A Study of Tucatinib vs. Placebo in Combination With Capecitabine & Trastuzumab in Patients With Advanced HER2+ Breast Cancer
Condition: HER2 Positive Breast Cancer
MeSH terms: Breast Neoplasms
Intervention: tucatinib; capecitabine; trastuzumab; placebo
Intervention description: 300 mg orally twice daily; 1000 mg/m2 orally twice daily on Days 1-14 of each 21-day cycle; 8 mg/kg intravenously (IV) on Day 1 of Cycle 1, followed by 6 mg/kg on Day1 of each 21-day cycle. In regions where approved, trastuzumab may be given at 600mg subcutaneously once every 3-weeks at either study initiation or crossing over from previous IV trastuzumab.; Oral dose twice daily
Intervention MeSH terms: Capecitabine; Trastuzumab; Tucatinib
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Masking description: Masking applied only during the Double-blind phase of the trial. The Unblinded Phase is open-label.
Enrollment: 612.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No
Keywords: Tucatinib; Capecitabine; Trastuzumab; Xeloda; Herceptin; Breast Cancer; ARRY-380; ONT-380; HER2 Positive Breast Carcinoma; HER2 Positive Locally Advanced Breast Cancer; HER-2 Positive Breast Cancer; HER-2 Positive Breast Carcinoma; HER-2 Positive Locally Advanced Breast Cancer; Recurrent Breast Carcinoma; Stage IV Breast Cancer; Metastatic Breast Cancer; Breast Carcinoma; Metastatic Malignant Neoplasm in the Brain; Brain Metastases in Breast Cancer; Asymptomatic Brain Metastases in Breast Cancer; Low Symptomatic Brain Metastases in Breast Cancer; Seattle Genetics

Summary:

      This study is being done to see if tucatinib works better than placebo to help patients who
      have a specific type of breast cancer called HER2 positive breast carcinoma. The breast
      cancer in this study is either metastatic (spread into other parts of the body) or cannot be
      removed completely with surgery. All patients in the study will get capecitabine and
      trastuzumab, two drugs that are often used to treat this cancer.

      There are two parts to this study. The first part of the study is already complete. Patients
      were randomly assigned to get either tucatinib or placebo (a pill with no medicine). Since
      this part was "blinded," neither patients nor their doctors knew whether a patient got
      tucatinib or placebo.

      The second part of the study is called the Unblinded Phase. In this part of the study,
      participants and their doctors know which drugs are being given. Participants who used to get
      or are currently getting placebo may be able to start taking tucatinib instead.

      Each treatment cycle lasts 21 days. Patients will swallow tucatinib pills two times every
      day. They will swallow capecitabine pills two times a day during the first two weeks of each
      cycle. Patients will get trastuzumab injections from the study site staff on the first day of
      every cycle.
    

Eligibility criteria:

        Double-blind Phase Inclusion Criteria

          -  Histologically confirmed HER2+ breast carcinoma, with HER2+ defined by in situ
             hybridization (ISH), immunohistochemistry (IHC), or fluorescence in situ hybridization
             (FISH) methodology

          -  Received previous treatment with trastuzumab, pertuzumab, and T-DM1

          -  Progression of unresectable locally advanced or metastatic breast cancer after last
             systemic therapy (as confirmed by investigator), or be intolerant of last systemic
             therapy

          -  Have measurable or non-measurable disease assessable by RECIST 1.1

          -  Eastern Cooperative Oncology Group (ECOG) Performance Status of 0 or 1

          -  Adequate hepatic and renal function and hematologic parameters

          -  Left ventricular ejection fraction (LVEF) ≥ 50%

          -  CNS Inclusion - Based on screening brain magnetic resonance imaging (MRI), patients
             must have one of the following:

               1. No evidence of brain metastases

               2. Untreated brain metastases not needing immediate local therapy

               3. Previously treated brain metastases not needing immediate local therapy

                    1. Brain metastases previously treated with local therapy may either be stable
                       since treatment or may have progressed since prior local CNS therapy

                    2. Patients treated with CNS local therapy for newly identified lesions found
                       on contrast brain MRI performed during screening for this study may be
                       eligible to enroll if the following criteria are met:

                  i. Time since whole brain radiation therapy (WBRT) is ≥ 21 days prior to first
                  dose of study treatment, time since stereotactic radiosurgery (SRS) is ≥ 7 days
                  prior to first dose of study treatment, or time since surgical resection is ≥ 28
                  days.

                  ii. Other sites of disease assessable by RECIST 1.1 are present

               4. Relevant records of any CNS treatment must be available to allow for
                  classification of target and non-target lesions

        Double-blind Phase Exclusion Criteria

          -  Previously been treated with:

               1. lapatinib within 12 months of starting study treatment (except in cases where
                  lapatinib was given for ≤ 21 days and was discontinued for reasons other than
                  disease progression or toxicity)

               2. neratinib, afatinib, or other investigational HER2/epidermal growth factor
                  receptor (EGFR) or HER2 tyrosine kinase inhibitor (TKI) at any time previously

               3. capecitabine (or other fluoropyrimidine) for metastatic disease except in cases
                  where capecitabine was given for < 21 days and was discontinued for reasons other
                  than disease progression or toxicity. Patients who have received capecitabine for
                  adjuvant or neoadjuvant treatment at least 12 months prior to starting study
                  treatment are eligible.

          -  Clinically significant cardiopulmonary disease

          -  Carriers of Hepatitis B or Hepatitis C or have other known chronic liver disease

          -  Positive for human immunodeficiency virus (HIV)

          -  Unable for any reason to undergo MRI of the brain

          -  Have used a strong CYP3A4 or CYP2C8 inhibitor within 5 half-lives of the inhibitor, or
             a strong CYP3A4 or CYP2C8 inducer within 5 days prior to first dose of study treatment

          -  Have known dihydropyrimidine dehydrogenase deficiency (DPD)

          -  CNS Exclusion - Based on screening brain MRI, patients must not have any of the
             following:

               1. Any untreated brain lesions > 2.0 cm in size, unless approved by medical monitor

               2. Ongoing use of systemic corticosteroids for control of symptoms of brain
                  metastases at a total daily dose of > 2 mg of dexamethasone (or equivalent)

               3. Any brain lesion thought to require immediate local therapy. Patients who undergo
                  local treatment for such lesions identified by screening contrast brain MRI may
                  still be eligible for the study based on criteria described under CNS inclusion
                  criteria

               4. Known or suspected leptomeningeal disease (LMD)

               5. Poorly controlled seizures Unblinded Phase Crossover Inclusion Criteria -
                  Participants who were randomized to the control arm (placebo + trastuzumab +
                  capecitabine) must meet the following criteria to be eligible to crossover to the
                  experimental arm.

          -  Have measurable or non-measurable disease assessable by RECIST 1.1

          -  For patients who were randomized to the control arm and on the long-term follow-up
             period at the time of crossover screening: have progression of unresectable locally
             advanced or metastatic breast cancer after last systemic therapy (as confirmed by
             investigator), or be intolerant of last systemic therapy.

          -  Have an ECOG Performance Status of 0 or 1

          -  Have a life expectancy of at least 6 months

          -  Have adequate hepatic and renal function and hematologic parameters

          -  Left ventricular ejection fraction (LVEF) ≥ 50%

          -  CNS Inclusion - Based on screening brain magnetic resonance imaging (MRI), patients
             must have one of the following:

             i. No evidence of brain metastases ii. Untreated brain metastases not needing
             immediate local therapy iii. Previously treated brain metastases not needing immediate
             local therapy

          -  Brain metastases previously treated with local therapy may either be stable since
             treatment or may have progressed since prior local CNS therapy

          -  Patients treated with CNS local therapy for newly identified lesions found on contrast
             brain MRI performed during screening for this study may be eligible to enroll if the
             following criteria are met:

               1. Time since whole brain radiation therapy (WBRT) is ≥ 21 days prior to first dose
                  of study treatment, time since stereotactic radiosurgery (SRS) is ≥ 7 days prior
                  to first dose of study treatment, or time since surgical resection is ≥ 28 days.

               2. Other sites of disease assessable by RECIST 1.1 are present Unblinded Phase
                  Crossover Exclusion Criteria - Participants who were randomized to the control
                  arm (placebo + trastuzumab + capecitabine) will be excluded from the crossover to
                  the experimental arm for any of the following reasons.

          -  Discontinuation of study treatment due to an adverse event while on the double-blind
             phase of the study. If the adverse event leading to discontinuation of study treatment
             has resolved, the patient may be allowed to crossover with approval from the medical
             monitor.

          -  History of exposure to the following cumulative doses of anthracyclines:

               -  Doxorubicin > 360 mg/m^2

               -  Epirubicin > 720 mg/m^2

               -  Mitoxantrone > 120 mg/m^2

               -  Idarubicin > 90 mg/m^2

               -  Liposomal doxorubicin > 550 mg/m^2

          -  History of allergic reactions to trastuzumab, capecitabine, or compounds chemically or
             biologically similar to tucatinib

             o Exceptions for Grade 1 or 2 infusion related reactions to trastuzumab that were
             successfully managed, or known allergy to one of the excipients in the study drugs

          -  Have received treatment with any systemic anti-cancer therapy, non-CNS radiation, or
             experimental agent within 3 weeks prior to start of crossover therapy

          -  Any toxicity related to prior cancer therapies that has not resolved to ≤ Grade 1,
             with the following exceptions:

               -  Alopecia and neuropathy (must have resolved to ≤ Grade 2)

               -  CHF (must have been ≤ Grade 1 in severity at the time of occurrence and must have
                  resolved completely)

               -  Anemia (must have resolved to ≤ Grade 2)

          -  Have clinically significant cardiopulmonary disease

          -  Have known myocardial infarction or unstable angina within 6 months prior to start of
             crossover therapy

          -  Require therapy with warfarin or other coumarin derivatives

          -  Inability to swallow pills or significant gastrointestinal disease which would
             preclude the adequate oral absorption of medications

          -  Have used a strong CYP2C8 inhibitor within 5 half-lives of the inhibitor or have used
             a strong CYP2C8 or CYP34A inducer within 5 days prior to start of the crossover
             (tucatinib) treatment.

          -  Known dihydropyrimidine dehydrogenase deficiency

          -  Unable to undergo contract MRI of the brain

          -  Have evidence within 2 years prior to start of crossover therapy of another malignancy
             that required systemic treatment

          -  CNS Exclusion:

          -  CNS Exclusion - Based on screening brain MRI, patients must not have any of the
             following:

               -  Any untreated brain lesions > 2.0 cm in size, unless approved by medical monitor

               -  Ongoing use of systemic corticosteroids for control of symptoms of brain
                  metastases at a total daily dose of > 2 mg of dexamethasone (or equivalent)

               -  Any brain lesion thought to require immediate local therapy. Patients who undergo
                  local treatment for such lesions identified by screening contrast brain MRI may
                  still be eligible for the study based on criteria described under CNS inclusion
                  criteria

               -  Known or suspected leptomeningeal disease (LMD)

               -  Poorly controlled seizures