Patient case: 56-year-old female with breast cancer; genetic feature: ERBB2

Clinical trial: Paclitaxel and Cyclophosphamide With or Without Trastuzumab Before Surgery in Treating Patients With Previously Untreated Stage I-III Breast Cancer

Summary: This phase II trial studies the side effects and how well giving paclitaxel and cyclophosphamide with or without trastuzumab before surgery works in treating patients with previously untreated stage I-III breast cancer. Drugs used in chemotherapy, such as paclitaxel and cyclophosphamide, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Monoclonal antibodies, such as trastuzumab, can block tumor growth in different ways. Some block the ability of tumor cells to grow and spread. Others find tumor cells and help kill them or carry tumor-killing substances to them. Giving combination chemotherapy with or without trastuzumab before surgery may make the tumor smaller and reduce the amount of normal tissue that needs to be removed

Detailed description: PRIMARY OBJECTIVES:
  I. To evaluate the toxicities and tolerability of a neoadjuvant dose-dense regimen cyclophosphamide and paclitaxel with or without trastuzumab/radiation therapy (as clinically indicated) in patients with newly diagnosed stage T1cN0 and II-III breast cancer; followed by maintenance trastuzumab in human epidermal growth factor receptor 2 (HER2) positive OR Adriamycin (doxorubicin hydrochloride) followed by radiation therapy (RT) in stage II-III triple negative HER2 (-), estrogen receptor (ER) (-), progesterone receptor (PR) (-) stage T1cN0 and II-III breast cancer patients.
  II. To determine the pathological complete response rate (pCR) of this treatment regimen.
  III. To identify possible gene expression profile signatures from whole genome array analysis that correlate with clinical response/resistance to chemotherapy as measured by pathologic complete response rate (pCR).
  OUTLINE:
  NEOADJUVANT THERAPY: Patients receive paclitaxel intravenously (IV) over 3 hours and cyclophosphamide IV over 1 hour on day 1. Patients with HER2-positive cancer also receive trastuzumab IV over 30 minutes on day 1. Treatment repeats every 14 days for up to 6 courses in the absence of disease progression or unacceptable toxicity. Patients without metastasis undergo mastectomy or breast conserving surgery 4-8 weeks later.
  POST-SURGERY/SYSTEMIC THERAPY:
  HER2-POSITIVE PATIENTS: Patients receive standard radiation therapy. Patients also receive trastuzumab IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 13 courses in the absence of disease progression or unacceptable toxicity.
  ER/PR POSITIVE PATIENTS: Patients receive standard adjuvant hormonal or endocrine therapy.
  STAGE T1cN0 TRIPLE NEGATIVE PATIENTS: Patients receive standard radiation therapy.
  STAGE II-III TRIPLE NEGATIVE PATIENTS: Patients receive doxorubicin hydrochloride IV over 15 minutes on day 1. Treatment repeats every 14 days for up to 4 courses in the absence of disease progression or unacceptable toxicity. Patients also receive standard radiation therapy.
  After completion of study treatment, patients are followed up every 3 months for 2 years.

Eligibility: Inclusion Criteria:
  -  Women with histologically proven invasive breast cancer without distant metastases and lymph node negative and a clinical tumor classification of T1cN0 or stage II-III
  -  Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1
  -  At least one lesion that can be accurately measured in two dimensions utilizing mammogram, ultrasound, or magnetic resonance imaging (MRI) images to define specific size and validate complete clinical and pathologic response
  -  Patients who received radiation therapy > 5 years ago for malignancies other than breast cancer and whose radiation therapy field is not overlapping with the 20% isodose line of current radiation field are eligible, provided that radiation therapy was completed > 5 years ago and that there is no evidence of the second malignancy at the time of study entry
  -  All malignant disease must be able to be encompassed within a single irradiation field
  -  Absolute neutrophil count greater than or equal to 1,500/mcl
  -  Platelet count equal to or greater than 150,000/mcl
  -  Hemoglobin > 11gm/dl
  -  Alkaline phosphatase equal or less than 1.5 times the upper limit of normal (ULN)
  -  Total bilirubin equal to or less than 1.5 times the ULN
  -  Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) no greater than 1.5 times the ULN
  -  Creatinine less than 1.5 times the ULN
  -  All included patients must have normal cardiac function as defined by an ejection fraction of > 50% and no decrease in wall motion by echocardiogram
  -  The patient must be aware of the neoplastic nature of his/her disease and willingly provide written, informed consent after being informed of the procedure to be followed, the experimental nature of the therapy, alternatives, potential benefits, side-effects, risks, and discomforts
  -  Women of reproductive potential must be non-pregnant and non-nursing and must agree to employ an effective barrier method of birth control throughout the study and for up to 6 months following treatment
  -  Women of child-bearing potential must have a negative pregnancy test within 7 days of initiating study; (no childbearing potential is defined as age 55 years or older and no menses for two years or any age with surgical removal of the uterus and/or both ovaries)
  Exclusion Criteria:
  -  Any patient with inflammatory breast cancer or stage IV or confirmed metastatic disease
  -  Patients who have had any prior chemotherapy, or endocrine therapy for the treatment of breast cancer or any other cancer
  -  Patients who cannot undergo surgery
  -  Patients with a known or documented anaphylactic reaction or allergy to any of chemotherapy agents used in this protocol, or to antiemetics appropriate for administration in conjunction with protocol-directed therapy
  -  Uncontrolled inter-current illness including, but not limited to ongoing or active infection requiring intravenous antibiotics, symptomatic congestive heart failure, unstable angina pectoris, or serious, uncontrolled cardiac arrhythmia, that might jeopardize the ability of the patient to receive the therapy program outlined in this protocol with reasonable safety
  -  Patients with preexisting grade II peripheral neuropathy
  -  Pregnant and nursing women are excluded from this study because the chemotherapy agents and radiation therapy all have the potential for teratogenic or abortifacient effects
  -  Patients with prior malignancy will be excluded except for adequately treated basal cell or squamous cell skin cancer, adequately treated noninvasive carcinomas
  -  Inability to cooperate with treatment protocol
  -  Patients with known human immunodeficiency virus (HIV) infection, infectious hepatitis, type A, B or C, active hepatitis, or hepatic insufficiency
  -  Patients may not be receiving or have received any other investigational agents during/or within 1 month prior
  -  Any serious medical condition, laboratory abnormality, or psychiatric illness that would prevent the subject from signing the informed consent form
  -  Myocardial infarction within 6 months prior to enrollment or has New York Heart Association (NYHA) class III or IV heart failure uncontrolled angina, severe uncontrolled ventricular arrhythmias, or electrocardiographic evidence of acute ischemia or active conduction system abnormalities; prior to study entry, any electrocardiogram (ECG) abnormality at screening has to be documented by the investigator as not medically relevant

Relevance to patient case: definitely relevant