Patient case: 72-year-old male with Cholangiocarcinoma. Genetic variant: BRCA2. Other conditions: Diabetes.

Clinical trial: BMN 673 (Talazoparib), an Oral PARP Inhibitor, in People With Deleterious BRCA1/2 Mutation-Associated Ovarian Cancer Who Have Had Prior PARP Inhibitor Treatment

Summary: Background:
  - The new drug BMN 673 (talazoparib) has been shown to fight tumor cells in animals and some people. It is a PARP inhibitor. It works on tumor cell DNA damage repair process. Researchers want to see if BMN 673 shrinks cancer again in women with ovarian cancer and whose cancer initially got shrunk but grew back on the first PARP inhibitor.
  Objective:
  - To study BMN 673 (talazoparib) in people with ovarian cancer born with a BRCA mutation and whose cancer got shrunk but became worse after they took a similar drug.
  Eligibility:
  -  Women at least 18 years old:
  -  with recurrent and/or metastatic gBRCAm-associated ovarian cancer AND
  -  whose disease is growing after already being treated with PARP inhibitors AND
  -  with no other treatment(s) in between the first PARP inhibitors and a screening visit.
  Design:
  -  Participants will be screened with medical history, physical exam, and heart and blood tests.
  -  Participants will take the study drug by mouth once daily. They will take the drug in 28-day cycles.
  -  They will keep a diary of doses and any side effects.
  -  Participants will have 4 study visits in cycle 1, then 1 visit every cycle. Visits may include:
  -  Blood tests
  -  Physical exam
  -  Computed tomography (CT) or magnetic resonance imaging (MRI) scans. Participants will lie in a machine that takes pictures of their body.
  -  Ultrasound
  -  Participants will have a biopsy before starting the study drug. A small piece of tumor tissue will be removed by needle, guided by a scan. They may have two more biopsies later.
  -  Participants will be followed for 30 days after taking the last dose of study drug. A physical exam, blood tests, and CT or other scans will be done.
  -  Participants will have follow-up calls to ask about any side effects.

Detailed description: Background:
  -  Patients with germline BRCA1/2 mutations (gBRCAm) demonstrate repeated therapeutic susceptibility to DNA damaging agents, especially platinums, even if they have previously progressed on a similar (platinum-based) regimen.
  -  PARP inhibitors (PARPi) have clinical activity in gBRCAm-associated malignancies, although patients eventually develop progressive disease.
  -  BMN 673 (talazoparib) is a novel PARPi, with excellent oral bioavailability and greater anti-tumor activity in vitro and in vivo at lower concentrations than first generation PARPi.
  -  It is unknown whether secondary BRCA mutations or other potential mechanisms of clinical resistance portend cross-resistance to a highly potent PARPi.
  Objectives:
  -To determine the objective response rate (CR+PR) of single agent BMN 673 (talazoparib) in ovarian cancer patients with gBRCAm who have progressed on prior PARPi therapy.
  Eligibility:
  -  Women with recurrent and/or metastatic gBRCAm-associated ovarian cancer, with progression on PARPi monotherapy within the immediate prior 2 months of the time of screening visit.
  -  Patients should have responded to their prior PARPi therapy (CR, PR or SD>4months).
  -  Patients cannot have received another therapy between stopping their first PARPi therapy\ and initiating therapy on this trial, but must be off the prior PARPi for at least 4 weeks.
  -  ECOG performance status 0-2 and adequate organ and marrow function.
  Design:
  -  This is an open label, single arm phase II trial to examine activity of BMN 673 (talazoparib).
  -  Patients will receive BMN 673 (talazoparib) at the RP2D of 1mg p.o. once daily on 28 day cycles.
  -  Research samples including whole blood, plasma, CTCs, and tumor biopsies will be obtained for PD endpoints at baseline, cycle 1 day 29 (prior to cycle 2 day 1), and/or at progression in all patients.
  -  Patients will be evaluated every two cycles for response using RECISTv1.1 criteria and every cycle for safety using CTCAEv4.0.

Eligibility: -  INCLUSION CRITERIA:
  -  Recurrent, and/or metastatic germline BRCA 1/2 mutation-associated ovarian cancer, with progression on a PARP inhibitor monotherapy after attaining a response to that PARPi (CR, PR, or SD greater than or equal to 4mo)
  -  Progression should have occurred within the immediate prior 2 months of the time of screening visit, with no intervening anti-cancer therapy.
  -  Patients must be at least 4 weeks from the last dose of prior PARP inhibitor.
  -  All patients must have at least one lesion deemed safe to biopsy and be willing to undergo mandatory baseline biopsy. It is preferred that this lesion be a lesion that progressed or arose while on the prior PARP therapy.
  -  Histopathologic diagnosis of ovarian cancer (including primary peritoneal and fallopian tube cancers) must be confirmed in the Laboratory of Pathology, NCI.
  -  Age greater than or equal to18 years.
  -  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:
  -  absolute neutrophil count greater than or equal to 1,500/mcL
  -  platelets greater than or equal to100,000/mcL
  -  total bilirubin less than or equal to 1.5X upper limit of normal, unless known Gilbert s syndrome
  -  AST(SGOT)/ALT(SGPT) less than or equal to 3 x institutional upper limit of normal
  -  creatinine < 1.5 X upper limit of normal
  OR
  -  measured creatinine clearance >60 mL/min/1.73 m2 for patients with serum creatinine levels > 1.5 x upper limit of normal.
  -  hemoglobin greater than or equal to 10 mg/dL (in the absence of transfusion within 24 hours prior to dosing).
  -  All patients must have measurable disease by RECIST.
  -  Use of raloxifene for bone health is allowed.
  -  Patients must be at least 1 week from the last dose of complementary or alternative medications.
  -  Patients who have had major surgery must be fully recovered and greater than or equal to 4 weeks postoperative prior to enrolling on study.
  -  Women of child-bearing potential 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 at least three months following the last dose of experimental therapy and must have a negative urine or serum pregnancy test within 7 days prior to the start of the study.
  -  Patient must be able to swallow pills.
  -  Integral biomarkers: all patients who are eligible for the study due to a history of positive BRCA1/2 mutation must provide documented evidence of their deleterious germline mutation status, obtained in a CLIA-certified laboratory, including but not limited to Myriad Genetics prior to study enrollment. Variants of uncertain significance (VUS) of BRCA1/2 and BRCA1/2 somatic mutations are not considered deleterious germline BRCA1/2 mutations. Due to the long acceptance of BRCA 1 and BRCA 2 mutation testing through Myriad, Myriad results will be acceptable. If testing for BRCA 1 and BRCA 2 mutation is done by other organizations, a genetic consultation report from a qualified medical professional confirming that the laboratory results showed a recognized germ line deleterious BRCA 1 or BRCA 2 mutation or deleterious BRCA 1 rearrangement is required.
  -  Ability to understand and the willingness to sign a written informed consent document.
  EXCLUSION CRITERIA:
  -  Patients who have had prior BMN 673 (talazoparib) therapy.
  -  Patients with known brain metastases diagnosed within 1 year will be excluded from this clinical trial because of their poor prognosis and because they often develop progressive neurologic dysfunction that would confound the evaluation of neurologic and other adverse events. Exception: patients with brain metastases diagnosed greater than 1 year prior to study entry may be considered if they received sterilizing therapy to the CNS (resection or radiation) and have been CNS progression-free for the 1-year period.
  -  Lack of recovery of prior cancer therapy-related adverse events to Grade less than or equal to 1 (NCI CTCAE v4.03; except alopecia). Stable persistent grade 2 peripheral neuropathy may be allowed as determined on a case-by-case basis at the discretion of the PI. Patients with platinum-related grade 2 or greater hypomagnesemia (on replacement) will be eligible.
  -  Uncontrolled intercurrent illness including, but not limited to, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, clinically significant GI bleeding or hemoptysis within 28 days prior to the start of the study, or psychiatric illness/social situations that would limit compliance with study requirements.
  -  Patients with active infection will not be eligible, but may become eligible once infection has resolved and they are at least 7 days from completion of antibiotics.
  -  Another previous or current invasive malignancy within the last 2 years, with the exception of curatively treated stage Ia cervical carcinoma, or resected stage Ia endometrial cancer, and noninvasive nonmelanoma skin cancers.
  -  HIV-positive patients on combination antiretroviral therapy are ineligible because of the potential for pharmacokinetic interactions with BMN 673 (talazoparib). HIV- positive patients who are not on cART and have CD4 counts > 500 are eligible.
  -  History of allergic reactions attributed to compounds of similar chemical or biologic composition to BMN 673 (talazoparib)
  Patients who are receiving any other investigational or commercial agents with the intent to treat the malignancy.
  -  Patients with gastrointestinal conditions that might predispose for drug intolerability or poor drug absorption.
  -  Use of nasogastric or G-tube administration.

Relevance to patient case: not relevant