Anatomic Stage IV Breast Cancer AJCC v8, Metastatic Breast Carcinoma, Prognostic Stage IV Breast Cancer AJCC v8
Conditions
Brief summary
This phase II trial studies how well letrozole, anastrozole, or fulvestrant work when given together with ribociclib, palbociclib, and/or abemaciclib in treating patients with hormone receptor (HR) positive breast cancer that has spread to other places in the body (metastatic) and has an ERS1 activating mutation. Letrozole, anastrozole, ribociclib, palbociclib, and abemaciclib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Estrogen can cause the growth of breast cancer cells. Hormone therapy using fulvestrant may fight breast cancer by blocking the use of estrogen by the tumor cells. It is not yet known if giving letrozole, anastrozole, or fulvestrant with ribociclib, palbociclib, and/or abemaciclib will work better in treating patients with breast cancer.
Detailed description
PRIMARY OBJECTIVE: I. To assess progression free survival (PFS) with transition to fulvestrant compared with continuing aromatase inhibitor (AI) therapy in patients with emergence of estrogen receptor 1 (ESR1) mutations in plasma. SECONDARY OBJECTIVES: I. To assess circulating tumor deoxyribonucleic acid (ctDNA) ESR1 mutant allele fraction (MAF) and kinetics with fulvestrant compared with AI. II. To assess the prevalence of ESR1 mutations in patients with secondary resistance to endocrine therapy. III. To correlate ctDNA with cancer antigens (CA) 15-3 tumor marker changes. IV. To assess overall survival (OS) with transition to fulvestrant compared with continuing AI therapy in patients with emergence of ESR1 mutations. V. To assess PFS and time to next treatment (TTNT) on next line of therapy after progression on fulvestrant versus (vs.) AI in combination with CDKI. EXPLORATORY OBJECTIVES: I. Characterize other co-existing actionable genomic alterations of interest in relation to ESR1 and clinical outcomes. II. To determine frequency of other actionable genomic alterations and frequency of enrollment on genotype-matched therapy. OUTLINE: Patients are randomized to 1 of 2 arms. ARM I: Patients receive ribociclib orally (PO) once daily (QD), palbociclib PO QD on days 1-21, and/or abemaciclib PO twice daily (BID) on days 1-28. Patients also receive fulvestrant intramuscularly (IM) for 2 injections over 1-2 minutes each on days 1 and 15 of cycle 1 and day 2 of subsequent cycles. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. ARM II: Patients receive ribociclib orally PO QD, palbociclib PO QD on days 1-21, and/or abemaciclib PO BID on days 1-28. Patients also receive letrozole PO QD or anastrozole PO QD on days 1-28. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. After completion of study treatment, patients are followed up for 30 days.
Interventions
DRUGAbemaciclib
Given PO
DRUGAnastrozole
Given PO
DRUGFulvestrant
Given IM
DRUGLetrozole
Given PO
DRUGPalbociclib
Given PO
DRUGRibociclib
Given PO
Sponsors
National Cancer Institute (NCI)
M.D. Anderson Cancer Center
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 * Absolute neutrophil count (ANC) \>= 1.5 x 10\^9/L * Platelets \>= 50 x 10\^9/L * Hemoglobin (Hb) \>= 9 g/dL * Total serum bilirubin =\< 2.0 mg/dL * Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) =\< 2.5 x upper limit of normal (ULN) (=\< 5 x ULN in patients with liver metastases) * Serum creatinine =\< 1.5 x ULN * Activating ESR1 mutation (e.g. D538G, Y537S/N, S463P) identified on ctDNA. Novel ESR1 alterations allowed as per discretion of principal investigator (PI) * On AI with CDK4/6 inhibitor (palbociclib, ribociclib, or abemaciclib) as first line therapy for metastatic breast cancer (MBC) for at least 12 months without evidence of clinical progression * Patients with histologically confirmed HR positive (estrogen receptor \[ER\] positive \[+\] and/or progesterone receptor \[PR\]+ \[\> 10%\]), MBC
Exclusion criteria
* Pregnant or lactating women * Received prior therapy for MBC (except for AI use for up to 4 weeks prior to initiation of CDK4/6 inhibitor) * Prior therapy with fulvestrant in the metastatic setting * Corrected QT (QTc) interval \> 480 msec, Brugada syndrome or known history of QTc prolongation or Torsade de Pointes * Psychiatric illness which would limit informed consent * Patients with de novo metastatic disease * Patients who have any severe and/or uncontrolled medical conditions such as: unstable angina pectoris, symptomatic congestive heart failure, myocardial infarction =\< 6 months prior to enrollment, serious uncontrolled cardiac arrhythmia, or any other clinically significant cardiac disease, active (acute or chronic) or uncontrolled severe infection, liver disease such as cirrhosis, decompensated liver disease, and active and chronic hepatitis (i.e. quantifiable hepatitis B virus \[HBV\]-DNA and/or positive hepatitis B surface antigen \[HbsAg\], quantifiable hepatitis C virus \[HCV\]-ribonucleic acid \[RNA\]), severe hepatic impairment (Child-Pugh C) * Human immunodeficiency virus (HIV)-positive patients on combination antiretroviral therapy * Expected survival \< 6 months * Any serious medical illness, other than that treated by this study, which would limit survival to less than 1 month * Patients with a history of non-compliance to medical regimens or who are considered potentially unreliable or will not be able to complete the entire study * Patients who are currently part of or have participated in any clinical investigation with an investigational drug within 1 month prior to dosing * Women of child-bearing potential (WOCBP), defined as all women physiologically capable of becoming pregnant, must use highly effective methods of contraception during the study and 8 weeks after the end of treatment. Highly effective contraception methods include combination of any two of the following: placement of an intrauterine device (IUD) or intrauterine system (IUS); barrier methods of contraception: condom or occlusive cap (diaphragm or cervical/vault caps) with spermicidal foam/gel/film/cream/vaginal suppository; total abstinence or; male/female sterilization * Male patients whose sexual partner(s) are WOCBP who are not willing to use adequate contraception, during the study and for 8 weeks after the end of treatment
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Progression-free Survival (PFS) | Up to 30 days | Survival curves for PFS will be analyzed using the Kaplan-Meier method and survival difference across groups will be examined by log rank test. Will estimate the treatment comparison with 95% confidence intervals and p-value using Cox proportional hazards regression and we will assess the proportional hazard assumption using graphs of rescaled Schoenfeld residuals and related tests. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Circulating Tumor Deoxyribonucleic Acid (ctDNA) ESR1 Mutant Allele Fraction (MAF) and Kinetics | Up to 30 days | Graphical analysis, such as scatter plots with Lowess smoothers, will be used to assess the correlative structure of outcomes and compare MAF between fulvestrant and aromatase inhibitor-treated groups. The Pearson correlation, or its non-parametric analogue, the Spearman correlation, will be used to estimate the linear correlation among variables. |
| Prevalence of Emergence of Estrogen Receptor 1 (ESR1) Mutations | Up to 30 days | Will be assessed by the secondary resistance of endocrine therapy. |
| Changes in Cancer Antigens (CA) 15-3 Tumor Marker | Up to 30 days | Will correlate ctDNA with CA 15-3 tumor marker changes. |
| Overall Survival (OS) | Up to 30 days | Survival curves for OS will be analyzed using the Kaplan-Meier method and survival difference across groups will be examined by log rank test. Will estimate the treatment comparison with 95% confidence intervals and p-value using Cox proportional hazards regression and we will assess the proportional hazard assumption using graphs of rescaled Schoenfeld residuals and related tests. |
| Time to Next Treatment | Up to 30 days | Will be assessed on next line of therapy after progression. |
Countries
United States
Participant flow
Recruitment details
Study was opened to accrual on 5/31/2019. The study was intended for patients with ESR1 mutations. Despite modifications, accrual was poor and the closed to accrual on 8/24/2023
Pre-assignment details
Of the 49 patients screened, 6 patients harbored ESR1 mutation. 4 patients were randomized to the study. 1 patient withdrew consent due to frequent travel/visits after randomization (AI arm). 1 patient was a screen fail due to elevated LFTs, and 1 patient passed away prior to study intervention)
Participants by arm
| Arm | Count |
|---|---|
| Fulvestrant Fulvestrant (Faslodex), a selective estrogen receptor antagonist, was initially indicated for treatment of HR positive MBC in post-menopausal women with disease progression following prior anti-estrogen therapy. | 1 |
| Continuing AI After Randomization CDK inhibitors e.g. palbociclib (Ibrance), ribociclib (Kisqali), and abemaciclib (verzenio) are approved for the first line treatment of HR positive advanced breast cancers in combination with aromatase inhibitors as well as in combination with fulvestrant with disease progression following prior endocrine therapy. | 3 |
| Total | 4 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Overall Study | Death | 1 | 0 |
| Overall Study | Disease Progession | 0 | 2 |
| Overall Study | Withdrawal by Subject | 0 | 1 |
Baseline characteristics
| Characteristic | Fulvestrant | Continuing AI After Randomization | Total |
|---|---|---|---|
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 1 Participants | 1 Participants | 2 Participants |
| Age, Categorical Between 18 and 65 years | 0 Participants | 2 Participants | 2 Participants |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants | 1 Participants | 1 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 1 Participants | 2 Participants | 3 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 1 Participants | 3 Participants | 4 Participants |
| Sex: Female, Male Female | 1 Participants | 3 Participants | 4 Participants |
| Sex: Female, Male Male | 0 Participants | 0 Participants | 0 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 1 / 1 | 0 / 3 |
| other Total, other adverse events | 1 / 1 | 3 / 3 |
| serious Total, serious adverse events | 0 / 1 | 0 / 3 |
Outcome results
Primary
Progression-free Survival (PFS)
Survival curves for PFS will be analyzed using the Kaplan-Meier method and survival difference across groups will be examined by log rank test. Will estimate the treatment comparison with 95% confidence intervals and p-value using Cox proportional hazards regression and we will assess the proportional hazard assumption using graphs of rescaled Schoenfeld residuals and related tests.
Time frame: Up to 30 days
Population: No data was collected since despite modifications, accrual was poor and the closed. Outcome Measure has zero total analyzed at the protocol specified timepoint.
Secondary
Changes in Cancer Antigens (CA) 15-3 Tumor Marker
Will correlate ctDNA with CA 15-3 tumor marker changes.
Time frame: Up to 30 days
Population: No data was collected since despite modifications, accrual was poor and the closed. Outcome Measure has zero total analyzed at the protocol specified timepoint.
Secondary
Circulating Tumor Deoxyribonucleic Acid (ctDNA) ESR1 Mutant Allele Fraction (MAF) and Kinetics
Graphical analysis, such as scatter plots with Lowess smoothers, will be used to assess the correlative structure of outcomes and compare MAF between fulvestrant and aromatase inhibitor-treated groups. The Pearson correlation, or its non-parametric analogue, the Spearman correlation, will be used to estimate the linear correlation among variables.
Time frame: Up to 30 days
Population: No data was collected since despite modifications, accrual was poor and the closed. Outcome Measure has zero total analyzed at the protocol specified timepoint.
Secondary
Overall Survival (OS)
Survival curves for OS will be analyzed using the Kaplan-Meier method and survival difference across groups will be examined by log rank test. Will estimate the treatment comparison with 95% confidence intervals and p-value using Cox proportional hazards regression and we will assess the proportional hazard assumption using graphs of rescaled Schoenfeld residuals and related tests.
Time frame: Up to 30 days
Population: No data was collected since despite modifications, accrual was poor and the closed. Outcome Measure has zero total analyzed at the protocol specified timepoint.
Secondary
Prevalence of Emergence of Estrogen Receptor 1 (ESR1) Mutations
Will be assessed by the secondary resistance of endocrine therapy.
Time frame: Up to 30 days
Population: No data was collected since despite modifications, accrual was poor and the closed. Outcome Measure has zero total analyzed at the protocol specified timepoint.
Secondary
Time to Next Treatment
Will be assessed on next line of therapy after progression.
Time frame: Up to 30 days
Population: No data was collected since despite modifications, accrual was poor and the closed. Outcome Measure has zero total analyzed at the protocol specified timepoint.