Neratinib +/- Fulvestrant in Metastatic HER2 Non-amplified But HER2 Mutant Breast Cancer
Condition: Breast Neoplasms
MeSH terms: Breast Neoplasms
Intervention: Neratinib; Fulvestrant; Trastuzumab; Tumor biopsy; Research blood sample
Intervention description: -Optional at baseline and disease progression; -Baseline, cycle 1 day 15, cycle 2 day 1, cycle 3 day 1, day 1 of each odd cycle, end of treatment (progression)
Intervention MeSH terms: Trastuzumab; Fulvestrant
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Enrollment: 56.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No
Keywords: Neratinib; fulvestrant; HER2 mutation; metastatic breast cancer; trastuzumab

Summary:

      This phase II study will test cancer to see if it has a HER2 mutation and, if so, see how
      HER2 mutated cancer responds to treatment with neratinib.
    

Eligibility criteria:

        Inclusion Criteria for Pre-registration (for patients with unknown HER2 mutation status to
        have tumor tissue screened centrally by Washington University GPS laboratory):

          -  Histologically or cytologically confirmed HER2-negative (0 or 1+ by IHC or
             non-amplified by FISH) breast cancer that is stage IV.

          -  Agree to provide archival tumor material for research

          -  There is no limitation on the number of prior lines of systemic therapy.

          -  Presence of measurable or non-measurable disease by RECIST 1.1 is acceptable, except
             to be eligible for the Part II fulvestrant-naive ER+ cohort, at least one measurable
             disease by RECIST 1.1 is required.

          -  At least 18 years of age.

          -  ECOG performance status ≤ 2

          -  Adequate organ function as defined below within 8 weeks of pre-registration:

               -  Serum creatinine ≤1.5 x ULN

               -  Chil-Pugh class A if with liver disease

          -  Able to understand and willing to sign an IRB approved written informed consent
             document.

        Note: HER2 mutation testing may be performed while the patient is receiving active systemic
        therapy for metastatic breast cancer so that the result can be used to determine
        eligibility for study drug therapy in the future.

        Exclusion Criteria for Pre-registration:

          -  Testing for LVEF is not required for pre-registration, but patient must not have a
             recent LVEF < LLN or have symptoms of congestive heart failure.

          -  Uncontrolled intercurrent illness including, but not limited to, ongoing or active
             infection, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social
             situations that would limit compliance with study requirements.

          -  Acute or currently active hepatic or biliary disease requiring antiviral therapy (with
             the exception of Gilbert's syndrome, asymptomatic gallstones, liver metastases, or
             stable chronic liver disease per investigator assessment).

          -  History of significant cardiac disease, cardiac risk factors, or uncontrolled
             arrhythmias.

          -  Symptomatic intrinsic lung disease or extensive tumor involvement of the lungs
             resulting in dyspnea at rest.

        Inclusion Criteria for Registration (for patients initially pre-registered and with HER2
        mutation identified by Washington University GPS laboratory)

          -  Tumor tissue tested positive for HER2 mutation. HER2 mutations detected by Guardant360
             are also eligible.

          -  Agree to provide archival tumor material for research

          -  ECOG performance status ≤2

          -  Adequate organ function as defined below within 2 weeks of registration:

               -  ANC ≥1.5 x 10^9/L

               -  Platelet count ≥100 x 10^9/L

               -  Serum creatinine ≤1.5 x ULN

               -  Child-Pugh class A if with liver disease

          -  The patient must have completed radiation therapy and be at least 1 week from the last
             systemic chemotherapy administration, with adequate recovery of bone marrow and organ
             functions, before starting neratinib.

          -  Presence of disease progression on the most recent disease evaluation.

          -  Patients with known brain metastasis are eligible, but must have received radiation
             and be off steroids and stable (without evidence of disease progression by imaging or
             exam) for 3 months.

          -  QTc interval ≤450 msec for men or < or ≤ 470 msec for women within 2 weeks of
             registration.

          -  LVEF > or = institutional ILLN within 4 weeks of registration.

          -  Women of childbearing potential and men must agree to use adequate contraception
             (hormonal or barrier method of birth control, abstinence) prior to study entry and for
             the duration of study participation. Should a woman become pregnant or suspect she is
             pregnant while participating in this study, she must inform her treating physician
             immediately. Men must agree and commit to use a barrier method of contraception while
             on treatment and for 3 months after the last dose of the investigational product.

          -  Able to understand and willing to sign an IRB approved written informed consent
             document.

          -  There is no limitation on the number of prior lines of systemic therapy.

          -  To be eligible for the Part II fulvestrant-naive ER+ cohort, prior treatment with
             fulvestrant is not allowed. In addition, ER and/or PR positivity by institutional
             standard is required on pathology from the most recent tumor specimen if biopsy was
             done unless the tissue source (for example, pleural effusion or ascites or bone
             biopsy) may yield false negative ER and/or PR result, in which case the pathology from
             an earlier time point could be used and a discussion with the study chair is required.

          -  To be eligible for the Part II fulvestrant-treated ER+ cohort, prior disease
             progression on fulvestrant is required. In addition, ER and/or PR positivity by
             institutional standard is required on pathology from the most recent tumor specimen
             unless the tissue source (for example, pleural effusion or ascites or bone biopsy) may
             yield false negative ER and/or PR result, in which case the pathology form an earlier
             time point could be used and a discussion with the study chair is required.

        Inclusion Criteria for Registration (for patients with HER2 mutation identified at an
        outside CLIA certified location):

          -  Histologically or cytologically confirmed HER2-negative (0 or 1+ by IHC or
             non-amplified by FISH) breast cancer that is stage IV.

          -  Tumor tissue or circulating tumor DNA tested positive for HER2 mutation. Mutations
             outside the list will be assessed on a case-by-case basis by the study team to
             determine eligibility.

          -  Presence of measurable or non-measurable disease by RECIST 1.1 is acceptable, except
             to be eligible for the Part II fulvestrant-naïve ER+ cohort, at least one measurable
             disease by RECIST 1.1 is required.

          -  At least 18 years of age.

          -  ECOG performance status < 2 (see Appendix A).

          -  Adequate organ function as defined below within 2 weeks of registration:

               -  Absolute neutrophil count: ≥1.5 × 109/L (1500/mm3)

               -  Platelet count: ≥100 × 109/L (100,000/mm3)

               -  Serum creatinine: ≤1.5 x ULN

               -  Child-Pugh class A if with liver disease

          -  The patient must have completed radiation therapy and be at least 1 week from the last
             systemic therapy administration, with adequate recovery of bone marrow and organ
             functions, before starting neratinib.

          -  Presence of disease progression on the most recent disease evaluation.

          -  Patients with known treated brain metastasis are eligible, but must have received
             radiation and be off steroids and stable (without evidence of disease progression by
             imaging or exam) for 3 months.

          -  QTc interval ≤ 450 msec for men or ≤ 470 msec for women within 2 weeks of
             registration.

          -  LVEF > institutional LLN within 4 weeks of registration.

          -  Women of childbearing potential and men must agree to use adequate contraception
             (hormonal or barrier method of birth control, abstinence) prior to study entry and for
             the duration of study participation. Should a woman become pregnant or suspect she is
             pregnant while participating in this study, she must inform her treating physician
             immediately. Men must agree and commit to use a barrier method of contraception while
             on treatment and for 3 months after the last dose of the investigational product

          -  Able to understand and willing to sign an IRB approved written informed consent
             document.

          -  There is no limitation on the number of prior lines of systemic therapy.

          -  To be eligible for the Part II fulvestrant-naïve ER+ cohort, prior treatment with
             fulvestrant is not allowed. In addition, ER and/or PR positivity by institutional
             standard is required on pathology from the most recent tumor specimen if biopsy was
             done unless the tissue source (for example, pleural effusion or ascites or bone
             biopsy) may yield false negative ER and/or PR result, in which case the pathology from
             an earlier time point could be used and a discussion with the study chair is required.

          -  To be eligible for the Part II fulvestrant-treated ER+ cohort, prior disease
             progression on fulvestrant is required. In addition, ER and/or PR positivity by
             institutional standard is required on pathology from the most recent tumor specimen
             unless the tissue source (for example, pleural effusion or ascites or bone biopsy) may
             yield false negative ER and/or PR result, in which case the pathology from an earlier
             time point could be used and a discussion with the study chair is required.

        Exclusion Criteria for Registration:

          -  Currently receiving any other investigational agents or systemic cancer therapy.

          -  Currently taking medications and herbal or dietary supplements that are strong
             cytochrome P450 (CYP) 3A4 inducers or inhibitors. The washout period must have been
             completed prior to the start of neratinib if the patient was taking any of these
             agents. If unavoidable, patients taking CYP3A4 inhibitors should be monitored closely.

          -  Uncontrolled intercurrent illness including, but not limited to, ongoing or active
             infection symptomatic congestive heart failure, unstable angina pectoris, cardiac
             arrhythmia, or psychiatric illness/social situations that would limit compliance with
             study requirements.

          -  Acute or currently active/requiring antiviral therapy hepatic or biliary disease (with
             the exception of patients with Gilbert's syndrome, asymptomatic gallstones, liver
             metastases, or stable chronic liver disease per investigator assessment).

          -  Pregnant and/or breastfeeding.

          -  History of significant cardiac disease, cardiac risk factors, or uncontrolled
             arrhythmias.

          -  Symptomatic intrinsic lung disease or extensive tumor involvement of the lungs
             resulting in dyspnea at rest.

          -  Experiencing grade 2 or greater diarrhea.

          -  Prior treatment with neratinib

          -  Child-Pugh class B or C liver dysfunction