Highlights
- Vepdegestrant, a first-in-class oral PROTAC ER degrader, demonstrates superior efficacy to fulvestrant in ESR1-mutant advanced breast cancer.
- In ESR1-mutant patients, vepdegestrant doubles median progression-free survival compared to fulvestrant.
- Preclinical studies show robust ER degradation, tumor regression, and synergy with CDK4/6 and PI3K/mTOR inhibitors.
- Safety profile is manageable; higher rates of grade ≥3 adverse events than fulvestrant but low discontinuation rates.
Study Background and Disease Burden
Estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer constitutes the majority of hormone-driven metastatic breast cancers in postmenopausal women. Despite advances with endocrine therapies and cyclin-dependent kinase 4/6 (CDK4/6) inhibitors, resistance—often driven by ESR1 mutations—remains a major clinical challenge, leading to disease progression and limited therapeutic options. Fulvestrant, a selective ER degrader (SERD), has been a standard-of-care for endocrine-resistant disease, but its efficacy is limited, especially in the context of ESR1 mutations and prior CDK4/6 exposure, and its intramuscular administration presents practical limitations. There is an unmet need for more potent, orally available ER degraders that can overcome both wild-type and mutant ER-driven resistance mechanisms.
Study Design
The VERITAC-2 trial was a phase 3, open-label, randomized study evaluating the efficacy and safety of vepdegestrant—a novel oral proteolysis-targeting chimera (PROTAC) ER degrader—versus fulvestrant in patients with ER+/HER2– advanced breast cancer. Eligible patients had received one prior line of CDK4/6 inhibitor plus one or two lines of endocrine therapy for advanced disease. Randomization (1:1) was stratified by ESR1 mutation status and visceral disease presence. Patients received vepdegestrant 200 mg orally daily or fulvestrant 500 mg intramuscularly (per standard schedule). The primary endpoint was progression-free survival (PFS), assessed by blinded independent central review, both in the ESR1-mutant subgroup and the overall population. Safety and tolerability were also evaluated.
Key Findings
Efficacy
Among 624 randomized patients (313 vepdegestrant, 311 fulvestrant), 270 had detectable ESR1 mutations. In this subgroup, vepdegestrant resulted in a median PFS of 5.0 months (95% CI, 3.7–7.4), compared to 2.1 months (95% CI, 1.9–3.5) with fulvestrant (hazard ratio [HR], 0.58; 95% CI, 0.43–0.78; P<0.001). In the intention-to-treat population, median PFS was 3.8 months (95% CI, 3.7–5.3) with vepdegestrant versus 3.6 months (95% CI, 2.6–4.0) for fulvestrant (HR, 0.83; 95% CI, 0.69–1.01; P=0.07), not reaching statistical significance.
Preclinical Data
Vepdegestrant demonstrated ≥90% degradation of both wild-type and mutant ER proteins, robustly inhibiting ER-dependent breast cancer cell proliferation. In MCF7 xenograft models, tumor growth inhibition (TGI) ranged from 87–123%—superior to fulvestrant (31–80% TGI). In hormone-independent, ESR1-mutant (Y537S) patient-derived xenograft (PDX) models, vepdegestrant induced tumor regression and retained efficacy in models resistant to palbociclib. Notably, vepdegestrant showed synergistic tumor regression when combined with CDK4/6 inhibitors (palbociclib, abemaciclib, ribociclib), mTOR inhibitor (everolimus), and PI3K inhibitors (alpelisib, inavolisib).
Safety
Grade 3 or higher adverse events occurred in 23.4% of the vepdegestrant group versus 17.6% with fulvestrant. Treatment discontinuation due to adverse events was infrequent (2.9% for vepdegestrant; 0.7% for fulvestrant). Common adverse events were consistent with the known safety profile of endocrine therapies and included gastrointestinal symptoms, fatigue, and cytopenias; no new safety signals emerged.
Expert Commentary
The VERITAC-2 data mark a pivotal advance in the management of endocrine-resistant ER+/HER2– advanced breast cancer, particularly for patients harboring ESR1 mutations—a subgroup with historically limited benefit from available SERDs. The substantially improved PFS and robust preclinical synergy with key pathway inhibitors position vepdegestrant as a promising, orally available alternative to fulvestrant. However, the lack of significant benefit in the overall population underscores the heterogeneity of endocrine resistance mechanisms and highlights the importance of biomarker-driven therapy. The manageable safety profile and oral administration further enhance clinical utility, especially for patients seeking less invasive regimens.
Nevertheless, several questions remain. The absolute gain in PFS, while statistically significant in ESR1-mutant cases, is modest, and longer-term outcomes such as overall survival and quality of life are not yet fully characterized. Cross-trial comparisons with emerging oral SERDs and PROTACs, as well as real-world data, will be critical to contextualize its place in therapy. Ongoing trials investigating vepdegestrant in combination with targeted agents and in earlier disease settings are eagerly awaited.
Conclusion
Vepdegestrant represents a significant step forward for patients with ESR1-mutant, ER+/HER2– advanced breast cancer, offering superior progression-free survival compared to fulvestrant and a favorable oral dosing regimen. While its benefit appears confined to molecularly defined subgroups, the agent holds promise for future combinatorial strategies and personalized endocrine therapy. Further research is essential to define its long-term impact, optimal sequencing, and integration into standard care.
References
1. Campone M, De Laurentiis M, Jhaveri K, et al. Vepdegestrant, a PROTAC Estrogen Receptor Degrader, in Advanced Breast Cancer. N Engl J Med. 2025;393(6):556-568. doi:10.1056/NEJMoa2505725
2. Gough SM, Flanagan JJ, Teh J, et al. Oral Estrogen Receptor PROTAC Vepdegestrant (ARV-471) Is Highly Efficacious as Monotherapy and in Combination with CDK4/6 or PI3K/mTOR Pathway Inhibitors in Preclinical ER+ Breast Cancer Models. Clin Cancer Res. 2024;30(16):3549-3563. doi:10.1158/1078-0432.CCR-23-3465
