Enhertu Reduces Risk of Invasive Disease or Death in HER2+ Breast Cancer

October 18, 2025
Ashling Wahner

Enhertu led to a 53% reduction in the risk of invasive disease or death versus Kadcyla in some patients with high-risk, HER2-positive breast cancer.

Among patients with high-risk, HER2-positive primary breast cancer with residual invasive disease following neoadjuvant therapy, treatment with Enhertu (fam-trastuzumab deruxtecan-nxki; T-DXd) was associated with a statistically significant and clinically meaningful improvement in invasive disease–free survival (IDFS) versus Kadcyla (ado-trastuzumab emtansine; T-DM1), clinical trial results have shown.

Interim analysis findings from the phase 3 DESTINY-Breast05 trial were presented at the 2025 ESMO Congress.

Treatment with Enhertu (818 patients) led to a 53% reduction in the risk of invasive disease or death compared with Kadcyla (817 pstients). The three-year IDFS rates were 92.4% with Enhertu versus 83.7% with Kadcyla.

“Patients benefited [from Enhertu] irrespective of age cohorts, region of accrual, hormone receptor status, disease status at presentation, post-therapy pathologic nodal status and dual or single HER2-targeted therapy, as well as irrespective of the sequence or usage of radiation therapy for that minority of patients who did not receive [radiation] treatment,” Dr. Charles E. Geyer Jr. said in the presentation.

Geyer is a professor of medicine and chief of the Division of Malignant Hematology and Medical Oncology at the University of Pittsburgh Medical Center Hillman Cancer Center.

What Was the Rationale for DESTINY-Breast05?

Previously, the phase 3 KATHERINE trial showed that Kadcyla improved IDFS and overall survival compared with Herceptin (trastuzumab) in patients with HER2-positive early breast cancer with residual invasive disease after neoadjuvant therapy. However, patients with advanced locoregional disease or positive nodal status following neoadjuvant therapy had three-year IDFS rates of 76% and 83%, respectively; the seven-year IDFS rates were 67% and 72%, respectively. These data reinforce the unmet need for improved post-neoadjuvant treatment in this population, Geyer emphasized.

What Was the Design of DESTINY-Breast05?

This global, multicenter, randomized, open-label trial enrolled patients with residual invasive disease in the breast and/or axillary lymph nodes after neoadjuvant chemotherapy with a HER2-directed therapy. Patients needed to present with high-risk disease prior to neoadjuvant therapy, defined as inoperable early breast cancer or operable early breast cancer with axillary node–positive disease after neoadjuvant therapy. Patients also needed to have centrally confirmed HER2-positive disease and an ECOG performance status of 0 or 1. Enrolled patients were stratified by extent of disease at presentation (inoperable versus operable), type of HER2-targeted neoadjuvant therapy received (single versus dual), hormone receptor status (positive versus negative), and post-neoadjuvant therapy pathologic nodal status (positive versus negative).

Patients were randomly assigned to receive intravenous (IV) Enhertu at 5.4 mg/kg every three weeks for 14 cycles, or IV Kadcyla at 3.6 mg/kg every three weeks for 14 cycles. Treatment was followed by a 40-day safety follow-up period.

Notably, concomitant adjuvant endocrine therapy was allowed per local practice protocols. Additionally, radiotherapy, if administered, could be initiated concurrently with study therapy or completed prior to the initiation of study therapy per the investigator. An interstitial lung disease (ILD) monitoring program was required for patients who received radiotherapy.

IDFS served as the primary end point, with disease-free survival (DFS) as a key secondary end point. Other secondary end points included OS, distant recurrence–free interval (DRFI), brain metastasis–free interval (BMFI) and safety.

What Did the DESTINY-Breast05 Patient Population Look Like?

In total, 1635 patients were randomly assigned to receive Enhertu (818 patients) or Kadcyla (817 patients). In the Enhertu arm, 806 patients received treatment. A total of 27.7% of patients in this arm discontinued treatment due to side effects (17.9%), patient withdrawal (7.4%), disease recurrence (0.2%), physician decision (1.9%) and protocol deviation (0.2%). In total, 72.3% of patients in this arm completed study treatment, and the median study duration was 29.9 months.

In the Kadcyla arm, 801 patients received treatment. A total of 23.7% of patients in this arm discontinued treatment due to side effects (12.7%), patient withdrawal (6.2%), disease recurrence (3.7%), physician decision (0.6%), protocol deviation (0.1%) and other reasons (0.1%). In total, 76.3% of patients in this arm completed study treatment, and the median study duration was 29.7 months.

In the Enhertu arm, the median age was 50.3 years, Asian patients were the most predominant race (48.8%), and most patients had HER2 3+ disease by immunohistochemistry (IHC) (82.6%), hormone receptor–positive disease (71%), inoperable disease (52.7%), positive nodal status (80.7%), received dual HER2-targeted therapy with Herceptin plus Perjeta (pertuzumab) (77.9%), prior anthracycline use (51.7%) and received prior adjuvant radiotherapy (93.4%). In the Kadcyla arm, the median age was 50.6 years, Asian patients were the most predominant race (47.2%), and the highest proportions of patients had HER2 3+ disease by IHC (82.%), hormone receptor–positive disease (71.4%), inoperable disease (51.9%), positive nodal status (80.5%), received dual HER2-targeted therapy with Herceptin plus Perjeta (78.5%), prior anthracycline use (48.8%), and received prior adjuvant radiotherapy (92.9%).

What Additional Efficacy Outcomes Were Observed in DESTINY-Breast05?

Overall, investigators observed lower rates of distant and local recurrences, including central nervous system (CNS) recurrences, with Enhertu versus Kadcyla. The numbers of patients with recurrences in these respective arms were as follows:

  • Distant recurrence: 42 (non-CNS, 25; CNS, 17); 77 (non-CNS, 52; CNS, 25)
  • Local invasive recurrence: 1; 5
  • Regional recurrence: 1; 6
  • Contralateral invasive disease: 0; 6
  • Death without prior reported event: 7; 8

A DFS benefit was observed with Enhertu versus Kadcyla. The three-year DFS rates were 92.3% with Enhertu versus 83.5% with Kadcyla.

DRFI, BMFI and OS benefits were also seen with Enhertu versus Kadcyla. The respective three-year DRFI rates were 93.9% and 86.1%. The respective three-year BMFI rates were 97.6% and 95.1%. The respective three-year OS rates were 97.4% and 95.7%.

Regarding on-study treatment exposure, in the Enhertu arm, the median study treatment duration was 9.8 months, and 72.3% of patients completed the planned 14 cycles of therapy. In the Kadcyla arm, the median study treatment duration was 9.7 months, and 76.3% of patients completed the planned 14 cycles of therapy. Notably, patients who discontinued the study before receiving 14 cycles of study treatment were permitted to receive an additional HER2-targeted therapy per standard of care (SOC) guidelines to complete 14 total cycles of HER2-targeted adjuvant therapy.

What Was the Safety Profile of Enhertu vs Kadcyla in DESTINY-Breast05?

In the Enhertu arm, any-grade treatment-emergent side effects were reported in 99.5% of patients, and 50.6% of patients experienced grade 3 (severe) or higher treatment-emergent side effects. Serious treatment-emergent side effects (17.4%) and those associated with drug discontinuation (17.9%; drug-related ILD/pneumonitis, 10.8%), drug interruptions (49.6%), dose reductions (26.4%) and deaths (0.4%; ILD/pneumonitis, two patients; respiratory tract infection adjudicated as not ILD, one patient) also occurred.

In the Kadcyla arm, any-grade treatment-emergent side effects were reported in 98.4% of patients, and 51.9% of patients experienced grade 3 or higher treatment-emergent side effects. Serious treatment-emergent side effects (13.6%) and those associated with drug discontinuation (12.9%; drug-related ILD/pneumonitis, 2.5%), drug interruptions (41.1%), dose reductions (26.6%) and deaths (0.6%; leiomyosarcoma of the uterus, aneurysm, non-neutropenic sepsis, ovarian cancer and traumatic pneumothorax, one each) also occurred.

The most commonly reported treatment-emergent side effects in the Enhertu and Kadcyla arms, respectively, were nausea (71.3%; 29.3%), constipation (32.0%; 16.2%), decreased neutrophil counts (31.6%; 14.4%), vomiting (31.0%; 9.0%), decreased white blood cell counts (29.7%; 13.0%), fatigue (29.5%; 20.2%), radiation pneumonitis (28.8%; 27%), anemia (28.3%; 17.0%), increased aspartate aminotransferase levels (25.6%; 50.2%), increased alanine aminotransferase levels (23.7%; 45.3%), diarrhea (23.2%; 8.6%), decreased platelet counts (21.2%; 49.8%), decreased appetite (20.0%; 10%), headache (15.8%; 20.7%), and arthralgia (10.3%; 20.5%).

The rates of adjudicated drug-related ILD in the Enhertu and Kadcyla arms were as follows:

  • Any-grade: 9.6% versus 1.6%
  • Grade 1 (mild): 2% versus 1%
  • Grade 2 (moderate): 6.5% versus 0.6%
  • Grade 3 (severe): 0.9% versus 0%
  • Grade 4 (life-threatening): 0% versus 0%
  • Grade 5 (fatal): 0.2% versus 0%

No differences in adjudicated drug-related ILD instances were observed based on adjuvant radiotherapy timing (sequential or concurrent). Investigators observed similar distributions of any-grade adjudicated drug-related ILD events with sequential (Enhertu arm, 10.7%; Kadcyla arm, 2.6%) and concurrent (9.6%; 1%) radiotherapy.

The rates of left ventricular dysfunction in the Enhertu and Kadcyla arms were as follows:

  • Any-grade: 2.9% versus 1.7%
  • Grade 1: 0.1% versus 0%
  • Grade 2: 2.5% versus 1.4%
  • Grade 3: 0.2% versus 0.4%
  • Grade 4: 0% versus 0%
  • Grade 5: 0% versus 0%

“Adjuvant [Enhertu] demonstrated superior efficacy with manageable safety in patients with high-risk, HER2-positive early breast cancer and residual invasive disease after neoadjuvant therapy, which represents a potential new SOC in this post-neoadjuvant setting,” Geyer concluded.

References

  1. “Trastuzumab deruxtecan (T-DXd) vs trastuzumab emtansine (T-DM1) in patients (pts) with high-risk human epidermal growth factor receptor 2–positive (HER2+) primary breast cancer (BC) with residual invasive disease after neoadjuvant therapy (tx): interim analysis of DESTINY-Breast05,” Dr. Charles E. Geyer et al., presented at: 2025 ESMO Congress; October 17-21, 2025; Berlin, Germany. Abstract LBA1.
  2. Kadcyla. Prescribing information. Genentech; revised May 2025; https://www.gene.com/download/pdf/kadcyla_prescribing.pdf

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