiregion, and serial sampling [Time frame: Through study completion, 15 years]
• Characterisation of change in molecular phenotypes and genotypes between different regions in a single tumour [Time frame: Through study completion, 15 years]
• Characterisation of change in molecular phenotypes and genotypes between different tumours across time [Time frame: Through study completion, 15 years]
• Concordance and comparison of molecular alterations between liquid biopsies (blood, ascites, pleural fluid) and tumour needle biopsy samples [Time frame: Through study completion, 15 years]
• Characterisation of molecular and imaging tumour profiles and correlation with clinical characteristics, treatment responses and patient outcomes [Time frame: Through study completion, 15 years]