Patient case: 45-year-old female with colon cancer; genetic feature: PIK3CA (E545K)

Clinical trial: Phase 2, Endocrine Therapy + OSI-906 With or Without Erlotinib for Hormone-sensitive Metastatic Breast Cancer

Summary: RATIONALE: Estrogen can cause the growth of breast cancer cells. Hormone therapy using letrozole +/- goserelin (the latter for pre-menopausal women only) may fight breast cancer by lowering the amount of estrogen the body makes. OSI-906 and erlotinib hydrochloride may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. It is not yet known whether hormone therapy and OSI-906 are more effective when given with or without erlotinib hydrochloride in treating hormone-sensitive metastatic breast cancer.
  PURPOSE: This phase II trial is studying how well giving hormone therapy together with OSI-906 with or without erlotinib hydrochloride works in treating hormone-sensitive patients with metastatic breast cancer.

Detailed description: OBJECTIVES:
  Primary
  -  To determine the antitumor activity of letrozole +/- goserelin (the latter for pre-menopausal women only) in combination with IGF-1R inhibitor OSI-906 with or without erlotinib hydrochloride, measured by time to progression, in patients with hormone-sensitive metastatic breast cancer.
  Secondary
  -  To determine the safety of these regimens in these patients.
  -  To determine the response rate in patients treated with these regimens.
  -  To measure circulating C-peptide, IGF-1, and IGFBP-3 levels in patients treated with these regimens.
  -  To correlate the expression of IGF-IR, EGFR, HER2, Y1316 and Y1131 pIGF-1R, PTEN, S473 pAkt, pMAPK, S118 (MAPK site), and S167 (Akt and S6 site) pER in formalin-fixed paraffin blocks (FFPB) with clinical outcome and luminal A vs. luminal B subtypes of breast cancer.
  -  To correlate the mutational status of PI3K (E542K, E545K, H1047R) in DNA extracted from FFPB or fresh biopsy with clinical outcome and luminal A vs. luminal B subtypes of breast cancer
  OUTLINE: This is a multicenter study. Stratification will be based on previous exposure to endocrine therapy: (Arm I) no previous endocrine therapy or have completed adjuvant therapy > 6 months prior to study enrollment; (Arm II) patients that had previous endocrine therapy in the metastatic setting or had metastatic recurrence within 6 months of adjuvant endocrine therapy.
  -  Arm I: Patients receive oral letrozole once daily on days 1-28 +/- subcutaneous goserelin* on day 1 and oral IGF-1R inhibitor OSI-906 twice daily on days 1-28. Treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity.
  -  Arm II: Patients receive oral letrozole +/- subcutaneous goserelin* and IGF-1R inhibitor OSI-906 as in arm I. Patients also receive oral erlotinib hydrochloride once daily on days 1-28. Treatment repeats every 28 days in the absence of disease progression or unacceptable toxicity.
  NOTE: *Goserelin will only be given to premenopausal patients.
  Tumor tissue samples from original diagnosis or from fresh biopsy tissue are collected for biomarker analysis and other studies.
  After completion of study therapy, patients are followed periodically.

Eligibility: DISEASE CHARACTERISTICS:
  -  Histologically confirmed invasive breast carcinoma
  -  Stage IV disease
  -  No locally recurrent resectable disease
  -  No symptomatic brain metastases
  -  History of brain metastases allowed provided the patient is clinically stable for > 3 weeks after completion of radiotherapy AND is not taking steroids or therapeutic anticonvulsants that are CYP3A4 modifiers
  -  Hormone receptor status:
  -  Estrogen receptor and/or progesterone receptor positive tumor by immunohistochemistry (IHC)
  PATIENT CHARACTERISTICS:
  -  Pre- or post-menopausal
  -  ECOG performance status 0-1
  -  Life expectancy ≥ 6 months
  -  ANC ≥ 1,250/mm^3
  -  Platelet count ≥ 100,000/mm^3
  -  Creatinine ≤ 1.5 times upper limit of normal (ULN)
  -  Bilirubin ≤ 1.5 times ULN (≤ 3 times ULN if liver metastasis is present)
  -  For patients with Gilbert syndrome, direct bilirubin will be measured instead of total bilirubin
  -  SGOT and SGPT ≤ 1.5 times ULN (≤ 3 times ULN if liver metastasis is present)
  -  Alkaline phosphatase ≤ 1.5 times ULN (≤ 3 times ULN if liver metastasis is present)
  -  Not pregnant or nursing
  -  Negative pregnancy test
  -  Fertile patients must use effective barrier contraception during and for 3 months after completion of study therapy
  -  Able to swallow and retain oral medication
  -  Baseline QTc ≤ 450 msec
  -  No other invasive cancer within the past 5 years except for completely resected basal cell or squamous cell skin cancer or successfully treated cervical carcinoma in situ
  -  No malabsorption syndrome significantly affecting gastrointestinal function
  -  No diabetes, fasting glucose > 150mg/dL, or receiving ongoing anti-hyperglycemic therapies
  -  No concurrent uncontrolled illness including, but not limited to, any of the following:
  -  Ongoing or active infection requiring parenteral antibiotics
  -  Impaired lung function (i.e., COPD or lung conditions requiring oxygen therapy)
  -  Symptomatic congestive heart failure (NYHA class III or IV heart disease)
  -  Unstable angina pectoris, angioplasty, stenting, or myocardial infarction within the past 6 months
  -  Uncontrolled hypertension, defined as systolic BP > 180 mm Hg or diastolic BP > 100 mm Hg on two consecutive measurements taken ≥ 1 week apart, despite adequate medical support
  -  Clinically significant cardiac arrhythmia (multifocal premature ventricular contractions, bigeminy, trigeminy, or ventricular tachycardia that is symptomatic or requires treatment)
  -  Psychiatric illness and/or social situation that would compromise patient safety or limit compliance with study requirements, including maintenance of a compliance/pill diary
  PRIOR CONCURRENT THERAPY:
  -  See Disease Characteristics
  -  Recovered from prior therapy
  -  At least 2 weeks since prior investigational drugs
  -  No more than 4 prior chemotherapy treatments in the metastatic setting
  -  Does not include endocrine therapy or single-agent biologic therapy
  -  No concurrent CYP3A4 or CYP1A2 modifiers
  -  No other concurrent anticancer therapy, including chemotherapy, radiotherapy, surgery, immunotherapy, hormonal therapy, or biologic therapy
  -  Concurrent radiotherapy to painful bone metastases or areas of impeding bone fracture allowed provided radiotherapy is initiated before study therapy

Relevance to patient case: not relevant