Cisplatin and Paclitaxel With or Without Everolimus in Treating Patients With Stage II or Stage III Breast Cancer

Official Title: “A Phase II Neo-Adjuvant Study of Cisplatin, Paclitaxel With or Without RAD001 in Patients With Triple-negative Locally Advanced Breast Cancer.”

RATIONALE: Drugs used in chemotherapy, such as cisplatin and paclitaxel, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Everolimus may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth and by blocking blood flow to the tumor. Giving chemotherapy together with everolimus before surgery may make the tumor smaller and reduce the amount of normal tissue that needs to be removed. It is not yet known whether cisplatin and paclitaxel are more effective when given together with or without everolimus in treating patients with breast cancer.

PURPOSE: This randomized phase II trial is studying how well cisplatin and paclitaxel work when given together with or without everolimus in treating patients with stage II or stage III breast cancer.

OBJECTIVES:

Primary - To determine the pathological complete response in patients with triple-negative, stage II or III breast cancer treated with neoadjuvant cisplatin and paclitaxel with or without everolimus.

Secondary - To determine the safety profile of these treatment regimens. - To evaluate tumor response to these treatment regimens as measured by ultrasound before definitive surgery. - To evaluate the rate of breast conservation surgery after treatment with these regimens. - To determine treatment-mediated changes in cell cycle position, proliferation, and apoptosis as well as status, levels, and phosphorylation state of S6K, p53, p73, and p63 and select p53 family target genes before and after initiation of paclitaxel. - To isolate RNA and generate microarray data sets from pre- and post-treatment biopsy material to identify a pre-treatment gene signature that will predict response. - To isolate RNA and generate microarray data sets from pre- and post-treatment biopsy material to identify a change in gene signature after the first treatment that will predict response. - To isolate RNA and generate microarray data sets from pre- and post-treatment biopsy material to determine if previously established p63 and p73 gene signatures predict response to treatment. - To isolate RNA and generate microarray data sets from pre- and post-treatment biopsy material to determine if a change will be observed in p63 and p73 gene signatures between pre- and post-treatment biopsies. - To isolate RNA and generate microarray data sets from pre- and post-treatment biopsy material to determine if triple-negative breast cancers can be clustered into different subtypes on the basis of gene expression, given the size of the microarray data set that will be generated from this clinical trial and previous clinical trials (> 100 tumors). - To isolate RNA and generate microarray data sets from pre- and post-treatment biopsy material to determine if p63 and p73 gene signatures can sub-classify triple-negative breast cancers.

OUTLINE: This is a multicenter study. Patients are stratified according to initial lymph node status (positive vs negative involvement) and tumor grade (low or intermediate vs high). Patients are randomized to 1 of 2 treatment arms. - Arm I: Patients receive cisplatin IV over 1 hour and oral everolimus once weekly in weeks 1-12 and paclitaxel IV over 1 hour once weekly in weeks 4-12 in the absence of disease progression or unacceptable toxicity. - Arm II: Patients receive cisplatin IV over 1 hour and oral placebo once weekly in weeks 1-12 and paclitaxel IV over 1 hour once weekly in weeks 4-12 in the absence of disease progression or unacceptable toxicity.

Approximately 3-6 weeks after the completion of neoadjuvant therapy, patients undergo partial or total mastectomy with lymph node evaluation. Patients may then receive additional chemotherapy or radiotherapy.

Patients undergo ultrasound-guided core biopsies at baseline and in weeks 1, 4, and 12 for analysis of proliferation, apoptosis, and pathway activity markers via IHC or western blotting and RNA microarrays.

Patients are followed up within 3 weeks after surgery.

Intervention(s) in this Clinical Trial

• Drug: cisplatin
  • Given IV
• Drug: everolimus
  • Given orally
• Drug: paclitaxel
  • Given IV
• Other: placebo
  • Given orally

Arms, Groups and Cohorts in this Clinical Trial

• Experimental: Arm I
  • Cisplatin 25 mg/m2 IV weekly + RAD001 5 mg PO daily for 1 week followed by Cisplatin 25 mg/m2 IV + Paclitaxel 80 mg/m2 IV weekly + RAD001 5 mg PO daily for 11 weeks
• Active Comparator: Arm II
  • Cisplatin 25 mg/m2 IV weekly + placebo PO daily for 1 week followed by Cisplatin 25 mg/m2 IV + Paclitaxel 80 mg/m2 IV weekly + placebo PO daily for 11 weeks

Primary Measures

• Pathological complete response
  • Time Frame: at the time of surgery
    Safety Issue?: No

Secondary Measures

• Rate of breast conservation surgery
  • Time Frame: at the time of surgery
    Safety Issue?: No
• Clinical tumor response to neoadjuvant therapy as measured by ultrasound immediately before surgery
  • Time Frame: within 3 weeks of scheduled surgery
    Safety Issue?: No
• Therapy-mediated changes in cell cycle position, proliferation, and apoptosis as well as status, levels, and phosphorylation state of p53, p73, and p63 and select p53 family target genes
  • Time Frame: 1 week after initiation of study drugs
    Safety Issue?: No
• Ability of p63 and p73 gene signatures to predict patient response
  • Time Frame: 1 week after study drug initiation
    Safety Issue?: No

• Eligibility criteria

Inclusion criteria:

• Patients must provide informed written consent.
• Patient must be ≥ 18 years of age.
• ECOG performance status 0-1.
• Clinical stage II or stage III triple-negative (ER and/or PR no staining or weak staining in less than 5% cells by immunohistochemistry [IHC] and HER2-negative by Herceptest [0, 1+] or FISH) invasive mammary carcinoma, confirmed by histological analysis.
• Patients who have measurable* residual tumor at the primary site
• *Measurable disease: any mass that can be reproducibly measured by physical examination, mammogram, and/or ultrasound and can be accurately measured in at least one dimension (longest diameter to be recorded) as 10 mm (1 cm), either in the breast or axillary lymph nodes.
• Available core biopsies from the time of diagnosis. These may include sections of paraffin-embedded material.
• Patients who will undergo surgical treatment with either segmental resection or total mastectomy.
• Patients must have adequate hematologic, hepatic, and renal function. All tests must be obtained less than 4 weeks from study entry. This includes:
• ANC >/=1500/mm3
• Platelet count >/=100,000/mm3
• Creatinine </=1.5X upper limits of normal
• Bilirubin, SGOT, SGPT </=1.5X upper limits of normal*
• * for patients with Gilbert‟s syndrome, direct bilirubin will be measured instead of total bilirubin.
• The patient must have not had anyprior chemotherapy for primary breast cancer.
• Patients with a prior history of contra-lateral breast cancer are eligible if they have no evidence of recurrence of their initial primary breast cancer within the last 5 years.
• Able to swallow and retain oral medication.
• Four days prior to biopsy procedures patients must be off medications that could increase risk of bleeding (i.e. ASA, NSAIDS, Coumadin, heparin products)
• Potential subjects must complete all screening assessments as outlined in the protocol.
• The pre-menopausal patient must have had a negative pregnancy test and agreed to use birth control methods while participating in the study. Note: Women of childbearing age and their male counterparts should use a barrier method of contraception during and for 3 months following protocol therapy.
• Ineligibility Criteria

Exclusion Criteria:

• Locally recurrent breast cancer.
• Pregnant or lactating women.
• Evidence of distant metastatic disease (i.e. lung, liver, bone, brain, etc.)
• Use of CYP3A4 modifiers (Appendix A)
• Serious medical illness that in the judgment of the treating physician places the patient at high risk of operative mortality.
• Malabsorption syndrome, disease significantly affecting gastrointestinal function, or resection of the stomach or small bowel.
• History of other malignancy. Subjects who have been disease-free for 5 years, or subjects with a history of completely resected non-melanoma skin cancer or successfully treated in situ carcinomas are eligible.
• History of hepatitis B or hepatitis C. If patient is judged to be at risk for having had exposure to viral B or C hepatitis (i.e. illicit IV drug use, blood transfusion prior to 1990, body piercing, tattoos, etc.), appropriate testing should be performed (i.e. Hepatitis B surface antigen antibody, and Hepatitis C antibody)
• Active or uncontrolled infection requiring parenteral antibiotics.
• Dementia, altered mental status, or any psychiatric condition that would prohibit the understanding or rendering of informed consent.
• Symptomatic neuropathy (≥ grade 2).
• Concurrent anti-cancer therapy (chemotherapy, radiation therapy, surgery, immunotherapy, hormonal therapy, or any other biologic therapy) other than the ones specified in the protocol.
• Concurrent treatment with an investigational agent.
• Used an investigational drug within 15 days or 5 half-lives, whichever is longer, preceding the first dose of randomized therapy.

Gender Eligibility for this Clinical Trial: Both

Minimum Age for this Clinical Trial: 18 Years

Maximum Age for this Clinical Trial: N/A

Are Healthy Volunteers Accepted for this Clinical Trial?: No

Lead Investigator: Vanderbilt-Ingram Cancer Center Other

Overall Clinical Trial Officials and Contacts

Ingrid Mayer, M.D. Principal Investigator Vanderbilt-Ingram Cancer Center  

Overall Contact: Vanderbilt-Ingram Cancer Center Clinical Trials Office 800-811-8480 

Information obtained from ClinicalTrials.gov on February 12, 2012

Link to the current ClinicalTrials.gov record. http://clinicaltrials.gov/show/NCT00930930

Study ID Number: VICC BRE 0904

ClinicalTrials.gov Identifier: NCT00930930

Health Authority: United States: Food and Drug Administration

Clinical trial summary from the National Cancer Institute's PDQ® database