Afatinib and Paclitaxel in Patients With Advanced HER2-Positive Trastuzumab-Refractory Advanced Esophagogastric Cancer
Condition: Esophageal Cancer; Gastric Cancer
Intervention: Afatinib and Paclitaxel
Intervention description: All patients receiving therapy on trial with afatinib and trastuzumab will continue on afatinib and trastuzumab until disease progression or intolerable toxicity. All additional patients will be enrolled on afatinib and paclitaxel. Patients will be treated with afatinib and paclitaxel combination. Patients will receive oral afatinib 40 mg daily plus paclitaxel 80 mg/m^2 intravenously on day 1, 8, and 15 of a 28-day cycle.
Intervention MeSH terms: Paclitaxel; Afatinib
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 42.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No
Keywords: ESOPHAGUS; STOMACH; Afatinib; paclitaxel; trastuzumab; 11-166

Summary:

      The purpose of this study is to find out what effects, good or bad, the combination of
      standard chemotherapy agent paclitaxel with the investigational (experimental) drug afatinib
      that targets HER2, has on HER2-positive esophagogastric cancer that started to get bigger
      despite previous treatment with trastuzumab. The doctors will also study the tumor to
      understand why it grew while on trastuzumab treatment and to see the effects afatinib and
      paclitaxel has on the tumor.
    

Eligibility criteria:

        Inclusion Criteria:

          -  Pathologically or cytologically confirmed esophagogastric cancer.

          -  HER2 overexpression and/or amplification as determined by immunohistochemistry (3+) or
             FISH (≥2.0)

          -  Previously received trastuzumab as part of a regimen in the perioperative or
             metastatic setting with evidence of progression 9Zr-trastuzumab use as imaging agent
             for 89Zr-trastuzumab PET permitted..

          -  May have previously received lapatinib as part of a regimen in the perioperative or
             metastatic setting with evidence of progression of disease. Washout period for
             lapatinib of 14 days.

          -  Completion of previous chemotherapy regimen ≥2 weeks prior to the start of study
             treatment. Other chemotherapy regimens may have been administered between the time of
             progression on prior trastuzumab containing regimen and protocol therapy. No
             restriction on prior chemotherapy regimens for advanced stage disease.

          -  At least one measurable metastatic lesion according to RECIST 1.1 criteria. Ascites,
             pleural effusions, and bone metastases are not considered measurable. Minimum
             indicator lesion size = 10 mm by helical CT or = 20 mm by conventional techniques.
             Pathological nodes must be = 15 mm by the short axis to be considered measurable.

          -  Patients aged 18 years or older, as no dosing or adverse event data are currently
             available on the use of afatinib in patients <18 years of age, children are excluded
             from this study.

          -  Life expectancy of at least three (3) months.

          -  Karnofsky performance status ≥60%

          -  All patients with disease technically amenable to biopsy will be asked to undergo a
             biopsy. Patient must agree to allow 2 biopsies of any malignant lesion that can be
             accessed by endoscopy or with the aid or radiology (i.e. CT guided).

          -  Patients who have previously provided samples at any time after trastuzumab resistance
             will be exempt from biopsy at the start of therapy.

          -  Consent to preservation of frozen and fixed samples of tumor cores for evaluation

          -  Able to swallow and retain oral medication.

          -  Negative serum HCG pregnancy test for premenopausal women of reproductive capacity and
             for women less than 12 months after menopause.

          -  Willingness to use birth control while on study.

          -  Asymptomatic, central nervous system metastases are permitted.

        Exclusion Criteria:

          -  Patients receiving any concurrent anticancer therapy or investigational agents with
             the intention of treating esophagogastric cancer. 89Zr-trastuzumab uses as imaging
             agent for 89Zr-trastuzumab PET permitted.

          -  Prior disease progression on docetaxel or paclitaxel in metastatic setting.

          -  Patients who are unwilling to consent to mandatory tumor biopsy. Patients with
             archival tissue permitted to enroll on study per MSK Principal Investigator discretion
             Women who are pregnant or breast feeding.

          -  Concurrent radiotherapy is not permitted for disease progression on treatment on
             protocol (except in the context specified in section 9.0), but might be allowed for
             pre-existing non-target lesions with approval from the principal investigator of the
             trial.

          -  Concurrent medical conditions which may increase the risk of toxicity, including
             ongoing or active infection, history of significant bleeding disorder unrelated to
             cancer (congenital bleeding disorders, acquired bleeding disorders within one year),
             HIV-positive.

          -  Subjects with acute Hepatitis B are not eligible. Subjects with chronic hepatitis are
             eligible if their condition is stable and in the opinion of the investigator, if
             consulted, would not pose a risk to subject safety.

          -  History or presence of clinically relevant cardiovascular abnormalities such as
             uncontrolled hypertension, congestive heart failure NYHA classification of 3, unstable
             angina or poorly controlled arrhythmia. Myocardial infarction within 6 months prior to
             study entry.

          -  Baseline (< 1 month before treatment) cardiac left ventricular function with resting
             ejection fraction of less than 50% measured by echocardiogram.

          -  Known pre-existing interstitial lung disease.

          -  Significant or recent acute gastrointestinal disorders with diarrhea as a major
             symptom e.g., Crohn's disease, malabsorption, or CTCAEGrade >2 diarrhea of any
             etiology.

          -  Unwillingness to give written informed consent, unwillingness to participate, or
             inability to comply with the protocol for the duration of the study.

          -  Active hepatitis B infection, active hepatitis C infection

          -  Known HIV carrier

          -  Known or suspected active drug or alcohol abuse. Restricted Therapies

          -  Additional experimental anti-cancer treatment and/or standard chemo-, immunotherapy,
             hormone treatment (with the exception of megestrol acetate), or concurrent
             radiotherapy is not allowed concomitantly with the administration of study treatment
             (with the exception listed in section 9.0) 89Zr-trastuzumab use as imaging agent for
             89Zr-trastuzumab PET permitted. Afatinib is a substrate of P-gp and its plasma
             concentrations can be affected by the use of P-gp inhibitors (data on file) and it is
             also likely that P-gp inducers could also influence afatinib plasma concentrations.

          -  The use of potent P-gp inhibitors (including cyclosporine, erythromycin, ketoconazole,
             itraconazole, quinidine, Phenobarbital salt with quinidine, ritonavir, valspodar,
             verapamil) and potent P-gp inducers (including St John's wort, rifampicin) has to be
             avoided during treatment with afatinib. Any exemptions to this have to be discussed
             with the principal investigator.