T-DM1 Alone Versus T-DM1 and Metronomic Temozolomide in Secondary Prevention of HER2-Positive Breast Cancer Brain Metastases Following Stereotactic Radiosurgery

Sponsor

National Cancer Institute (NCI) (NIH)

Overall Status

Active, not recruiting

CT.gov ID

NCT03190967

Collaborator

(none)

Enrollment

Location

Arms

62.4

Anticipated Duration (Months)

0.2

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

Background:

Sometimes breast cancer spreads (metastasizes) to the brain. Researchers want to study new treatments for brain metastases. The drug Temozolomide is approved to treat brain tumors. Researchers want to see if combining it with the drug T-DMI prevents the formation of new metastases in the brain.

Objective:

To study if Temozolomide with T-DM1 lowers the chance of having new metastases in the brain.

Eligibility:

Adults at least 18 years old with a HER2-positive breast cancer that has spread to the brain and was recently treated with stereotactic radiation or surgery.

Design:

Participants will be screened with

Medical history
Physical exam
Heart tests
A scan (CT) that makes a picture of the body using a small amount of radiation
A scan (MRI) that uses a magnetic field to make an image of the brain
Blood tests.
Pregnancy test.

The study will be done in 3-week cycles.

All participants will get T-DM1 on Day 1 of every cycle through a small plastic tube inserted in an arm vein.

Some participants will also take Temozolomide capsules by mouth every day.

Participants will keep a medication diary.

During the study, participants will also:

Repeat most of the screening tests.
Answer questions about their general well-being and functioning.

Participants will have lumbar puncture at least 2 times. A needle is inserted into the spinal canal low in the back and cerebrospinal fluid is collected. This will be done with local anesthesia and with the help of images.

Participants will be asked to provide tumor samples when available.

Participants will have a follow-up visit about 1 month after stopping the study drug. They will be contacted by telephone or email every 3 months after that.

Condition or Disease	Intervention/Treatment	Phase
Breast Cancer Brain Metastasis Brain Cancer	Drug: T-DM1 Drug: TMZ	Phase 1/Phase 2

Detailed Description

Background:

Breast cancer is the most common cancer in women. In the HER2+ subtype, brain metastases can occur in up to 25-40% of patients.
The standard therapy for brain metastases continues to be surgery or stereotactic radiosurgery (SRS) and/or whole brain radiation therapy (WBRT).
Currently, independently of localized or systemic treatment modality, once brain metastases are established, options for treatment are limited, and the disease almost invariably progresses, limiting not only survival but also quality of life in most patients.
Preclinical literature suggests the hypothesis that preventing the formation of a metastasis by a drug may be more efficacious than attempting to shrink an established lesion.
Our group has shown in vitro and in vivo in animal models injected with a brain tropic MGMT+ cell line, that even in very low doses temozolomide (TMZ) administered in a prophylactic, metronomic fashion can significantly prevent development of brain metastases.
We propose a secondary-prevention clinical trial with oral TMZ given to HER2+ breast cancer patients with brain metastases after recent local treatment (SRS or surgical resection) in combination with the anti-HER2 agent T-DM1 for systemic control of disease.

Objectives:

Phase I (run in): to identify the maximum tolerated dose (MTD) of TMZ when used in combination with T-DM1.
Phase II: to determine if the combination regimen of T-DM1 and temozolomide improves the freedom from distant new brain metastases following stereotactic radiosurgery or surgical resection in HER2-positive breast cancer brain metastases, as compared to T-DM1 alone guided by one-year results as an important benchmark for measuring improvement.

Eligibility:

Phase I:

Histologically confirmed HER2+ breast cancer.
ECOG performance status 0-2 and adequate organ and marrow function.
Brain metastases, treated within 12 weeks of study entry with SRS, resection or WBRT.
Patients with leptomeningeal metastatic disease are ineligible.
Patients that are unable to complete a brain MRI with contrast are ineligible.
Patients with breast tissue expanders must have those removed before enrollment.
HBV, HCV or HIV-positive patients are ineligible.
Patient with impaired cardiac function or clinically significant cardiac disease are ineligible.
Corticosteroids will be allowed at enrollment and during the first month of treatment with T-DM1 after SRS, up to a dose of no more than 10mg of dexamethasone daily or equivalent. Patients that need to continue corticosteroids after the initial month will not be allowed to increase the dose after that period, and will be taken off protocol.

Phase II:

Histologically confirmed HER2+ breast cancer.
ECOG performance status 0-2 and adequate organ and marrow function.
1-10 brain metastases, by contrast MRI, treated within 12 weeks of study entry with SRS and/or resection.
Patients with leptomeningeal metastatic disease are ineligible.
Patients with history of WBRT are ineligible.
Patients that are unable to complete a brain MRI with contrast are ineligible.
Patients with breast tissue expanders must have those removed before enrollment.
HBV, HCV or HIV-positive patients are ineligible.
Patient with impaired cardiac function or clinically significant cardiac disease are ineligible.
Corticosteroids will be allowed at enrollment and during the first month of treatment with T-DM1 after SRS, up to a dose of no more than 10mg of dexamethasone daily or equivalent. Patients that need to continue corticosteroids after the initial month will not be allowed to increase the dose after that period, and will be taken off protocol.

Design:

This is a Phase I/II open label study that will evaluate the potential benefit of TMZ in prevention of new brain metastases in patients with limited brain metastases from HER2+ breast cancer, previously treated with SRS or surgical resection of brain metastases.
All patients will receive the standard second-line therapy for HER2+ metastatic breast cancer: T-DM1. During phase II patients will be randomized between T-DM1 plus TMZ versus T-DM1 alone.
Phase I run in: T-DM1 3.6 mg/kg IV every 21 days plus TMZ 30, 40 or 50 mg/m^2 daily.
Phase II: T-DM1 3.6 mg/kg versus T-DM1 3.6mg/kg plus TMZ at recommended phase 2 dose (RP2D).
Phase I will follow a standard 3+3 design. Thus, with 3 dose levels, up to 18 patients may be included in the initial safety evaluation.
In the phase II portion of the trial, a total of 49 evaluable subjects per arm (98 total) will need to be randomized over a 3-year period and followed for an additional 2 years from the date of entry of the last patient, with occurrence of 79 total relapses in both arms combined, in order to have 80% power to compare the curves.

Study Design

Study Type:

Interventional

Actual Enrollment :

12 participants

Allocation:

Randomized

Intervention Model:

Sequential Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

Phase I/II Study of T-DM1 Alone Versus T-DM1 and Metronomic Temozolomide in Secondary Prevention of HER2-Positive Breast Cancer Brain Metastases Following Stereotactic Radiosurgery

Actual Study Start Date :

Apr 18, 2018

Anticipated Primary Completion Date :

Jun 30, 2023

Anticipated Study Completion Date :

Jun 30, 2023

Arms and Interventions

Arm	Intervention/Treatment
Experimental: 1 / Phase I T-DM1 + TMZ in dose escalation	Drug: T-DM1 T-DM1 3.6 mg/kg IV every 21 days Drug: TMZ Phase I: TMZ 30, 40 or 50 mg/m2 daily Phase II: TMZ at RP2D estimated in Phase I
Active Comparator: 2A / Phase II / T-DM1 alone T-DM1	Drug: T-DM1 T-DM1 3.6 mg/kg IV every 21 days
Experimental: 2B / Phase II / T-DM1 + TMZ T-DM1 + TMZ at RP2D	Drug: T-DM1 T-DM1 3.6 mg/kg IV every 21 days Drug: TMZ Phase I: TMZ 30, 40 or 50 mg/m2 daily Phase II: TMZ at RP2D estimated in Phase I

Arm

Intervention/Treatment

Experimental: 1 / Phase I

T-DM1 + TMZ in dose escalation

Drug: T-DM1

T-DM1 3.6 mg/kg IV every 21 days

Drug: TMZ

Phase I: TMZ 30, 40 or 50 mg/m2 daily Phase II: TMZ at RP2D estimated in Phase I

Active Comparator: 2A / Phase II / T-DM1 alone

T-DM1

Drug: T-DM1

T-DM1 3.6 mg/kg IV every 21 days

Experimental: 2B / Phase II / T-DM1 + TMZ

T-DM1 + TMZ at RP2D

Drug: T-DM1

T-DM1 3.6 mg/kg IV every 21 days

Drug: TMZ

Phase I: TMZ 30, 40 or 50 mg/m2 daily Phase II: TMZ at RP2D estimated in Phase I

Outcome Measures

Primary Outcome Measures

MTD of temozolomide when used with T-DM1 [every 21 days]
Maximum tolerated dose of TMZ when used in combination with T-DM1
Median amount of time subject survives without disease progression after treatment [at progression]
Median time to progression

Secondary Outcome Measures

adverse event frequency [30 days after treatment]
List of adverse event frequency 30 days after treatment
Number of patients with DLTs at each dose level [30 days after treatment]
Number of patients with DlTs at each dose level 30 days after treatment
Time to whole brain irradiation [At progression]
Time to whole brain irradiation
Median survival [Death]
Median amount of time subjects survive after therapy

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years and Older

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

INCLUSION CRITERIA:

Phase 1 Inclusion Criteria

Patients must have histologically confirmed HER2-positive breast cancer for which standard curative measures do not exist or are no longer effective. HER2 testing must have been performed in a laboratory accredited by the College of American Pathologists (CAP) or another accrediting entity.
Patients must have brain metastases, treated within 12 weeks of study entry with SRS, resection or WBRT. A minimum interval of 3 weeks between completion of brain SRS and/or resection and 6 weeks for WBRT and the start of treatment in this trial will be observed to allow proper healing. The presence of concomitant extracranial metastatic disease is allowed for enrollment.
Corticosteroids will be allowed at enrollment and during the first month of treatment

with T-DM1 after SRS, up to a dose of no more than 10mg of dexamethasone daily or equivalent. Patients that need to continue corticosteroids after the initial month will be allowed to continue in the protocol treatment if no further increase in dose is necessary. Patients that need increase in dose of corticosteroid after initial month will be taken off protocol treatment.

Age greater than or equal to18 years. Because breast cancer is not commonly found in pediatric population and no dosing or adverse event data are currently available on the use of temozolomide in combination with T-DM1 in patients <18 years of age, children are excluded from this study, but will be eligible for future pediatric trials.
ECOG performance status less than or equal to 2 (Karnofsky greater than or equal to 60%, see Appendix A)
Patients must have normal organ and marrow function as defined below:
leukocytes greater than or equal to 3,000/mcL
absolute neutrophil count greater than or equal to 1,000/mcL
platelets greater than or equal to 100,000/mcL
total bilirubin within normal institutional limits
AST(SGOT)/ALT(SGPT) <3.0 X institutional upper limit of normal
creatinine up to 1.5 upper institutional limits, OR
creatinine clearance greater than or equal to 60 mL/min/1.73 m(2) for patients with creatinine levels above institutional normal.
Alkylating agents as well as other therapeutic agents used in this trial are known to be teratogenic, women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation and for 7 months (women) or 4 months (men) after treatment completion. 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.
Ability of subject to understand and the willingness to sign a written informed consent document.

Phase 2 Inclusion Criteria

Patients must have histologically confirmed HER2-positive breast cancer for which standard curative measures do not exist or are no longer effective. HER2 testing must have been performed in a laboratory accredited by the College of American Pathologists (CAP) or another accrediting entity.
Patients must have 1-10 brain metastases, by contrast MRI, treated within 12 weeks of study entry with SRS and/or resection. A minimum interval of 3 weeks between completion of brain SRS and/or resection and the start of treatment in this trial will be observed to allow proper healing. The presence of concomitant extracranial metastatic disease is allowed for enrollment.
Corticosteroids will be allowed at enrollment and during the first month of treatment with T-DM1 after SRS, up to a dose of no more than 10mg of dexamethasone daily or equivalent. Patients that need to continue corticosteroids after the initial month will be allowed to continue in the protocol treatment if no further increase in dose is necessary. Patients that need increase in dose of corticosteroid after initial month will be taken off protocol treatment.
Age greater than or equal to 18 years. Because breast cancer is not commonly found in pediatric population and no dosing or adverse event data are currently available on the use of temozolomide in combination with T-DM1 in patients <18 years of age, children are excluded from this study, but will be eligible for future pediatric trials.
ECOG performance status less than or equal to 2 (Karnofsky greater than or equal to 60%)
Patients must have normal organ and marrow function as defined below:
leukocytes greater than or equal to 3,000/mcL
absolute neutrophil count greater than or equal to 1,000/mcL
platelets greater than or equal to 100,000/mcL
total bilirubin within normal institutional limits
AST(SGOT)/ALT(SGPT) <3.0 X institutional upper limit of normal
creatinine up to 1.5 upper institutional limits, OR
creatinine clearance greater than or equal to 60 mL/min/1.73 m(2) for patients with creatinine levels above institutional normal.
Alkylating agents as well as other therapeutic agents used in this trial are known to be teratogenic, women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation and for 7 months (women) or 4 months (men) after treatment completion. 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.
Ability of subject to understand and the willingness to sign a written informed consent document.

EXCLUSION CRITERIA:

Phase 1 Exclusion Criteria

Patients who are receiving any other investigational agents.
Patients unable to speak or understand English, since they cannot complete neurocognitive evaluation.
Patients with known leptomeningeal metastatic disease.
Patients with major symptoms or impairments related to brain metastases, such as aphasia or severe confusion, will be excluded per PI discretion when those symptoms preclude proper neurocognitive evaluation during the study treatment.
Patients who have received previous treatment with T-DM1 and had systemic progression of disease while on it, are ineligible. Patients receiving treatment with T- DM1 whose only site of disease progression was brain are allowed to enroll in this trial.
Patients who have received chemotherapy in the previous 3 weeks (6 weeks for nitrosoureas or mitomycin).
HBV (HBs Ag positive) or HCV (anti-HCV positive) patients are ineligible because of potential reactivation of hepatitis virus with temozolomide use.
Grade greater than or equal to 3 peripheral neuropathy according to (NCI CTCAE) version 4.0.
Cerebral Vascular Accident (CVA) or Transitory Ischemic Attack (TIA) in the year before enrollment, or presence of residual symptoms from CVA that happened more than a year before.
Pulmonary Embolism (PE) in the 3 months before enrollment. Anticoagulation is permitted.
Impaired cardiac function or clinically significant cardiac disease including the following:
New York Heart Association grade III or IV congestive heart failure.
Myocardial infarction within the last 12 months.
Subjects with impaired LVEF (<50%).
Patients with inability to complete brain MRI studies with contrast.
Patients with breast tissue expanders must have those removed before enrollment.
History of allergic reactions attributed to compounds of similar chemical or biologic composition to temozolomide or T-DM1. Patients who are tolerating TDM1 successfully with premedications and slower infusion will be allowed.
Patients receiving medications that are strong CYP3A4 inhibitors or inducers are ineligible. In vitro studies indicate that DM1, the cytotoxic component of T-DM1, is metabolized mainly by CYP3A4 and to a lesser extent by CYP3A5. Concomitant use of strong CYP3A4 inhibitors with T-DM1 should be avoided due to the potential for an increase in DM1 exposure and toxicity. Consider an alternate medication with no or minimal potential to inhibit CYP3A4. Lists including medications and substances known or with the potential to interact with CYP3A4 isoenzymes are provided in Appendix B.
Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, that would limit compliance with study requirements.
Pregnant women are excluded from this study because temozolomide is an alkylating 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 temozolomide and/or T-DM1, breastfeeding should be discontinued if the mother is treated with either of those agents. These potential risks may also apply to other agents used in this study.
HIV-positive patients are excluded because these patients are at increased risk of lethal infections when treated with marrow-suppressive therapy.
Patients with any other concomitant invasive malignancies are ineligible. Prior invasive cancers treated with curative intent, and with no evidence of recurrent disease, may be eligible after PI evaluation. Patients with treated limited stage basal cell or squamous cell carcinoma of the skin or carcinoma in situ of the breast or cervix are eligible.

Phase 2 Exclusion Criteria

Patients who are receiving any other investigational agents.
Patients unable to speak or understand English, since they cannot complete neurocognitive evaluation.
Patients with known leptomeningeal metastatic disease.
Patients previously treated with whole brain radiation therapy (WBRT).
Patients with major symptoms or impairments related to brain metastases, such as aphasia or severe confusion, will be excluded per PI discretion when those symptoms preclude proper neurocognitive evaluation during the study treatment.
Patients who have received previous treatment with T-DM1 and had systemic progression of disease while on it, are ineligible. Patients receiving treatment with T- DM1 whose only site of disease progression was brain are allowed to enroll in this trial.
Patients who have received chemotherapy in the previous 3 weeks (6 weeks for nitrosoureas or mitomycin).
HBV (HBs Ag positive) or HCV (anti-HCV positive) patients are ineligible because of potential reactivation of hepatitis virus with temozolomide use.
Grade greater than or equal to 3 peripheral neuropathy according to (NCI CTCAE) version 4.0.
Cerebral Vascular Accident (CVA) or Transitory Ischemic Attack (TIA) in the year before enrollment, or presence of residual symptoms from CVA that happened more than a year before.
Pulmonary Embolism (PE) in the 3 months before enrollment. Anticoagulation is permitted.
Impaired cardiac function or clinically significant cardiac disease including the following:
New York Heart Association grade III or IV congestive heart failure.
Myocardial infarction within the last 12 months.
Subjects with impaired LVEF (<50%).
Patients with inability to complete brain MRI studies with contrast.
Patients with breast tissue expanders must have those removed before enrollment.
History of allergic reactions attributed to compounds of similar chemical or biologic composition to temozolomide or T-DM1. Patients who are tolerating TDM1 successfully with premedications and slower infusion will be allowed.
Patients receiving medications that are strong CYP3A4 inhibitors or inducers are ineligible. In vitro studies indicate that DM1, the cytotoxic component of T-DM1, is metabolized mainly by CYP3A4 and to a lesser extent by CYP3A5. Concomitant use of strong CYP3A4 inhibitors with T-DM1 should be avoided due to the potential for an increase in DM1 exposure and toxicity. Consider an alternate medication with no or minimal potential to inhibit CYP3A4. Lists including medications and substances known or with the potential to interact with CYP3A4 isoenzymes are provided in Appendix B.
Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, that would limit compliance with study requirements.
Pregnant women are excluded from this study because temozolomide is an alkylating 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 temozolomide and/or T-DM1, breastfeeding should be discontinued if the mother is treated with either of those agents. These potential risks may also apply to other agents used in this study.
HIV-positive patients are excluded because these patients are at increased risk of lethal infections when treated with marrow-suppressive therapy.
Patients with any other concomitant invasive malignancies are ineligible. Prior invasive cancers treated with curative intent, and with no evidence of recurrent disease, may be eligible after PI evaluation.