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

Clinical trial: Trastuzumab in Treating Women With Primary Breast Cancer

Summary: RATIONALE: Monoclonal antibodies such as trastuzumab can locate tumor cells and either kill them or deliver tumor-killing substances to them without harming normal cells. It is not yet known whether trastuzumab is effective in treating primary breast cancer in women who have completed adjuvant chemotherapy.
  PURPOSE: This randomized phase III trial is studying two different regimens of trastuzumab and observation only to compare how well they work in treating women with breast cancer.

Detailed description: OBJECTIVES:
  Primary
  -  Compare the disease-free survival of women with HER2-positive primary breast cancer treated with trastuzumab (Herceptin®) for 1 year vs trastuzumab for 2 years vs standard supportive care.
  -  Compare the overall survival of patients treated with these regimens.
  -  Compare the relapse-free survival of patients treated with these regimens.
  -  Compare the distant disease-free survival of patients treated with these regimens.
  -  Compare the incidence of cardiac dysfunction in patients treated with these regimens.
  -  Evaluate the safety and tolerability of these regimens in these patients.
  Secondary
  -  Compare time to recurrence in patients treated with these regimens.
  -  Compare time to distant recurrence in patients treated with these regimens.
  -  Compare outcomes, in terms of disease-free survival, overall survival, recurrence-free survival, distant disease-free survival, time to recurrence, time to distant recurrence, cardiac safety, and overall safety, in patients treated with trastuzumab for 1 year vs 2 years.
  OUTLINE: This is a randomized, open-label, multicenter study. Patients are stratified according to nodal status (any nodal status and prior neoadjuvant chemotherapy vs no positive nodes and no prior neoadjuvant chemotherapy vs 1-3 positive nodes and no prior neoadjuvant chemotherapy vs 4 or more positive nodes and no prior neoadjuvant chemotherapy), prior adjuvant chemotherapy regimen (no anthracyclines or taxanes vs anthracyclines only vs anthracyclines and taxanes), receptor status and endocrine therapy (negative vs positive and no prior endocrine therapy vs positive and prior endocrine therapy), age (18 to 34 vs 35 to 49 vs 50 to 59 vs 60 and over), and participating center. Patients are randomized to 1 of 3 treatment arms.
  -  Arm I: Patients receive trastuzumab (Herceptin®) IV over 1.5 hours on day 1. Courses repeat every 3 weeks for up to 1 year in the absence of disease progression or unacceptable toxicity.
  -  Arm II: Patients receive trastuzumab as in arm I. Courses repeat every 3 weeks for up to 2 years in the absence of disease progression or unacceptable toxicity.
  -  Arm III: Patients receive no trastuzumab. Patients may later receive trastuzumab as in arm I or arm II.
  Patients are followed every 3 months for 2 years, every 6 months for 3 years, and then annually thereafter.
  PROJECTED ACCRUAL: Approximately 4,482 patients (1,494 per treatment arm) will be accrued for this study within 4 years.

Eligibility: DISEASE CHARACTERISTICS:
  -  Histologically confirmed nonmetastatic primary invasive adenocarcinoma of the breast
  -  Adequately excised
  -  Axillary nodes positive or negative
  -  No positive or suspicious internal mammary nodes identified by sentinel node technique that have not been irradiated
  -  No supraclavicular lymph node involvement
  -  HER2-positive disease with one of the following:
  -  3+ overexpression by immunohistochemistry (IHC)
  -  2+ overexpression by IHC and fluorescence in situ hybridization (FISH) with c-erbB2 gene amplification
  -  c-erbB2 gene amplification by FISH
  -  Previously treated with at least 3 months or 4 courses of approved neoadjuvant or adjuvant chemotherapy with or without radiotherapy
  -  No synchronous bilateral or multifocal breast cancer that is not HER2-positive
  -  No locally advanced or inflammatory breast cancer
  -  No clinical T4 primary breast tumor
  -  Prior curatively treated ipsilateral ductal carcinoma in situ of the breast is allowed
  -  Hormone receptor status:
  -  Estrogen receptor and progesterone receptor status known OR
  -  Estrogen receptor status known
  PATIENT CHARACTERISTICS:
  Age
  -  18 and over
  Sex
  -  Female
  Menopausal status
  -  Not specified
  Performance status
  -  ECOG 0-1
  Life expectancy
  -  Not specified
  Hematopoietic
  -  WBC at least 2,500/mm^3
  -  Absolute neutrophil count at least 1,500/mm^3
  -  Platelet count at least 100,000
  Hepatic
  -  Bilirubin no greater than 2 times upper limit of normal (ULN)
  -  AST and ALT no greater than 2.5 times ULN
  -  Alkaline phosphatase no greater than 2.5 times ULN
  Renal
  -  Creatinine no greater than 2 times ULN
  Cardiovascular
  -  LVEF at least 55% by echocardiography or MUGA
  -  No serious cardiac illness
  -  No documented congestive heart failure
  -  No high-risk uncontrolled arrhythmias
  -  No angina pectoris requiring antianginal medication
  -  No clinically significant valvular heart disease
  -  No evidence of transmural infarction on EKG
  -  No poorly controlled hypertension (i.e., systolic greater than 180 mm Hg or diastolic greater than 100 mm Hg)
  Pulmonary
  -  No severe pulmonary disease/illness
  Other
  -  No other malignancy except for curatively treated basal cell or squamous cell skin cancer, carcinoma in situ of the cervix, or other cancer that has been curatively treated, with no evidence of disease, and has less than 15% risk of recurrence over the next 10 years
  -  No other concurrent serious disease that would preclude study participation
  -  Not pregnant or nursing
  -  Negative pregnancy test
  -  Fertile patients must use effective barrier contraception
  PRIOR CONCURRENT THERAPY:
  Biologic therapy
  -  No prior peripheral stem cell or bone marrow stem cell transplantation as part of prior neoadjuvant or adjuvant chemotherapy regimen
  -  No prior biologic therapy or immunotherapy for breast cancer
  -  No prior anti-HER2 therapy for any reason
  -  No concurrent immunotherapy for breast cancer
  Chemotherapy
  -  See Disease Characteristics
  -  See Biologic therapy
  -  No prior cumulative dose of doxorubicin more than 360 mg/m^2 or epirubicin more than 720 mg/m^2
  -  No prior anthracyclines for another malignancy
  -  No more than 7 weeks since day 1 of last chemotherapy course
  -  No concurrent adjuvant chemotherapy
  Endocrine therapy
  -  No concurrent hormonal therapy, including aromatase inhibitors, pure antiestrogens, or progestational agents, for breast cancer
  -  Concurrent systemic adjuvant hormonal therapy for estrogen receptor-positive patients allowed
  -  Concurrent tamoxifen allowed
  Radiotherapy
  -  See Disease Characteristics
  -  No more than 6 weeks since completion of prior radiotherapy
  -  No prior mediastinal irradiation except for internal mammary node irradiation for the present breast cancer
  Surgery
  -  See Disease Characteristics
  -  No more than 6 weeks since prior definitive surgery
  -  Concurrent ovarian ablation allowed
  Other
  -  No other concurrent investigational therapy for breast cancer
  -  Concurrent bisphosphonate therapy allowed if started prior to study

Relevance to patient case: definitely relevant