Breast Carcinoma, Recurrent Breast Carcinoma, Stage IV Breast Cancer
Conditions
Keywords
Trastuzumab, Bevacizumab, Metastatic Breast Cancer, HER2/NEU
Brief summary
This randomized phase III trial studies first-line chemotherapy and trastuzumab to compare how well they work when given with or without bevacizumab in treating patients with breast cancer that overexpresses human epidermal growth factor receptor 2 (HER-2/NEU) and has spread to other areas of the body. Drugs used in chemotherapy, such as paclitaxel and carboplatin, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Monoclonal antibodies, such as trastuzumab and bevacizumab, may interfere with the ability of tumor cells to grow and spread. Bevacizumab may also stop the growth of breast cancer by blocking the growth of new blood vessels necessary for tumor growth. It is not yet known whether giving first-line chemotherapy together with trastuzumab is more effective with or without bevacizumab in treating patients with metastatic breast cancer that overexpresses HER-2/NEU.
Detailed description
PRIMARY OBJECTIVES: I. Evaluate efficacy of the addition of bevacizumab in patients eligible for first-line trastuzumab with chemotherapy for HER-2/NEU overexpressing metastatic breast cancer, by assessing the progression-free survival (PFS) after initiation of combination therapy. SECONDARY OBJECTIVES: I. Evaluate response rates (RR) in patients with measurable disease (Response Evaluation Criteria in Solid Tumors \[RECIST\]), when applicable. II. Evaluate overall survival (OS). III. Evaluate the proportion of progression-free at 6 months. IV. Compare the toxicity of chemotherapy/trastuzumab to that of chemotherapy/ trastuzumab in combination with bevacizumab. V. Evaluate left ventricular ejection fraction (LVEF) decline and clinical congestive heart failure (CHF). EXPLORATORY OBJECTIVES: I. Compare breast cancer symptoms and treatment related symptoms between patients receiving chemotherapy and trastuzumab with or without bevacizumab. II. Evaluate whether PFS correlates with vascular endothelial growth factor (VEGF) levels in breast tumor tissue. III. Analysis of circulating tumor cells and circulating endothelial cells (CEC). 1. Serially enumerate circulating tumor cells (CTC) and CEC in patients on study and determine whether: the number of CTC and CEC decrease in responding patients; the extent of CTC and CEC decrease is greater in the experimental arm, Arm B versus the control arm, Arm A; enumeration of CTC and CEC in responding patients correlate with progression free survival (PFS). 2. Perform an exploratory analysis of phosphorylation status of v-akt murine thymoma viral oncogene homolog (akt)-2 in circulating tumor cells. 3. Perform an exploratory analysis of reverse transcriptase (RT)-polymerase chain reaction (PCR) of CTC messenger ribonucleic acid (mRNA) to determine whether change in expression of selected downstream targets of bevacizumab therapy can serve as pharmacodynamic or surrogate markers of bevacizumab targeting and modulation. OUTLINE: Patients are randomized to 1 of 2 treatment arms. ARM A: INDUCTION THERAPY: Patients receive trastuzumab intravenously (IV) over 30-90 minutes on days 1, 8, 15, and 22 and paclitaxel IV over 60 minutes with or without carboplatin IV over 60 minutes on days 1, 8, and 15. Patients also receive placebo IV over 30-90 minutes on day 1 and 15. Treatment repeats every 4 weeks for 6 courses in the absence of disease progression or unacceptable toxicity. MAINTENANCE THERAPY: Beginning 1 week after the last dose of induction trastuzumab, patients receive trastuzumab IV over 30-90 minutes and placebo IV over 30-90 minutes on day 1. Treatment repeats every 3 weeks in the absence of disease progression or unacceptable toxicity. ARM B: INDUCTION THERAPY: Patients receive trastuzumab and paclitaxel with or without carboplatin as in Arm A. Patients also receive bevacizumab IV over 30-90 minutes on days 1 and 15. Treatment repeats every 4 weeks for 6 courses in the absence of disease progression or unacceptable toxicity. MAINTENANCE THERAPY: Beginning 1 week after the last dose of induction trastuzumab, patients receive trastuzumab IV over 30-90 minutes and bevacizumab IV over 30-90 minutes on day 1. Treatment repeats every 3 weeks in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up for 10 years. PROJECTED ACCRUAL: 489 patients
Interventions
BIOLOGICALBevacizumab
Given IV
DRUGCarboplatin
Given IV
DRUGPaclitaxel
Given IV
OTHERPlacebo
Given IV
BIOLOGICALTrastuzumab
Given IV
Sponsors
National Cancer Institute (NCI)
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
TRIPLE (Subject, Caregiver, Investigator)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Histologically confirmed breast cancer that overexpresses HER-2/NEU with evidence of metastatic disease and/or chest wall recurrence prior to randomization * HER-2/NEU overexpression is defined as 3+ HER-2 positivity as measured by immunohistochemistry OR HER-2 gene amplification as measured by fluorescent in situ hybridization (FISH, e.g. Vysis), per American Society of Clinical Oncology guidelines * NOTE: representative diagnostic tissue must be submitted for central diagnostic review for confirmation of HER-2/NEU overexpression within two weeks following patient randomization * Evaluable (measurable or non-measurable) disease is allowed if confirmed within 4 weeks prior to randomization * Prior endocrine treatment in the adjuvant or metastatic setting is allowed, provided last dose given \>= 2 weeks prior to randomization * Radiation therapy is allowed provided last dose is given \>= 3 weeks prior to randomization * Adjuvant trastuzumab therapy for breast cancer is allowed provided last dose was given \>= 12 months prior to diagnosis of recurrence * Adjuvant or neoadjuvant taxane therapy for breast cancer is allowed provided last dose was given \>= 12 months prior to diagnosis of recurrence * Adjuvant or neoadjuvant therapy with lapatinib is allowed provided last dose is given \>= 4 weeks prior to diagnosis of recurrence * Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 * Absolute neutrophil count \>= 1,000/mm\^3 * Platelet count \>= 100,000/mm\^3 * Total bilirubin =\< 1.5 mg/dL * Aspartate aminotransferase (AST) =\< 2 times upper limit of normal (ULN) (=\< 5 times normal in patients with known liver involvement) * Serum creatinine =\< 1.5 mg/dL * Urine protein: creatinine ratio =\< 0.5 OR 24-hour urine protein \< 1000 mg * International normalized ratio (INR) =\< 1.5 X ULN * Partial thromboplastin time (PTT) =\< 1.5 X ULN * Multi gated acquisition scan (MUGA) scan or echocardiogram (ECHO) within 6 weeks prior to randomization with an left ventricular ejection fraction (LVEF) above the institutional lower limit of normal * Patients must be able to understand and provide signed and dated written informed consent * Major surgical procedure within 4 weeks prior to randomization is not allowed (except for non-operative biopsy, which would not be considered major surgery); treatment can not begin until seven (7) days after placement of a vascular access device * Women must not be pregnant or breastfeeding; all females of childbearing potential must have a blood or urine test within 2 weeks prior to randomization to rule out pregnancy; women of childbearing potential and sexually active males must use an accepted and effective method of contraception * Patients on full-dose anticoagulants (e.g., warfarin) with PT/INR \> 1.5 may be eligible provided that both of the following criteria are met: * The patient has an in-range INR (usually between 2 and 3) on a stable dose of oral anticoagulant or on a stable dose of low molecular weight heparin * The patient has not active bleeding or pathological condition that carries a high risk of bleeding (e.g., tumor involving major vessels or known varices) * Patients with a concurrent active malignancy except carcinoma in situ of the cervix or non-melanoma skin cancers (unless disease-free for at least 5 years at study entry) are not allowed
Exclusion criteria
* Prior chemotherapy, trastuzumab, or bevacizumab for metastatic breast cancer * Patients who have had a cumulative dose of doxorubicin of greater than 360 mg/m\^2 or epirubicin of greater than 640 mg/m\^2 in the adjuvant or neo-adjuvant setting at any time * Patients with grade 2-4 neuropathy * Patients with a history or radiologic evidence of central nervous system (CNS) disease * Patients have a current non-healing wound or fracture * Patients have a hypersensitivity to paclitaxel or drugs using the vehicle Cremophor, Chinese hamster ovary cell products or other recombinant human antibodies * Patients have a serious medical or psychiatric illness that would prevent ability to safely participate or provide informed consent * Patients using any of the following drugs known to inhibit platelet function are not eligible: dipyridamole (Persantine), ticlopidine (Ticlid), clopidogrel (Plavix) and cilostazol (Pletal) * Clinically significant cardiovascular disease, including: * History of cerebrovascular (CVA) within 6 months * Uncontrolled hypertension * Myocardial infarction or unstable angina within 6 months * New York Heart Association class II or greater congestive heart failure, serious cardiac arrhythmia requiring medication, unstable angina pectoris * Clinically significant peripheral vascular disease
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Progression-free Survival | assessed every 3 months for patients within 2 years of registration, every 6 months for patients 3-5 years from registration and then yearly for up to10 years | Progression-free survival (PFS) was defined as time from date of randomization to first disease progression, new second breast primaries, or to death from any cause, whichever occurred first, otherwise cases were censored at date last documented to be free of progression. Disease progression was defined using the Response Evaluation Criteria in Solid Tumours (RECIST) version 1.0, as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions. Kaplan-Meier method was used to estimate the median PFS. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Overall Survival | assessed every 3 months for patients within 2 years of registration, every 6 months for patients 3-5 years from registration and then yearly for up to10 years | Overall survival (OS) is defined as the time from randomization until death (event), or censored at last date known alive. Kaplan-Meier method was used to estimate the median OS. |
| Proportion of Progression-free at 6 Months | assessed at baseline, at 3 and 6 months after study entry | Disease progression was defined using the Response Evaluation Criteria in Solid Tumours (RECIST) version 1.0, as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions. Proportion of progression-free at 6 months was calculated using the Kaplan-Meier method. |
| Overall Response Rate | assessed at baseline, every 12 weeks while on treatment, then very 3 months if patient is <2 years from study entry, every 6 months if 2-5 years from study entry, and annually if 6-10 years from study entry until disease progression | Overall response rate is defined as number of patients with complete response (CR) or partial response (PR) divided by all randomized patients. Responses are evaluated using the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline. CR is defined as disappearance of all target and non-target lesions. PR is defined as at least a 30% decrease in the sum of the diameters of target lesions (taking as reference the baseline sum diameters), and/or persistence of one or more non-target lesion(s). |
| Number of Patients Experiencing Congestive Heart Failure | assessed every 3 months while on treatment and at 3 months post treatment | Clinical congestive heart failure (CHF) was assessed using Left Ventricular Ejection Fraction (LVEF) and symptom information via the Cardiac Toxicity Form as well as symptom information collected via the Adverse Event Form. Clinical CHF was defined as symptomatic decline in LVEF to below the lower limit of normal (LLN) or symptomatic diastolic dysfunction. |
Countries
United States
Contacts
PRINCIPAL_INVESTIGATORIngrid Mayer
ECOG-ACRIN Cancer Research Group
Participant flow
Recruitment details
Ninety-six patients were randomized between November 9, 2007 and October 28, 2009 when the trial closed due to slow accrual.
Participants by arm
| Arm | Count |
|---|---|
| Arm A (Chemotherapy and Placebo) INDUCTION THERAPY: Patients receive trastuzumab IV over 30-90 minutes on days 1, 8, 15, and 22 and paclitaxel IV over 60 minutes with or without carboplatin IV over 60 minutes on days 1, 8, and 15. Patients also receive placebo IV over 30-90 minutes on day 1 and 15. Treatment repeats every 4 weeks for 6 courses in the absence of disease progression or unacceptable toxicity.
MAINTENANCE THERAPY: Beginning 1 week after the last dose of induction trastuzumab, patients receive trastuzumab IV over 30-90 minutes and placebo IV over 30-90 minutes on day 1. Treatment repeats every 3 weeks in the absence of disease progression or unacceptable toxicity.
Carboplatin: Given IV
Paclitaxel: Given IV
Placebo: Given IV
Trastuzumab: Given IV | 48 |
| Arm B (Chemotherapy and Bevacizumab) INDUCTION THERAPY: Patients receive trastuzumab and paclitaxel with or without carboplatin as in Arm A. Patients also receive bevacizumab IV over 30-90 minutes on days 1 and 15. Treatment repeats every 4 weeks for 6 courses in the absence of disease progression or unacceptable toxicity.
MAINTENANCE THERAPY: Beginning 1 week after the last dose of induction trastuzumab, patients receive trastuzumab IV over 30-90 minutes and bevacizumab IV over 30-90 minutes on day 1. Treatment repeats every 3 weeks in the absence of disease progression or unacceptable toxicity.
Bevacizumab: Given IV
Carboplatin: Given IV
Paclitaxel: Given IV
Trastuzumab: Given IV | 48 |
| Total | 96 |
Baseline characteristics
| Characteristic | Arm A (Chemotherapy and Placebo) | Arm B (Chemotherapy and Bevacizumab) | Total |
|---|---|---|---|
| Age, Continuous | 55 Years | 55 Years | 55 Years |
| Sex: Female, Male Female | 48 Participants | 48 Participants | 96 Participants |
| Sex: Female, Male Male | 0 Participants | 0 Participants | 0 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| other Total, other adverse events | 19 / 47 | 28 / 45 |
| serious Total, serious adverse events | 26 / 47 | 34 / 45 |
Outcome results
Primary
Progression-free Survival
Progression-free survival (PFS) was defined as time from date of randomization to first disease progression, new second breast primaries, or to death from any cause, whichever occurred first, otherwise cases were censored at date last documented to be free of progression. Disease progression was defined using the Response Evaluation Criteria in Solid Tumours (RECIST) version 1.0, as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions. Kaplan-Meier method was used to estimate the median PFS.
Time frame: assessed every 3 months for patients within 2 years of registration, every 6 months for patients 3-5 years from registration and then yearly for up to10 years
Population: All randomized patients
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Arm A (Chemotherapy and Placebo) | Progression-free Survival | 11.1 Months |
| Arm B (Chemotherapy and Bevacizumab) | Progression-free Survival | 13.8 Months |
p-value: 0.2495% CI: [0.43, 1.23]Regression, Cox
Secondary
Number of Patients Experiencing Congestive Heart Failure
Clinical congestive heart failure (CHF) was assessed using Left Ventricular Ejection Fraction (LVEF) and symptom information via the Cardiac Toxicity Form as well as symptom information collected via the Adverse Event Form. Clinical CHF was defined as symptomatic decline in LVEF to below the lower limit of normal (LLN) or symptomatic diastolic dysfunction.
Time frame: assessed every 3 months while on treatment and at 3 months post treatment
Population: All patients who began protocol treatment
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Arm A (Chemotherapy and Placebo) | Number of Patients Experiencing Congestive Heart Failure | 1 participants |
| Arm B (Chemotherapy and Bevacizumab) | Number of Patients Experiencing Congestive Heart Failure | 4 participants |
Secondary
Overall Response Rate
Overall response rate is defined as number of patients with complete response (CR) or partial response (PR) divided by all randomized patients. Responses are evaluated using the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline. CR is defined as disappearance of all target and non-target lesions. PR is defined as at least a 30% decrease in the sum of the diameters of target lesions (taking as reference the baseline sum diameters), and/or persistence of one or more non-target lesion(s).
Time frame: assessed at baseline, every 12 weeks while on treatment, then very 3 months if patient is <2 years from study entry, every 6 months if 2-5 years from study entry, and annually if 6-10 years from study entry until disease progression
Population: All randomized patients
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Arm A (Chemotherapy and Placebo) | Overall Response Rate | 0.542 proportion of participants |
| Arm B (Chemotherapy and Bevacizumab) | Overall Response Rate | 0.604 proportion of participants |
Secondary
Overall Survival
Overall survival (OS) is defined as the time from randomization until death (event), or censored at last date known alive. Kaplan-Meier method was used to estimate the median OS.
Time frame: assessed every 3 months for patients within 2 years of registration, every 6 months for patients 3-5 years from registration and then yearly for up to10 years
Population: All randomized patients
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Arm A (Chemotherapy and Placebo) | Overall Survival | 49.1 Months |
| Arm B (Chemotherapy and Bevacizumab) | Overall Survival | 63.0 Months |
p-value: 0.7595% CI: [0.61, 1.97]Regression, Cox
Secondary
Proportion of Progression-free at 6 Months
Disease progression was defined using the Response Evaluation Criteria in Solid Tumours (RECIST) version 1.0, as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions. Proportion of progression-free at 6 months was calculated using the Kaplan-Meier method.
Time frame: assessed at baseline, at 3 and 6 months after study entry
Population: All randomized patients
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Arm A (Chemotherapy and Placebo) | Proportion of Progression-free at 6 Months | 0.826 proportion of participants |
| Arm B (Chemotherapy and Bevacizumab) | Proportion of Progression-free at 6 Months | 0.871 proportion of participants |
Other Pre-specified
Change in FACT/NCCN Breast Symptom Index (FBSI) Between Baseline and Cycle 6 Induction
Participants indicated their level of breast symptoms across 8 items using the Functional Assessment of Cancer Therapy/National Comprehensive Cancer Network (FACT/NCCN) FBSI scale, each item on a 5-point Likert scale ranging from 0 (not at all) to 4(very much). Total score per patient, ranged from 0 to 32 with higher scores representing fewer symptoms.
Time frame: assessed at baseline and at cycle 6 induction prior to starting maintenance therapy
Population: All patients who reported their fatigue level using FACIT Fatigue subscale at both baseline and cycle 6 induction
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Arm A (Chemotherapy and Placebo) | Change in FACT/NCCN Breast Symptom Index (FBSI) Between Baseline and Cycle 6 Induction | 1 scores on a scale |
| Arm B (Chemotherapy and Bevacizumab) | Change in FACT/NCCN Breast Symptom Index (FBSI) Between Baseline and Cycle 6 Induction | 2 scores on a scale |
Other Pre-specified
Change in Fatigue Level Between Baseline and Cycle 6 Induction
Fatigue level was measured using Functional Assessment of Chronic Illness Therapy (FACIT) Fatigue subscale. Participants indicated their level of fatigue across 13 items, each item on a 5-point Likert scale ranging from 0 (not at all) to 4(very much). Total score per patient was calculated by taking the reverse of each item (unless specified not to), taking the sum of those items, multiplying the sum by the number of items in the scale, and then dividing that number by the number of answered items. Total score ranged from 0 to 52 with higher scores representing less fatigue.
Time frame: assessed at baseline and at cycle 6 induction prior to starting maintenance therapy
Population: All patients who reported their fatigue level using FACIT Fatigue subscale at both baseline and cycle 6 induction
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Arm A (Chemotherapy and Placebo) | Change in Fatigue Level Between Baseline and Cycle 6 Induction | 2.0 scores on a scale |
| Arm B (Chemotherapy and Bevacizumab) | Change in Fatigue Level Between Baseline and Cycle 6 Induction | 3.0 scores on a scale |
Other Pre-specified
Change in Level of Experiencing Side Effects Between Baseline and Cycle 6 Induction
Participants indicated their level of experiencing side effects across 1 item (Functional Assessment of Cancer Therapy \[FACT\] item G5) on a 5-point Likert scale ranging from 0 (not at all) to 4(very much). Total score per patient, ranged from 0 to 4 with a higher score representing better quality of life (QOL).
Time frame: assessed at baseline and at cycle 6 induction prior to starting maintenance therapy
Population: All patients who reported their level of experiencing side effects using FACT item G5 at both baseline and cycle 6 induction
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Arm A (Chemotherapy and Placebo) | Change in Level of Experiencing Side Effects Between Baseline and Cycle 6 Induction | 0 scores on a scale |
| Arm B (Chemotherapy and Bevacizumab) | Change in Level of Experiencing Side Effects Between Baseline and Cycle 6 Induction | 1 scores on a scale |
Other Pre-specified
Change in Neurotoxicity Level Between Baseline and Cycle 6 Induction
Participants indicated their level of neurotoxicity symptoms across 4 items using the Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-Ntx) scale, each item on a 5-point Likert scale ranging from 0 (not at all) to 4(very much). Total score per patient ranged from 0 to 16 with higher scores representing fewer neurotoxic symptoms.
Time frame: assessed at baseline and at cycle 6 induction prior to starting maintenance therapy
Population: All patients who reported their neurotoxicity level using FACT/GOG-Ntx scale at both baseline and cycle 6 induction
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Arm A (Chemotherapy and Placebo) | Change in Neurotoxicity Level Between Baseline and Cycle 6 Induction | 2 scores on a scale |
| Arm B (Chemotherapy and Bevacizumab) | Change in Neurotoxicity Level Between Baseline and Cycle 6 Induction | 3 scores on a scale |
Other Pre-specified
Number of Circulating Tumor Cells at Baseline
Number of circulating tumor cells per 7.5mL blood were counted prior to starting protocol therapy
Time frame: assessed at baseline prior to starting protocol therapy
Population: Patients who had blood sample drawn at baseline prior to starting protocol therapy
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Arm A (Chemotherapy and Placebo) | Number of Circulating Tumor Cells at Baseline | 4 number of cells per 7.5 mL blood |
| Arm B (Chemotherapy and Bevacizumab) | Number of Circulating Tumor Cells at Baseline | 2 number of cells per 7.5 mL blood |
Other Pre-specified
VEGF Levels in Breast Tumor by Immunohistochemistry Assay (Tumor Sample Has Not Been Analyzed Yet, no Results Could be Reported)
Tissue sections from the primary or metastatic paraffin blocks were subjected to VEGF immunohistochemistry (IHC). The VEGF cytoplasmic staining intensity was evaluated semiquantitavely using a classification from 0 to 3, with 0 representing lack of staining, 1 = low staining intensity, 2 = intermediate staining intensity and 3 = strong staining intensity. The fraction of positively staining cells will be determined as well (0 = lack of staining, 1 ≤ 1% cell staining, 2 = 1 - 10% cell staining, 3 = 10 - 50% cell staining, 4 = 50 - 90% cells staining and 5 ≤ 90% cells staining) (48). Staining intensity score zero and fraction of positively staining cells of ≤ 1% (scores zero and 1) will be considered as absence of staining and therefore negative overexpression of VEGF.
Time frame: assessed at baseline