Testing the Addition of Copanlisib to Eribulin for the Treatment of Advanced-Stage Triple Negative Breast Cancer
Study Details
Study Description
Brief Summary
This phase I/II trial studies the side effects and best dose of copanlisib and how well it works when given together with eribulin in treating patients with triple negative breast cancer that has spread to other places in the body (advanced stage). Copanlisib stops the growth of a protein called PI3K, which is often changed in tumor cells and causes resistance to treatment. Chemotherapy drugs, such as eribulin, 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. Giving copanlisib and eribulin may work better in treating advanced stage triple negative breast cancer compared to eribulin alone.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
|
Phase 1/Phase 2 |
Detailed Description
PRIMARY OBJECTIVES:
- To determine the safety, toxicity profile, dose limiting toxicity (DLT), maximum tolerated dose (MTD) and recommended phase 2 dose (RP2D) of copanlisib hydrochloride (copanlisib) in combination with eribulin mesylate (eribulin) in metastatic triple negative breast cancer (TNBC). (Phase I) II. To compare progression free survival (PFS) between eribulin and eribulin plus copanlisib arms in patients with metastatic TNBC treated with prior taxane and anthracycline. (Phase II)
SECONDARY OBJECTIVES:
- To determine the objective response rate (ORR) and clinical benefit rate (CBR) of the combination. (Phase I) II. To observe and record anti-tumor activity. (Phase I) III. To compare the ORR, CBR (complete response [CR]+partial response [PR]+stable disease [SD] >= 24 weeks) and safety of eribulin and eribulin plus copanlisib arms. (Phase II) IV. To compare the ORR, CBR, PFS of eribulin and eribulin plus copanlisib arms in patients with tumors harboring mutations in PIK3CA/ PTEN or with loss of PTEN expression by immunohistochemistry (IHC) on baseline tumor biopsy. (Phase II) V. To compare the ORR, CBR, PFS of eribulin and eribulin plus copanlisib arms in patients with tumors lacking PIK3CA/ PTEN pathway alterations. (Phase II) VI. To compare the ORR, CBR, PFS of eribulin and eribulin plus copanlisib arms in patients with tumors harboring loss of PTEN expression by IHC in pre-treatment metastatic site (in patients with available tissue from metastatic site). (Phase II) VII. To compare PTEN IHC results between paired archival primary tumor vs. baseline tumor biopsies. (Phase II) VIII. To assess targeted inhibition by copanlisib and eribulin by measuring treatment induced changes in phosphorylated (phospho)-AKT (T308), phospho-AKT (S473), phospho-histone H3, and inhibition of apoptosis (cleaved caspase 3) between post-treatment tumor (C2D1-2) versus baseline. (Phase II) IX. To compare the ORR, CBR, PFS of eribulin and eribulin plus copanlisib arms in patients with tumors harboring mutations in PIK3CA/PTEN by circulating tumor-derived deoxyribonucleic acid (ctDNA) at baseline, and potential changes over time. (Phase II)
EXPLORATORY OBJECTIVES:
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To compare PTEN IHC results between paired baseline tumor biopsy versus at time of disease progression.
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Assess baseline (pre-treatment) tumor tissue mutation or gene expression profiles to correlate treatment response.
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Assess intrinsic and adaptive resistance mechanisms by analyzing pre and post treatment biopsies for gene expression and proteomic changes.
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Determine circulating tumor DNA (ctDNA) mutation profiles at baseline and changes in mutation profile and variant allele frequencies (VAFs) on cycle 2 day 1 (C2D1) and at disease progression compared to baseline to correlate with treatment response.
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Assess circulating biomarkers predictive of treatment response. VI. Assess plasma and serum proteomics and metabolomics predictive of treatment response.
OUTLINE: This is a phase I dose-escalation study of copanlisib and eribulin followed by a phase II study. Patients are randomized to 1 of 2 groups.
GROUP I: Patients receive eribulin intravenously (IV) over 2-5 minutes on days 1 and 8. Cycles repeat every 21 days in the absence of disease progression or unacceptable toxicity.
GROUP II: Patients receive copanlisib IV over 60 minutes and eribulin IV over 2-5 minutes on days 1 and 8 or days 1 and 15. Cycles repeat every 21 or 28 days in the absence of disease progression or unacceptable toxicity.
After completion of study treatment, patients are followed up every 3 months for 3 years.
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Active Comparator: Group I (eribulin) Patients receive eribulin IV over 2-5 minutes on days 1 and 8. Cycles repeat every 21 days in the absence of disease progression or unacceptable toxicity. |
Drug: Eribulin Mesylate
Given IV
Other Names:
|
| Experimental: Group II (eribulin, copanlisib) Patients receive copanlisib IV over 60 minutes and eribulin IV over 2-5 minutes on days 1 and 8 or days 1 and 15. Cycles repeat every 21 or 28 days in the absence of disease progression or unacceptable toxicity. |
Drug: Copanlisib Hydrochloride
Given IV
Other Names:
Drug: Eribulin Mesylate
Given IV
Other Names:
|
Outcome Measures
Primary Outcome Measures
- Maximum tolerated dose (MTD) (Phase I) [Up to 28 days]
The maximum tolerated dose (MTD) is defined as the highest dose level at which at most 1 of 6 patients experience a dose limiting toxicity (DLT) during the observation window.
- Recommended phase 2 dose (RP2D) (Phase I) [Up to 28 days]
Recommended phase 2 dose is the maximum tolerated dose at which at most 1 of 6 patients experience a dose limiting toxicity during the observation window.
- Progression free survival (PFS) (Phase II) [From date of treatment start to date of progression or death, assessed up to 3 years following completion of study treatment]
Patients who have not experienced progression or death will be censored at last follow up. PFS will be estimated using the Kaplan-Meier product limit estimator.
Secondary Outcome Measures
- Objective Response Rate (ORR) (Phase I) [Up to 3 years]
The objective response rate (ORR) is defined as the proportion of patients with complete response, partial response by Response Evaluation Criteria in Solid Tumors (RECIST) v1.1.
- Clinical benefit rate (CBR) (Phase I) [Up to 3 years]
CBR defined as the proportion of patients with toxicity in each arm, in the overall population, and by PTEN/PIK3CA mutation status based on archival tumor tissue next generation sequencing.
- PFS (Phase I) [From start of treatment to time of progression or death, whichever occurs first, assessed up to 3 years]
PFS is defined from date of treatment start to date of progression or death. Patients who have not experienced progression or death will be censored at last follow up.
- ORR (Phase II) [Up to 3 years]
Measured in the overall population by treatment arm; by treatment arm in patients with triple negative breast cancer (TNBC) harboring mutations in PIK3CA/ PTEN or loss of PTEN expression by immunohistochemistry (IHC) of baseline (pre-treatment) biopsy; and by treatment arm in patients with TNBC harboring mutations in PIK3CA/ PTEN by circulating tumor deoxyribonucleic acid (ctDNA) at baseline (pre-treatment) biopsy and potential changes over time.
- CBR (Phase II) [Up to 3 years]
Measured in the overall population by treatment arm, in patients with TNBC harboring mutations in PIK3CA/ PTEN or loss of PTEN expression by IHC of baseline (pre-treatment) biopsy, by treatment arm in patients with TNBC harboring mutations in PIK3CA/ PTEN by ctDNA at baseline (pre-treatment) biopsy and potential changes over time.
- PFS (Phase II) [From start of treatment to time of progression or death, whichever occurs first, assessed up to 3 years]
Measured by treatment arm in patients with TNBC harboring mutations in PIK3CA/ PTEN or loss of PTEN expression by IHC of baseline (pre-treatment) biopsy and by treatment arm in patients with TNBC harboring mutations in PIK3CA/ PTEN by ctDNA at baseline (pre-treatment) biopsy and potential changes over time. PFS will be estimated using the Kaplan-Meier product limit estimator.
- Target inhibition of PI3K pathway and mitotic arrest [Up to 3 years]
Using phospho-AKT and phospho-histone H3 with eribulin plus copanlisib versus eribulin alone.
Other Outcome Measures
- Tumor tissue mutation or gene expression profiles [Up to 3 years]
Will correlate with treatment response
- Intrinsic and adaptive resistance mechanisms [Baseline up to 3 years]
Will analyze pre and post treatment biopsies for gene expression and proteomic changes.
- ctDNA mutation profiles and changes in mutation profile and variant allele frequencies (VAFs) [Baseline, cycle 2 day 1 (C2D2), and at disease progression]
Will determine ctDNA mutation profiles at baseline and changes in mutation profile and VAFs on C2D1 and at disease progression compared to baseline to correlate with treatment response.
- Circulating biomarkers predictive of treatment response [Up to 3 years]
- Plasma and serum proteomics and metabolomics predictive of treatment response [Up to 3 years]
- PTEN IHC results [Up to 3 years]
Will compare PTEN IHC results at disease progression compared to baseline.
Eligibility Criteria
Criteria
Inclusion Criteria:
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Patients must have metastatic or unresectable carcinoma of the breast that is estrogen receptor (ER) negative (less than 10%), progesterone receptor (PR) negative (less than 10%), and HER2 negative/unamplified
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Patients must have had prior treatment with an anthracycline and taxane, unless contraindicated
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Patients must have progressed on at least one and not more than five prior chemotherapy regimens, including in the neoadjuvant, adjuvant, and metastatic settings
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All patients must agree to provide archival tumor material (most recent archival tumor tissue immediately prior to enrollment is strongly preferred) for research and must agree to undergo research tumor biopsy before treatment if presence of easily accessible lesions (judged by the treating physician). For patients with bone only disease, or patients without easily accessible lesions for the baseline research biopsy, availability of archival tumor material (2 x 4-5 micron section unstained slides, plus 15-20 x 10 micron section unstained slides or a tumor rich block) from previous breast cancer diagnosis or treatment is required for PTEN and PIK3CA analysis
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Eastern Cooperative Oncology Group (ECOG) performance status =< 1 (Karnofsky >= 70%)
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Leukocytes >= 3,000/mcL
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Absolute neutrophil count >= 1,500/mcL
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Platelets >= 100,000/mcL
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Hemoglobin >= 8.0 g/dL
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Total bilirubin =< 1.5 x institutional upper limit of normal (ULN) (=< 3 x institutional ULN for patients with Gilbert syndrome)
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Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT]) / alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 3 x institutional ULN
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Lipase =< 1.5 x ULN
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Creatinine < 1.5 mg/dL AND glomerular filtration rate (GFR) >= 60 mL/min/1.73 m^2
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Partial thromboplastin time (PTT) =< 1.5 x ULN
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International normalized ratio (INR) =< 1.5 x ULN
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Patients with history of known type I or type II diabetes must have a fasting glucose level of < 120 mg/dL on at least 2 separate occasions or glycosylated hemoglobin measurement (HbA1c) < 8.5% at screening within 14 days prior to registration
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Patients who are therapeutically treated with an agent such as warfarin or heparin will be allowed to participate provided that their medication dose and INR/PTT is stable
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Prophylactic antiemetics may be administered according to standard practice. The routine use of standard antiemetics, including 5-HT3 blockers, such as granisetron, ondansetron, or an equivalent agent, is allowed as needed, as long as corrected QT (QTc) interval on baseline electrocardiogram (ECG) < 480 msec. The use of corticosteroids as antiemetics prior to copanlisib administration will not be allowed
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For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy, if indicated
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Human immunodeficiency virus (HIV)-infected patients on effective anti-retroviral therapy with undetectable viral load within 6 months are eligible for this trial provided they are on a stable regimen of anti-retroviral therapy (ART) with no medications otherwise prohibited by this protocol (e.g. drug-drug interactions)
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Patients with a history of hepatitis C virus (HCV) infection must have been treated and cured. For patients with HCV infection who are currently on treatment, they are eligible if they have an undetectable HCV viral load
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Patients with treated brain metastases are eligible if follow-up brain imaging after central nervous system (CNS)-directed therapy shows no evidence of progression. For patients with history of treated brain metastases, brain scans will be performed within 6 weeks of study enrollment. During study enrollment in the phase 2 portion of the study, brain MRI will be performed every 12 weeks or sooner if clinically-indicated in all patients with history of known brain metastases
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For phase 1 portion of the study only: patients with new or progressive brain metastases (active brain metastases) or leptomeningeal disease are eligible if the treating physician determines that immediate CNS specific treatment is not required and is unlikely to be required during the first cycle of therapy. This is not allowed for phase 2 portion of the study
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Patients with a prior or concurrent malignancy whose natural history or treatment does not have the potential to interfere with the safety or efficacy assessment of the investigational regimen are eligible for this trial
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Patients with known history or current symptoms of cardiac disease, or history of treatment with cardiotoxic agents, should have a clinical risk assessment of cardiac function using the New York Heart Association Functional Classification. To be eligible for this trial, patients should be class 2B or better. Patients with history of known congestive heart failure (left ventricular ejection fraction [LVEF] < 50%) must have documented LVEF >= 50% within 12 months of study enrollment
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Known mutation status for PIK3CA and PTEN from archival tumor tissue analysis
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The effects of copanlisib on the developing human fetus are unknown. For this reason and because maternal toxicity, developmental toxicity and teratogenic effects have been observed in nonclinical studies and PI3K inhibitors as well as other therapeutic agents used in this trial are known to be teratogenic, women of child-bearing potential must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation, and for 1 month after the last dose of study medication. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately. Men treated or enrolled on this protocol must also agree to use adequate contraception prior to the study, for the duration of study participation, and 3.5 months after completion of study treatment
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Ability to understand and the willingness to sign a written informed consent document. Participants with impaired decision-making capacity (IDMC) who have a legally-authorized representative (LAR) and/or family member available will also be eligible
Exclusion Criteria:
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Patients who have had chemotherapy or radiotherapy within 3 weeks
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Patients who have had prior treatment with nitrosoureas or mitomycin C
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Patients who have had prior treatment with eribulin
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Patients who have had prior treatment with PI3K/mTOR/AKT pathway inhibitor
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Clinically significant ECG abnormality, including prolonged corrected QT (QTc) interval > 480 msec or history of risk factors for Torsades de Pointes (TdP) (i.e. congestive heart failure, hypokalemia, hypomagnesemia, bradyarrhythmias, family history of long QT syndrome)
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Patients with pre-existing neuropathy of grade 2 or higher
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Myeloid growth factors within 14 days prior to treatment start
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Platelet transfusion within 7 days prior to treatment start
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Patients who have not recovered from adverse events due to prior anti-cancer therapy (i.e., have residual toxicities > grade 1) with the exception of alopecia
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Patients who are receiving any other investigational agents
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Immunosuppressive therapy is not allowed while on study
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Known tumor AKT mutation from archival tumor tissue analysis
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History of allergic reactions attributed to compounds of similar chemical or biologic composition to copanlisib, PI3K inhibitors, or other agents used in study
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Copanlisib is primarily metabolized by CYP3A4. Therefore, the concomitant use of strong inhibitors of CYP3A4 (e.g., ketoconazole, itraconazole, clarithromycin, ritonavir, indinavir, nelfinavir and saquinavir), and strong inducers of CYP3A4 (e.g. rifampin, phenytoin, carbamazepine, phenobarbital, St. John's Wort) are not permitted from 14 days prior to enrollment until the end of the study. Other medications that are prohibited while on copanlisib treatment:
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Herbal medications/preparations (except for vitamins)
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Anti-arrhythmic therapy other than beta blockers or digoxin
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Systemic corticosteroid therapy at a daily dose higher than 15 mg prednisone or equivalent is not permitted while on study. Previous corticosteroid therapy must be stopped or reduced to the allowed dose at least 7 days prior to the computed tomography/magnetic resonance imaging (CT/MRI) screening. If a patient is on chronic corticosteroid therapy, corticosteroids should be de-escalated to the maximum allowed dose before the screening. Patients may be using topical or inhaled corticosteroids. Short-term (up to 7 days) systemic corticosteroids above 15 mg prednisolone or equivalent will be allowed for the management of acute conditions (e.g., treatment non-infectious pneumonitis). The use of corticosteroids as antiemetics prior to copanlisib administration will not be allowed
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Patients with uncontrolled intercurrent illness
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Patients with psychiatric illness/social situations that would limit compliance with study requirements
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Patients with non-healing wound, ulcer, or bone fracture
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Patients with active, clinically serious infections > grade 2 (Common Terminology Criteria for Adverse Events Version 5.0 [CTCAEv5.0]) (viral, bacterial or fungal infection)
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History of known Pneumocystis jiroveci pneumonia (PJP) infection
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Patients with arterial or venous thrombotic or embolic events such as cerebrovascular accident (including transient ischemic attacks), deep vein thrombosis or pulmonary embolism within 3 months before the start of study medication
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Concurrent diagnosis of pheochromocytoma due to risk of hypertension with copanlisib
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Uncontrolled hypertension (defined as blood pressure >= 150/90 mm/Hg) despite optimal medical management (per investigator's opinion)
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Proteinuria as estimated by urine protein/creatinine ratio > 3.5 g/g on random urine sample or grade >= 3 as assessed by 24-hour urine protein collection
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Patients with history of or current autoimmune disease
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Patients with congenital QT prolongation
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The patient has a personal history of any of the following conditions: syncope of cardiovascular etiology, ventricular arrhythmia of pathological origin (including, but not limited to, ventricular tachycardia and ventricular fibrillation), or sudden cardiac arrest
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Pregnant women are excluded from this study because copanlisib is a PI3K inhibitor agent and eribulin is an anti-tubulin agent with the potential for teratogenic or abortifacient effects. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with copanlisib and eribulin, breastfeeding should be discontinued if the mother is treated with copanlisib and/or eribulin. These potential risks may also apply to other agents used in this study
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | University of Florida Health Science Center - Gainesville | Gainesville | Florida | United States | 32610 |
| 2 | Emory University Hospital/Winship Cancer Institute | Atlanta | Georgia | United States | 30322 |
| 3 | Siteman Cancer Center at West County Hospital | Creve Coeur | Missouri | United States | 63141 |
| 4 | Washington University School of Medicine | Saint Louis | Missouri | United States | 63110 |
| 5 | Siteman Cancer Center-South County | Saint Louis | Missouri | United States | 63129 |
| 6 | Siteman Cancer Center at Christian Hospital | Saint Louis | Missouri | United States | 63136 |
| 7 | Siteman Cancer Center at Saint Peters Hospital | Saint Peters | Missouri | United States | 63376 |
| 8 | NYP/Columbia University Medical Center/Herbert Irving Comprehensive Cancer Center | New York | New York | United States | 10032 |
| 9 | University of Oklahoma Health Sciences Center | Oklahoma City | Oklahoma | United States | 73104 |
| 10 | Vanderbilt Breast Center at One Hundred Oaks | Nashville | Tennessee | United States | 37204 |
| 11 | Vanderbilt University/Ingram Cancer Center | Nashville | Tennessee | United States | 37232 |
Sponsors and Collaborators
- National Cancer Institute (NCI)
Investigators
- Principal Investigator: Nusayba Bagegni, Duke University - Duke Cancer Institute LAO
Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- NCI-2020-02319
- NCI-2020-02319
- 10382
- 10382
- UM1CA186689
- UM1CA186704