Patient case: 54-year-old female with Breast cancer. Genetic variant: PTEN Loss. Other conditions: Congestive Heart Failure.

Clinical trial: Docetaxel Alone or in Combination With Vaccine to Treat Breast Cancer

Summary: This study will test whether giving a combination of a vaccine together with docetaxel is more effective against breast cancer than docetaxel alone. The Food and Drug Administration has approved docetaxel to treat many cancers, including breast cancer. The vaccine consists of three parts: 1) a "priming vaccine" called PANVAC (PAN (all) VAC (vaccine)) trademark [TM]-V, which is made from vaccinia virus; 2) a "boosting vaccine" called PANVAC[TM]-F, made from fowlpox virus; and 3) sargramostim, or granulocyte macrophage colony stimulating factor (GM-CSF), a protein that may help boost the immune system. Human genes are inserted into the vaccinia and fowlpox viruses to cause production of carcinoembryonic antigen (CEA) and mucin 1 (MUC-1)-two proteins that are often produced by cancer cells and can be used as a target for the immune system to attack the cancer. Another type of deoxyribonucleic acid (DNA) is inserted to cause production of other proteins that enhance immune activity.
  Patients 18 years of age or older with metastatic breast cancer (disease that has spread beyond the original site) and whose cancer produces CEA or mucin 1 (MUC-1) protein may be eligible for this study. Patients must have antigen type human leukocyte antigen A2 (HLA-A2). They may have received adjuvant docetaxel treatment at least 3 months before entering this study, prior hormonal therapy and up to three chemotherapy regimens. Candidates are screened with a medical history and physical examination, blood and urine tests, electrocardiogram, and computerized tomography (CT) or magnetic resonance imaging scans.
  Participants are randomly assigned to one of two treatment groups - docetaxel alone or docetaxel plus vaccine - as follows:
  Docetaxel Alone
  All patients receive docetaxel. The drug is infused through a vein over 30 to 60 minutes once a week for 3 consecutive weeks with 1 week off drug. Patients also take dexamethasone 12 hours and 1 hour before and 12 hours after the docetaxel to help prevent fluid retention (edema) that docetaxel may cause.
  Docetaxel Plus Vaccine
  Participants receive the priming vaccination followed by monthly boosting vaccinations, along with the weekly docetaxel therapy. With every vaccination, patients also receive an injection of sargramostim to increase the number of immune cells at the vaccination site. Sargramostim injections are given the day of vaccination and daily for the next 3 days. All vaccine and sargramostim doses are given as injections under the skin, usually in the thigh. Patients are observed in the clinic for 1 hour after each injection.
  Patients have blood tests every four weeks to monitor drug side effects and before every vaccination to check blood counts. A bone scan or CT scan (or both) is done every 2 to 3 months to check the response to treatment.
  Patients may continue receiving treatment as long as their disease does not worsen and they can tolerate the treatment without significant side effects. Patients assigned to receive docetaxel alone whose disease progresses after 3 months on the drug may choose to receive the vaccine or come off the study to receive other treatment options. Patients are monitored with yearly telephone calls for up to 15 years.

Detailed description: Background:
  Weekly docetaxel therapy is currently used as a standard treatment for patients with metastatic breast cancer.
  Although many patients initially respond to this form of therapy, the majority will eventually develop disease progression and die from their disease.
  We have explored the use of combining pox vector vaccines with docetaxel. In a recent clinical trial, men with prostate cancer were given both the vaccine and docetaxel without any significant toxicity and the docetaxel did not diminish immune responses to the vaccine.
  Objectives:
  To evaluate progression free survival comparing PANVAC + docetaxel vs. docetaxel alone in patients with metastatic breast cancer.
  To evaluate overall survival comparing PANVAC + docetaxel vs. docetaxel alone in patients with metastatic breast cancer.
  To evaluate in both arms cluster of differentiation 8 (CD8+) T cell responses directed against carcinoembryonic antigen (CEA) and mucin (MUC-1) in human leukocyte antigen 2 (HLA-A2), A3, and A24 positive patients by interferon-gamma enzyme linked immunosorbent spot (ELISPOT) assay.
  Eligibility:
  Metastatic breast cancer (either male or female) with evidence of metastatic disease (must have radiographic evidence of disease) and life expectancy of at least 4 months.
  Patients may have received unlimited prior hormonal therapy or chemotherapy, but no prior docetaxel for metastatic disease.
  Hematological eligibility parameters within 16 days of starting therapy:
  Granulocyte count greater than or equal to 1,500/mm^3, Platelet count greater than or equal to 100,000/mm^3, hemoglobin (Hgb) greater than or equal to 8 Gm/dL.
  Design:
  A randomized Phase II study evaluating the role of combining docetaxel with PANVAC[TM]-V (recombinant vaccinia containing the genes encoding for CEA, MUC-1, lymphocyte function-associated antigen 3 (LFA-3), intercellular adhesion molecule 1 (ICAM-1) and B7.1) and PANVAC[TM]-F (recombinant fowlpox containing the genes encoding for CEA, MUC-1, LFA-3, ICAM-1 and B7.1) vs. docetaxel alone to determine if the addition of the vaccine can prolong the time to disease progression as well as overall survival in patients with metastatic breast cancer.
  Patients randomized to docetaxel alone may receive sequential therapy with PANVAC[TM]-V and PANVAC[TM]-F at time of disease progression.
  In patients randomized to the concurrent therapy, PANVAC[TM]-V will be administered to patients 3 weeks prior to the start of chemotherapy as the initial vaccine.
  The immune responses to CEA and MUC-1 will then be boosted by administration of PANVAC[TM]-F.
  Sargramostim or granulocyte macrophage colony stimulating factor (GM-CSF) will be administered with each vaccine inoculation for four consecutive days only for patients treated at the National cancer Institute (NCI).

Eligibility: -  INCLUSION CRITERIA:
  -  Metastatic Breast Cancer (either male or female) with evidence of metastatic disease (must have radiographic evidence of measurable disease) on computed tomography (CT) scan or X-ray, or evidence of evaluable disease on bone scan that is consistent with metastasis and a life expectancy of at least 4 months. Patients may have received unlimited prior hormonal therapy and chemotherapy.
  -  Histologically confirmed adenocarcinoma of the breast cancer confirmed in the Pathology Clinical Center at National Cancer Institute (NCI), (or National Naval Medical Center (NNMC)) or MD Anderson Pathology Department prior to starting this study. Note: However, if no pathologic specimen is available, patients may enroll with a clinical course consistent with breast cancer and a pathological documentation of the disease.
  -  18 years of age or greater.
  -  May have received docetaxel in the adjuvant setting at least 12 months prior to study entry.
  -  Able to understand and give informed consent.
  -  Able to avoid close household contact (close household contacts are those who share housing or have close physical contact) for at least two weeks after recombinant vaccinia vaccination with persons with active or a history of eczema or other eczematoid skin disorders; those with other acute, chronic or exfoliative skin conditions (e.g., atopic dermatitis, burns, impetigo, varicella zoster, severe acne, or other open rashes or wounds) until condition resolves; pregnant or nursing women; children 3 years of age and under; and immunodeficient or immunosuppressed persons (by disease or therapy), including human immunodeficiency virus (HIV) infection. We have vaccinated over 700 cancer patients and have reported no cases of either self inoculation or person to person transmission of the virus.
  -  Eastern Cooperative Oncology Group (ECOG) performance status of 0 - 1.
  -  Serum creatinine less than 1.5 times upper limits of normal (ULN) OR creatinine clearance on a 24 hour urine collection of greater than or equal to 60 mL/min, standard liver function tests (LFT) limitations for patients receiving docetaxel therapy include bilirubin within ULN and serum glutamic oxaloacetic transaminase (SGOT)/serum glutamic pyruvic transaminase (SGPT) less than 1.5 times the ULN. If transaminases are greater than 1.5 times the ULN up to 2 times the ULN (as currently indicated), then alk phos should be less than 2.5 times the ULN. (Patients with renal abnormalities should be evaluated for creatinine clearance (CrCl) and interstitial abnormalities. A Cr Cl of greater than or equal to 60ml/min measured or calculated and proteinuria less than 1000mg per 24 hours are eligible unless explained by non-renal causes.)
  -  Recovered completely from any grade 3 or 4 reversible hematologic and non hematologic toxicity associated with recent therapy. Typically this is 3-4 weeks for patients who most recently received cytotoxic therapy. Patients previously treated with mitomycin c or carboplatin will require a minimum of 6 weeks.
  -  Hematological eligibility parameters (within 16 days of starting therapy):
  1. Granulocyte count greater than or equal to1,500/mm^3
  2. Platelet count greater than or equal to 100,000/mm^3
  3. Hemoglobin (Hgb) greater than or equal to 8 Gm/dL
  -  Must agree to use effective birth control or abstinence during and for a period of 4 months after the last vaccination therapy.
  -  Patients whose tumors are estrogen receptor (ER) positive should have failed primary hormone therapy unless clinically indicated, i.e. in patients with visceral disease or symptomatic bone disease where up front chemotherapy is warranted. Patients who progressed or recurred following Trastuzumab (Herceptin) therapy if a patient is fluorescence in situ hybridization (FISH) positive or immunohistochemistry (IHC) 3+ positive for human epidermal growth factor receptor 2 (Her-2 neu). Those patients who have progressed on trastuzumab may continue to receive the drug by their referring physician. However, if trastuzumab has been discontinued at the time of enrolling on study, it cannot be resumed while a patient remains on study.
  -  Patients randomized to docetaxel alone (arm B) may at time of progression go on to receive vaccine alone if their ECOG performance status remains 0-1, and they do not have any uncontrolled pain or organ dysfunction that would require another intervention such as radiation or chemotherapy.
  Furthermore, patients initially randomized to arm B that would like to cross over and continue vaccine therapy must meet on-study eligibility and exclusion criteria with the exception of liver transaminase requirement. Patients with liver transaminase levels within Grade 1 by Common Terminology Criteria for Adverse Events (CTCAE) v4.0 (up to 3 x ULN) will be allowed to crossover to vaccine.
  -  Patients should appear clinically stable (in the opinion of the principle investigator) to complete the full 3 month course of vaccination with an anticipated survival of 6 months or longer.
  -  No other active malignancies within the past 12 months (with the exception of non-melanoma skin cancers or carcinoma in situ of the bladder) or life threatening illnesses.
  -  Patients with cardiovascular symptoms should be fully evaluated for signs and symptoms of cardiovascular disease and other standard evaluations including electrocardiogram (EKG), chest X-ray, cardiac enzymes, and echocardiogram as clinically indicated.
  EXCLUSION CRITERIA:
  -  Patients should have no evidence of being immunocompromised as listed below.
  1. Human immunodeficiency virus positivity due to the potential for decreased tolerance and risk for severe side effects
  2. Active autoimmune diseases requiring treatment or a history of autoimmune disease that might be stimulated by vaccine treatment. This requirement is due to the potential risks of exacerbating autoimmunity Patients with endocrine disease that is controlled by replacement therapy including thyroid disease and adrenal disease and vitiligo may be enrolled
  3. Concurrent use of systemic steroids, except for local (topical, nasal, or inhaled) steroid use
  -  History of allergy or untoward reaction to prior vaccination with vaccinia virus.
  -  Pregnant or breast-feeding women
  -  Altered immune function, including immunodeficiency or history of immunodeficiency; eczema; history of eczema, or other eczematoid skin disorders; or those with acute, chronic or exfoliative skin conditions (e.g. atopic dermatitis, burns, impetigo, varicella zoster, severe acne, or other open rashes or wounds)
  -  Serious intercurrent medical illness which would interfere with the ability of the patient to carry out the treatment program, including, but not limited to, inflammatory bowel disease, Crohn's disease, ulcerative colitis, or active diverticulitis
  -  Clinically active brain metastasis, or a history of seizures that have been active within one year
  -  Medical conditions, which, in the opinion of the investigators would jeopardize the patient or the integrity of the data obtained
  -  Prior docetaxel chemotherapy for metastatic disease
  -  Serious hypersensitivity reaction to egg products
  -  Clinically significant cardiomyopathy requiring treatment
  -  Chronic hepatitis infection, including B and C, because of potential immune impairment
  -  Although topical steroids are allowed, steroid eye-drops are contraindicated
  -  Patients who have received prior PANVAC vaccine therapy
  -  Patients with a prior history of allergy to eggs or egg products should not receive the vaccine
  -  Patients with cardiac disease that have fatigue, palpitation, dyspnea or angina with ordinary physical activity (New York Heart Association class 2 or greater) are not eligible.
  -  Prior splenectomy.
  -  Cardiac complications, including recent myocardial infarction or cerebrovascular accident within one year, and/or unstable or uncontrolled angina.

Relevance to patient case: not relevant