Efficacy and Safety of Dose-dense Chemotherapy (ddEC-ddP) for Neoadjuvant Chemotherapy of HER2-negative Breast Cancer

Sponsor

Second Affiliated Hospital, School of Medicine, Zhejiang University (Other)

Overall Status

Recruiting

CT.gov ID

NCT04576143

Collaborator

Women's Hospital School Of Medicine Zhejiang University (Other), Changxing People's Hospital (Other), Zhejiang Provincial People's Hospital (Other), Hangzhou First People's Hospital, School of Medicine, Zhejiang Universiry (Other), Huizhou Municipal Central Hospital (Other)

260

Enrollment

Location

Arms

Anticipated Duration (Months)

3.1

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

Recent clinical studies showed that breast cancer patients especially for those with lymph node metastasis may benefit from dose-dense chemotherapy, like adriamycin and cyclophosphamide (AC) q2w×4→ paclitaxel (P) q2w×4. However, the studies on dose-dense (dd) regimen chemotherapy is mostly based on postoperative adjuvant chemotherapy and the optimum of dose-dense chemotherapy has not been determined for Chinese population with HER2-negative breast cancer patients. In our study, a prospective, randomized, open-label, multi-center clinical study was conducted to compare the efficacy and safety of dose-dense chemotherapy regimen (dd epirubicin/cyclophosphamide (EC) followed by dd paclitaxel (P)) and conventional chemotherapy (epirubicin/cyclophosphamide (EC) followed by docetaxel (T)) as preoperative neoadjuvant chemotherapy in the treatment of HER2-negative breast cancer in Chinese population.

Condition or Disease	Intervention/Treatment	Phase
HER2-negative Breast Cancer Neoadjuvant Chemotherapy	Drug: Epirubicin Drug: Cyclophosphamid Drug: Docetaxel Drug: Paclitaxel	Phase 2/Phase 3

Detailed Description

Neoadjuvant chemotherapy refers to systemic chemotherapy as the first step for treating breast cancer patients before planned local treatment like surgery for those without distant metastasis. Randomized trials of chemotherapy have demonstrated similar long-term outcomes when patients were given the same treatment preoperatively compared with postoperatively. It is reported that preoperative neoadjuvant chemotherapy can facilitate breast conservation, render inoperable tumors operable and provide important prognostic information at an individual patient level based on response to therapy.

According to the recommendation of National Comprehensive Cancer Network (NCCN) guideline, patients with inoperable breast cancer, such as inflammatory breast cancer, N3 nodal disease and T4 tumors are candidates for preoperative systemic therapy. As for those operable patients with HER2-positive disease and triple-negative breast cancer (TNBC), if T ≥2 or N ≥1, or large primary tumor relative to breast size in a patient who desires breast conservation, neoadjuvant chemotherapy is also preferred. Based on the results of NSABP-27 and Aberdeen clinical trials, chemotherapeutic drugs including taxanes (such as docetaxel, paclitaxel) and anthracyclines (such as doxorubicin, epirubicin) have become the standard neoadjuvant chemotherapy regimens for early operable patients and for HER2-negative breast cancer patients, anthracyclines combined with cyclophosphamide followed by docetaxel is mostly common used.

Limited to myelosuppression and bone marrow repair, conventional chemotherapy cycle is usually set once every 3-4 weeks. Recent years, the application of granulocyte colony stimulating factor (G-CSF), which can shorten the recovery time of leukocytes, enables dose-dense chemotherapy (maximum tolerable dose, every 2 weeks as a cycle) to become a treatment option for high-risk patients. The concept of dose-dense chemotherapy is based on a mathematical model developed by Norton and Simon, and relies on an understanding of Gompertzian model of tumor growth. Gompertzian kinetics explain that human neoplasms do not grow in an exponential fashion, instead the cell-doubling time becomes progressively longer as the tumor growth. Thus, cancer treatments that reduce the size of a tumor can promote faster tumor regrowth between treatments indirectly. So Norton-Simon hypothesis suggests that the most effective strategy is to expose the tumor to cytotoxic agents as frequently as possible to minimize regrowth between cycles.

The CALGB 9471 used a randomized, 2×2 factorial design to prospectively compare sequential doxorubicin, paclitaxel, cyclophosphamide with concurrent doxorubicin and cyclophosphamide followed by paclitaxel, and to compare dose-dense schedules with conventional schedules. A total of 2005 node-positive, previously untreated patients were enrolled. At a median follow-up of 36 months, dose-dense treatment significantly improved disease-free survival (DFS) and overall survival (OS) compared with conventionally scheduled treatment. The GIM2 study also demonstrated that dose-dense adjuvant chemotherapy (FEC-P and EC-P every 2 weeks a cycle) improved DFS and OS compared with standard interval chemotherapy (every 3 weeks a cycle). However, the studies on dose-dense chemotherapy is mostly based on postoperative adjuvant chemotherapy. We aim to conduct a prospective, randomized, open-label, multi-center clinical study to compare the efficacy and safety of dose-dense chemotherapy (dd epirubicin/cyclophosphamide (EC) followed by dd paclitaxel (P)) and conventional chemotherapy (epirubicin/cyclophosphamide (EC) followed by docetaxel (T)) as preoperative neoadjuvant chemotherapy in the treatment of HER2-negative breast cancer in Chinese population.

Study Design

Study Type:

Interventional

Anticipated Enrollment :

260 participants

Allocation:

Randomized

Intervention Model:

Parallel Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

Efficacy and Safety of Dose-dense Epirubicin and Cyclophosphamide Plus Paclitaxel as Neoadjuvant Chemotherapy for HER2-negative Early Breast Cancer：a Multicenter Randomized Controlled Trial

Actual Study Start Date :

Sep 20, 2020

Anticipated Primary Completion Date :

Jun 20, 2023

Anticipated Study Completion Date :

Sep 20, 2027

Arms and Interventions

Arm	Intervention/Treatment
Active Comparator: epirubicin/CTX × 4 - docetaxel × 4, every 3 weeks a cycle Cycle 1-4: Epirubicin i.v. 90 mg/m2, Cyclophosphamide i.v. 600 mg/m2 (One cycle = 21 days); Cycle 5-8: Docetaxel i.v. 100mg/m2 (One cycle = 21 days) .	Drug: Epirubicin i.v. 90 mg/m2 Other Names: Epirubicin Hydrochloride Drug: Cyclophosphamid i.v. 600 mg/m2 Other Names: CTX Drug: Docetaxel i.v. 100 mg/m2
Experimental: epirubicin/CTX × 4 - paclitaxel × 4, every 2 weeks a cycle Cycle 1-4: Epirubicin i.v. 90 mg/m2, Cyclophosphamide i.v. 600 mg/m2 (One cycle = 14 days); Cycle 5-8:Paclitaxel i.v. 175mg/m2 (One cycle = 14 days) .	Drug: Epirubicin i.v. 90 mg/m2 Other Names: Epirubicin Hydrochloride Drug: Cyclophosphamid i.v. 600 mg/m2 Other Names: CTX Drug: Paclitaxel i.v. 175 mg/m2 Other Names: PTX

Arm

Intervention/Treatment

Active Comparator: epirubicin/CTX × 4 - docetaxel × 4, every 3 weeks a cycle

Cycle 1-4: Epirubicin i.v. 90 mg/m2, Cyclophosphamide i.v. 600 mg/m2 (One cycle = 21 days); Cycle 5-8: Docetaxel i.v. 100mg/m2 (One cycle = 21 days) .

Drug: Epirubicin

i.v. 90 mg/m2

Other Names:

Epirubicin Hydrochloride

Drug: Cyclophosphamid

i.v. 600 mg/m2

Other Names:

CTX

Drug: Docetaxel

i.v. 100 mg/m2

Experimental: epirubicin/CTX × 4 - paclitaxel × 4, every 2 weeks a cycle

Cycle 1-4: Epirubicin i.v. 90 mg/m2, Cyclophosphamide i.v. 600 mg/m2 (One cycle = 14 days); Cycle 5-8:Paclitaxel i.v. 175mg/m2 (One cycle = 14 days) .

Drug: Epirubicin

i.v. 90 mg/m2

Other Names:

Epirubicin Hydrochloride

Drug: Cyclophosphamid

i.v. 600 mg/m2

Other Names:

CTX

Drug: Paclitaxel

i.v. 175 mg/m2

Other Names:

PTX

Outcome Measures

Primary Outcome Measures

pathological complete response (pCR) [Following the completion of 16 weeks or 24 weeks of neoadjuvant chemotherapy Treatment.]
pCR is defined as the absence of noninvasive tumor residuals in breast and axillary lymph nodes (ypT0/is ypN0) after neoadjuvant therapy.

Secondary Outcome Measures

objective response rate (ORR) [Following the completion of 16 weeks or 24 weeks of neoadjuvant chemotherapy Treatment.]
ORR is defined as the proportion of patients who achieved a complete response (CR) or partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST).
disease free survival (DFS) [Time of Surgery up to 5 years]
Events including local relapse, distant metastasis, contralateral breast cancer, second primary cancer or death from any cause
breast-conserving rate (BCR) [Following the completion of 16 weeks or 24 weeks of neoadjuvant chemotherapy Treatment.]
The rate of patients who were performed breast-conserving surgery.
Number of participants with adverse events [First Dose of chemotherapy up to 12 months.]
(like cardiotoxicity ,hematological toxicity，gastrointestinal symptoms) as a measure of safety

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years to 70 Years

Sexes Eligible for Study:

Female

Accepts Healthy Volunteers:

Inclusion Criteria:

Female aged 18-70 years old;
Histological confirmed with unilateral invasive carcinoma (all pathological types are applicable), clinical stage IIA-IIIA;
Definite reports on ER/PR/HER2 receptor showing all HER2 negative (HER2 is 0~1+ or 2+ but determined negative via fluorescence in situ hybridization (FISH) or chemiluminescent in situ hybridization (CISH) detected (no amplification) is defined as HER2 negative);
According to RECIST 1.1, there is at least one measurable objective focus, tumor size

2cm;

Eastern Cooperative Oncology Group (ECOG) performance score is 0 or 1;
Cardiac function: left ventricular ejection fraction (LVEF)≥55%;
Normal bone marrow function: White blood cell count > 4 × 10^{9/l, neutrophil count >
1.5 × 10}9/l, platelet count > 100 × 10^9/l and hemoglobin 9g/dl;
Normal liver and renal function: aspartate aminotransferase (AST) and ALT ≤2.5 folds of the upper limit of normal values, total bilirubin ≤1.5 folds of the upper limit of normal values; Serum creatinine ≤1.5 folds of the upper limit of normal value.
Informed consent form signed.

Exclusion Criteria:

HER2 is positive;
Metastasis at any location;
Previous neoadjuvant therapy, including chemotherapy, radiotherapy and hormone therapy;
Severe systemic disease and/or uncontrollable infection, unable to be enrolled in this study;
Known allergic or intolerable to chemotherapeutic agents;
Previously suffering from malignant tumors within 5 years (except for basal cell carcinoma and cervical carcinoma in situ), including contralateral breast cancer;
Cardiovascular disease: LVEF <50% (echocardiography) of New York Heart Association (NYHA) ≥ grade 2;
Pregnant and breast-feeding women; Pregnancy test showed positive results before drug administration after enrolling in to the study; Women at childbearing age refuse to take contraception measures during the treatment and 8 weeks after completion of treatment;
Already enrolled into other clinical trials;
The researchers judged the patients who were not suitable for this study.