Metastatic Breast Cancer, ER+ Breast Cancer, Advanced Breast Cancer
Conditions
Keywords
Fulvestrant, Palbociclib, Ipatasertib, ctDNA
Brief summary
Analysis of circulating tumour DNA (ctDNA) found in a patient's peripheral blood can identify cancer progression and predict a patient's response to therapy. By using ctDNA analysis and imaging techniques, the FAIM trial aims to determine whether the addition of the experimental drug ipatasertib to a standard combination of the hormone treatment fulvestrant and the targeted agent palbociclib increases progression free survival (PFS) for patients with hormone-receptor positive and human epidermal growth factor receptor 2 negative (HR+/HER2-) breast cancer.
Detailed description
Circulating tumour DNA (ctDNA) can be found in the peripheral blood of patients with cancer. ctDNA analysis provides a readily available, serial source of tumour DNA which can be used to monitor disease and predict a patients response to therapy. Relative changes in ctDNA after 15 days of treatment with palbociclib and fulvestrant has been found to strongly predict progression free survival (PFS) in hormone-receptor positive and human epidermal growth factor receptor 2 negative (HR+/HER2-) breast cancer patients: patients without ctDNA suppression after 2 weeks of treatment had a significantly shorter PFS compared to those with ctDNA suppression, identifying a group of patients who require additional therapy to prevent early progression. The FAIM trial is a randomised, open-label study which will aim to determine whether the addition of ipatasertib to standard of care CDK4/6 inhibitors + fulvestrant increases PFS in patients who lack ctDNA suppression after 15 days of treatment. Patients starting standard of care CDK4/6 inhibitors + fulvestrant will have a ctDNA assessment on cycle 1 day 1 (C1D1) and cycle 1 day 15 (C1D15). Those with high ctDNA levels at C1D15 will be randomised on a 1:1 basis to either standard of care (CDK4/6 inhibitors + fulvestrant) or standard of care plus the experimental drug ipatasertib (CDK4/6 inhibitor + fulvestrant + ipatasertib). Patients with ctDNA suppression at C1D15 will continue standard of care (fulvestrant+CDK4/6 inhibitor); the first 100 patients of this group will be followed for PFS and ctDNA collection. Patients without detectable ctDNA on C1D1 will be followed and treated according standard of care; the first 50 patients of this group will be followed for PFS, overall survival (OS), time to next treatment, and time to chemotherapy. Progression free survival will be monitored using RECIST 1.1.
Interventions
DRUGFulvestrant 500g
Fulvestrant 500mg administered intramuscularly in the buttocks slowly (1-2 minutes per injection) as two 5-mL injections (one in each buttock). Administered days 1 and 15 of Cycle 1. For subsequent cycles, patients will receive fulvestrant as described above in the clinic on Day 1 of each cycle or approximately every 4 weeks.
DRUGPalbociclib 75mg-125mg
Palboclicib 75mg-125mg once daily, dependent on toxicities. Oral administration. Treatment is continuous daily for 21 days, followed by 7 days off, to complete a 28 day cycle.
DRUGCDK4/6 Inhibitor
CDK4/6 inhibitor. As per current standard of care regime for ER+/HER2- breast cancer.
DRUGIpatasertib 300mg
Ipatasertib 300mg once daily. Oral administration. Treatment is continuous daily for 21 days, followed by 7 days off, to complete a 28 day cycle.
Sponsors
Royal Marsden NHS Foundation Trust
Pfizer
Hoffmann-La Roche
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Intervention model description
Patients starting standard of care CDK4/6 inhibitors and fulvestrant will have ctDNA assessment at Cycle 1 Day 1 (C1D1) and Cycle 1 Day 15 (C1D15). Patients with high ctDNA levels at C1D1 and D15 will be randomised in a 1:1 ratio to CDK4/6 inhibitor + fulvestrant (comparison arm) or palbociclib + fulvestrant + ipatasertib (interventional arm). Patients with ctDNA suppressed at C1D15 will continue standard of care, fulvestrant+CDK4/6 inhibitor (observational arm). The first 100 patients of this group will be followed for PFS, OS and ctDNA collection. Patients with no detectable ctDNA at screening will continue on standard of care. The first 50 of this group will be followed for PFS, OS, time to next treatment, and time to chemotherapy.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Histological diagnosis of metastatic or inoperable locally advanced ER positive/HER2 negative breast cancer. Assessment of ER and HER2 status as per local assessment. Histologically proven primary ER+ (Allred score 3/8 or greater, or stain in more than 1% of cancer cells) and HER2- (immunohistochemistry 0/1+ or negative by in situ hybridization) breast cancer as determined by local laboratory. 2. Willingness to consent for an archival tumour tissue sample (of advanced disease) to be requested for transfer to the Royal Marsden during study screening for future analysis. Patients without a metastatic biopsy are eligible if archival tumour from the breast primary tumour is available, but only after discussion with the Chief Investigator (see section 7.3.1). (PI assessment that a biopsy is not clinically appropriate will be required as evidence before discussion with the CI). 3. Previously treated with no more than one prior line of chemotherapy for advanced disease. 4. Patients eligible according to standard of care for fulvestrant in combination with a CDK4/6 inhibitor (abemaciclib, palbociclib, or ribociclib). 5. Patients must have progressed on or within 1 month from stopping prior endocrine therapy for advanced disease, or relapsed on or within 12 months of completing adjuvant endocrine therapy. 6. Measurable disease according to RECIST 1.1 or assessable bone disease (lytic or mixed lytic/sclerotic). 7. Eastern Cooperative Oncology Group (ECOG) performance status of 0, 1, or 2. 8. Adequate bone marrow, renal, and liver function within 14 days prior to the first study treatment on Day 1 of Cycle 1, defined as: * Neutrophils (ANC \>= 2000/uL), haemoglobin \>= 90 g/L, platelet count \>= 100 x 10\^9/L * Serum albumin \>= 3 g/dL * Total bilirubin \<= 1.5 times the upper limit of normal (ULN). Patients with known Gilbert syndrome may be enrolled if bilirubin \<= 3 times ULN * AST and ALT \<= 2.5 times ULN. Patients with documented liver or bone metastases may have AST and ALT \<= 5 times ULN * ALP \<= 2 times ULN. Patients with known liver involvement may have ALP \<= 5 times ULN. Patients with known bone involvement may have ALP \<= 7 times ULN * Serum creatinine \<= 1.5 times ULN or creatinine clearance \>= 50 mL/min using the Cockcroft-Gault formula * INR \< 1.5 times ULN and aPTT \< 1.5 times ULN. Patients requiring anticoagulation should receive low-molecular-weight heparin or a direct oral anticoagulant 9. Fasting glucose \<= 150 mg/dL and HbA1c \<= 7.5%. 10. Negative serum pregnancy test at screening for females of childbearing potential. 11. Patients able to have children must agree to use a highly effective method of contraception (failure rate less than 1% per year) throughout the study and for at least two years after the last dose of fulvestrant and 90 days after the last dose of palbociclib or ipatasertib. Patients must also agree to refrain from donating eggs or sperm during this period. 12. Pre- or peri-menopausal patients must be treated with licensed GnRH analogues as per standard of care. 13. Aged 18 years or older. 14. Written informed consent has been provided, signed and dated.
Exclusion criteria
1. Prior exposure to adjuvant CDK4/6 inhibitors (abemaciclib, palbociclib, or ribociclib) for early breast cancer less than 12 months (52 weeks or 365 days) prior to breast cancer recurrence. 2. Prior treatment with fulvestrant for advanced breast cancer. 3. Prior treatment with an AKT inhibitor, PIK3CA inhibitor, or mTOR inhibitor in any setting. 4. History of malabsorption syndrome or other condition that would interfere with enteral absorption, or inability or unwillingness to swallow oral medication. 5. Systemic chemotherapy within 14 days or endocrine therapy within 7 days prior to registration. 6. Major surgery within 4 weeks prior to registration. 7. Palliative radiotherapy within 14 days prior to registration. 8. Known leptomeningeal disease, untreated brain metastases, spinal cord compression, or symptomatic brain metastases requiring steroids. 9. Clinically significant, uncontrolled cardiac disease or cardiac repolarization abnormality, including but not limited to: * Angina pectoris, symptomatic pericarditis, coronary artery bypass graft, or myocardial infarction within 12 months prior to study entry * Symptomatic cardiac failure (NYHA class II to IV or LVEF \< 50%), uncontrolled hypertension, cardiac dysrhythmia requiring medication, significant or symptomatic bradycardia, long QT syndrome, family history of congenital long QT syndrome or idiopathic sudden death * Cerebrovascular accident or transient ischemic attack within 12 months * Known risk factors for prolonged QT interval or Torsade de Pointes * Uncorrected hypomagnesaemia or hypokalaemia of Grade 3 or higher * Systolic blood pressure \> 160 mmHg or \< 90 mmHg * Resting heart rate \< 50 beats per minute * Screening QTcF \> 470 ms based on the mean of three ECGs 10. Lung disease including any history of pneumonitis, interstitial lung disease, idiopathic pulmonary fibrosis, cystic fibrosis, aspergillosis, active tuberculosis, or opportunistic infections such as pneumocystis pneumonia or cytomegalovirus pneumonia. 11. Uncontrolled pleural effusion, pericardial effusion, or ascites as judged by the investigator. 12. Type I or II diabetes requiring insulin therapy. 13. Use of potent CYP3A4 inducers or inhibitors within 2 weeks or five elimination half-lives (whichever is longer) prior to the first dose of palbociclib with or without ipatasertib. 14. Known HIV infection or AIDS-related illness. 15. Active infection requiring systemic therapy. 16. Known acute or chronic hepatitis B or C infection. * Patients with resolved hepatitis B infection (HBsAg negative, HBcAb positive, and HBV DNA negative) are eligible * Patients positive for HCV antibody are eligible only if HCV RNA by PCR is negative 17. Clinically significant liver disease consistent with Child-Pugh class B or C. 18. Administration of a live vaccine within 4 weeks prior to study entry. 19. Diagnosis of another malignancy within 5 years, except for adequately treated basal cell carcinoma, squamous cell carcinoma of the skin, or carcinoma in situ of the breast or cervix. 20. Participation in another study involving investigational drugs within 4 weeks prior to study entry or during study participation. 21. Persisting toxicity related to prior therapy greater than Grade 1, except stable peripheral neuropathy Grade 2 or alopecia Grade 2. 22. Other severe acute or chronic medical condition or laboratory abnormality that may increase the risk associated with study participation or interfere with interpretation of results, including colitis, inflammatory bowel disease, active bowel inflammation (for example diverticulitis), psychiatric illness, recent or active suicidal ideation or behaviour, or end-stage renal disease requiring haemodialysis. 23. Known allergy or hypersensitivity to ipatasertib, palbociclib, fulvestrant, or any of their components. 24. Pregnancy or breastfeeding. 25. Requirement for chronic corticosteroid therapy greater than 10 mg prednisolone per day, or equivalent doses of other systemic corticosteroids or immunosuppressants for chronic disease.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Assess progression free survival (PFS) | Time from date of randomisation until the date of first documented progression or date of death from any cause, whichever comes first, assessed up to 51 months | To compare PFS in patients randomised between SOC palbociclib/fulvestrant + ipatasertib and SOC CDK4/6 inhibitor/fulvestrant alone, in advanced ER+/HER2- breast cancer patients with trackable mutations and high ctDNA after 2 weeks of CDK4/6 inhibitor/fulvestrant. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| To assess the AEs/SAEs for patients on palbociclib/fulvestrant/ipatasertib compared to palbociclib/fulvestrant alone | 51 months (treatment duration + follow-up duration) | To assess the overall safety and tolerability of standard of care palbociclib/fulvestrant + ipatasertib compared to standard of care CDK4/6 inhibitor/fulvestrant alone. Safety will be evaluated continuously by monitoring adverse events and serious adverse events, graded according to NCI CTCAE Version 5.0. SAEs will be collected from registration until 30 days post last trial treatment administration. AEs will be collected from Cycle 2 day 1 until 30 days post last trial treatment administration. |
| Assess overall survival | 51 months (treatment duration + follow-up duration) | • To assess Overall Survival (OS) in patients receiving standard of care palbociclib/fulvestrant + ipatasertib compared to SOC CDK4/6 inhibitor/fulvestrant alone. |
| Assess objective response rate | 51 months (treatment duration + follow-up duration) | • To assess the objective response rate in patients receiving SOC palbociclib/fulvestrant + ipatasertib compared to SOC CDK4/6 inhibitor/fulvestrant alone. |
| Report progression free survival (PFS) in patients with low ctDNA and high ctDNA | Time from date of randomisation until the date of first documented progression or date of death from any cause, whichever comes first, assessed up to 51 months | • To report progression free survival (PFS) in patients with suppressed ctDNA on standard of care CDK4/6 inhibitor/fulvestrant within the observational arm. |
| Compare progression free survival (PFS) in the subgroup of advanced ER+/HER2- breast cancer patients | Time from date of randomisation until the date of first documented progression or date of death from any cause, whichever comes first, assessed up to 51 months | To report PFS in patients randomised between standard of care palbociclib/fulvestrant + ipatasertib and standard of care CDK4/6 inhibitor/fulvestrant alone, in the subgroup of advanced ER+/HER2- breast cancer patients with PIK3CA/PTEN/AKT1 mutations or PTEN loss. |
Countries
United Kingdom
Contacts
PRINCIPAL_INVESTIGATORAlicia Okines
Royal Marsden NHS Foundation Trust
Outcome results
None listed