Patient case: 46-year-old female with papillary thyroid carcinoma; genetic feature: NTRK1

Clinical trial: Phase 2b Study of Taxol Plus Sorafenib or Placebo in Patients With Advanced Breast Cancer

Summary: RATIONALE: Drugs used in chemotherapy, such as paclitaxel, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Sorafenib 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 paclitaxel together with sorafenib may kill more tumor cells.
  PURPOSE: This randomized phase II trial is studying how well paclitaxel works when given together with or without sorafenib in treating patients with locally recurrent or metastatic breast cancer.

Detailed description: OBJECTIVES:
  Primary
  -  Compare progression-free survival of patients with locally recurrent or metastatic breast cancer treated with sorafenib tosylate and paclitaxel versus placebo and paclitaxel as first-line therapy.
  Secondary
  -  Compare the objective response rate and duration of response in patients treated with these regimens.
  -  Compare the time to progression in patients treated with these regimens.
  -  Compare the survival of patients treated with these regimens.
  -  Compare the safety of patients treated with these regimens.
  -  Compare the change from baseline in the Functional Assessment of Cancer Therapy for Breast Cancer quality of life assessment score in patients treated with these regimens.
  OUTLINE: This is a double-blind, randomized, multicenter study. Patients are stratified according to site of metastatic disease (visceral [i.e., soft internal organs of the body, including lungs, heart, and the organs of the digestive, excretory, and reproductive systems] vs nonvisceral [i.e., osseous or soft tissue] sites). Patients are randomized to 1 of 2 treatment arms.
  -  Arm I: Patients receive paclitaxel IV over 1 hour once weekly for 3 weeks. Patients also receive oral sorafenib tosylate twice daily on days 1-28.
  -  Arm II: Patients receive paclitaxel as in arm I and oral placebo twice daily on days 1-28.
  In both arms, treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity.
  Quality of life is assessed at baseline, and every 8 weeks for 24 weeks, and then every 12 weeks for the duration of study participation.
  After completion of study therapy, patients are followed every 4 months.

Eligibility: DISEASE CHARACTERISTICS:
  -  Histologically or cytologically confirmed adenocarcinoma of the breast
  -  Locally recurrent or metastatic disease
  -  Locally recurrent disease not amenable to resection with curative intent
  -  Measurable or evaluable disease
  -  No HER-2 overexpression (defined as positive for gene amplification by FISH or 3+ overexpression by IHC)
  -  No unknown HER-2 status
  -  No active brain metastases
  -  Patients with neurological symptoms and known brain metastases treated with definitive therapy must undergo contrast CT scan or brain MRI to exclude active brain metastasis
  -  Previously treated brain metastases allowed provided at least 3 months since prior definitive therapy (including steroids) AND no evidence of disease
  -  Hormone receptor status not specified
  PATIENT CHARACTERISTICS:
  -  Male or female
  -  Menopausal status not specified
  -  ECOG performance status 0-1
  -  Not pregnant or nursing for ≥ 2 weeks after completion of study therapy
  -  Negative pregnancy test
  -  Fertile patients must use effective contraception during and for ≥ 2 weeks after completion of study therapy
  -  Hemoglobin ≥ 9.0 g/dL
  -  ANC ≥ 1,500/mm³
  -  Platelet count ≥ 100,000/mm³
  -  Total bilirubin ≤ 1.5 times the upper limit of normal (ULN)
  -  ALT and AST ≤ 2.5 times ULN (≤ 5 times ULN for patients with liver involvement)
  -  INR ≤ 1.5 and aPTT within normal limits
  -  Anticoagulation therapy (e.g., warfarin or heparin) allowed
  -  Stable INR required for patients on warfarin
  -  Creatinine ≤ 1.5 times the ULN
  -  Able to swallow and retain oral medication
  -  More than 4 weeks since prior significant traumatic injury
  -  No evidence or history of bleeding diathesis or coagulopathy
  -  No serious nonhealing wound, ulcer, or bone fracture
  -  No substance abuse or medical, psychological, or social condition that would interfere with study participation or evaluation of study results
  -  No pre-existing peripheral neuropathy ≥ grade 2
  -  No clinically significant cardiac disease, including any of the following:
  -  New York Heart Association class II-IV congestive heart failure
  -  Unstable angina (i.e., angina symptoms at rest) or new-onset angina within the past 3 months
  -  Myocardial infarction within the past 6 months
  -  No cardiac ventricular arrhythmias requiring anti-arrhythmic therapy
  -  No uncontrolled hypertension (i.e., systolic blood pressure [BP] > 150 mm Hg or diastolic BP > 90 mm Hg despite optimal medical management)
  -  No thrombolic, embolic, venous, or arterial events such as a cerebrovascular accident, including transient ischemic attacks within the past 6 months
  -  No pulmonary hemorrhage or bleeding event > grade 2 within the past 4 weeks
  -  No other hemorrhage or bleeding event ≥ grade 3 within the past 4 weeks
  -  No active clinically serious infection > grade 2
  -  No known HIV infection or chronic hepatitis B or C
  -  No other prior or concurrent cancer except carcinoma in situ of the cervix, treated basal cell skin cancer, superficial bladder tumors (e.g., Ta and Tis), or any cancer curatively treated for > 5 years
  -  No known or suspected allergy to sorafenib tosylate or hypersensitivity to paclitaxel or drugs using the vehicle Cremophor
  PRIOR CONCURRENT THERAPY:
  -  More than 12 months since prior adjuvant or neoadjuvant taxane therapy
  -  At least 3 weeks since other prior adjuvant chemotherapy
  -  At least 3 weeks since prior hormonal therapy for locally recurrent or metastatic disease
  -  No prior chemotherapy for locally recurrent or metastatic breast cancer
  -  More than 4 weeks since prior major surgery or open biopsy
  -  At least 3 weeks since prior radiotherapy
  -  Previously irradiated area must not be the only site of disease
  -  More than 30 days or 5 half-lives, whichever is longer, since prior investigational drug
  -  No prior or concurrent bevacizumab or any other licensed or investigational drugs that target VEGF or VEGF-receptor
  -  More than 3 weeks since prior and no concurrent Hypericum perforatum (St. John's wort ) or rifampin (rifampicin)
  -  No concurrent cytochrome P450 enzyme-inducing antiepileptic drugs (e.g., phenytoin, carbamazepine, or phenobarbital)
  -  No concurrent irinotecan hydrochloride or doxorubicin hydrochloride
  -  No other concurrent anticancer therapy (i.e., chemotherapy, radiotherapy, surgery, immunotherapy, biologic therapy, or tumor embolization)
  -  No concurrent nonconventional therapies (e.g., herbal)
  -  No concurrent palliative radiotherapy

Relevance to patient case: not relevant