Study to Compare a Mono Atezolizumab Window Followed by a Atezolizumab - CTX Therapy With Atezolizumab - CTX Therapy

Study Overview
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Brief Summary
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This is a randomized, open-label, adaptive, two arm, multicentre, Phase II trial comparing a neoadjuvant chemotherapy with PDL1-inhibition (Atezolizumab) and Atezolizumab two-week window to chemotherapy with PDL1-inhibition (Atezolizumab) and identify biomarkers predicting (early) response to or resistance against Atezolizumab (alone and with CTX) allowing patients stratification in future clinical trials

Official Title
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An Adaptive Randomized Neoadjuvant Two Arm Trial in Triple-negative Breast Cancer Comparing a Mono Atezolizumab Window Followed by a Atezolizumab - CTX Therapy With Atezolizumab - CTX Therapy (neoMono)

Conditions
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Triple-negative Breast Cancer

Intervention / Treatment
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* Drug: Atezolizumab 840 MG in 14 ML Injection
* Drug: Atezolizumab 1200 MG in 20 ML Injection
* Drug: Carboplatin
* Drug: Paclitaxel
* Drug: Epirubicin
* Drug: Cyclophosphamide
* Procedure: Biopsy Arm A
* Procedure: Biopsy Arm B
* Procedure: Surgery


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Female and male patients, age at diagnosis 18 years and above Written informed consent prior to admission to this study Histologically confirmed unilateral primary invasive carcinoma of the breast Clinical T1c - T4d Stage N0-N3 until 21 patients (5%) with stage N3 are randomized, thereafter N0-N2 Triple negative breast cancer defined by and confirmed by central pathology: ER negative (<10% positive cells in IHC) and PR negative (<10% positive cells on IHC) HER2 negative breast cancer: Either defined by IHC: ICH scores of 0-1 or an ICH score of 2 in combination with a negative in-situ-hybridization (ISH) Or defined by ISH: negative ISH Identifiable PD-L1 IC-status by central pathology (positive or negative) by means of VENTANA PD-L1 (SP142) assay; positive status is defined by PD-L1 expression on IC on ≥ 1% of the tumor area, negative status is defined by PD-L1 expression on IC on < 1% of the tumor area No clinical evidence for distant metastasis (cM0) Tumor block available for translational research Performance Status Eastern Cooperative Oncology Group (ECOG) ≤ 1 or KI ≥ 80 % Negative pregnancy test (urine or serum) within 7 days prior to screening in premenopausal patients Women of childbearing potential and male patients with partners of childbearing potential must accept to implement a highly effective (less than 1% failure rate according to Pearl index) including at least one non-hormonal contraceptive measures during the study treatment and for 5 months following the last dose of study treatment such as: Intrauterine device (IUD) bilateral tubal occlusion vasectomized partner sexual abstinence The patient must be accessible for treatment and follow-up Normal cardiac function: Normal electrocardiogram (ECG) (within 6 weeks prior to screening) Normal left ventricular ejection fraction (LVEF) on echocardiorgaphy Normal thyroid function o Normal TSH and FT4 Blood counts within 14 days prior screening: absolute neutrophile count (ANC) must be ≥ 1,500/mm3 Platelet count must be ≥ 100,000 / mm3 Hemoglobin must be ≥ 10 g/dl Hepatic functions: Total bilirubin must be ≤ 1 upper limit of normal (ULN) for the lab unless the patient has a bilirubin elevation > 1 x ULN to 1.5 x ULN due to Gilbert's disease or similar syndrome involving slow conjugation of bilirubin Alkaline phosphatase must be ≤ 2.5 x ULN for the lab AST and ALT must be ≤1.5 x ULN for the lab. Patients with AST and ALT or alkaline phosphatase > 1 x ULN are eligible for inclusion if liver imaging (computerized tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET-CT, or PET scan) performed within 3 months prior to randomization (and part of standard of care) does not demonstrate metastatic disease and the requirements in criterion (just above) are met Patients with alkaline phosphatase that is > 1 x ULN but less than or equal to 2.5 x ULN or with unexplained bone pain are eligible if bone imaging does not demonstrate metastatic disease. Creatinine clearance ≥ 40 ml/min performed 28 days prior to screening Exclusion Criteria: Previous history of malign diseases, non-melanoma skin cancer and carcinoma of the cervix are allowed if treated with curative intent Any other disease, metabolic dysfunction, physical examination finding, or clinical laboratory finding that, in the investigator's opinion, gives reasonable suspicion of a disease or condition that contraindicates the use of Paclitaxel, Carboplatin, Epirubicin, Cyclophosphamide or Atezolizumab Psychological, familial, sociological or geographical conditions that do not permit compliance with the study protocol Concurrent treatment with other drugs that are contraindicating the use of the study drugs Existing pregnancy Breastfeeding Sequential breast cancer Concurrent treatment with other experimental drugs and participation in another clinical trial or clinical research project (except registry study) within 30 days prior to study entry Severe and relevant co-morbidity that would interact with the application of cytotoxic agents or the participation in the study including but not confined to: Uncompensated chronic heart failure or systolic dysfunction (LVEF < 55%, congestive heart failure (CHF) New York Heart Association (NYHA) classes II-IV), unstable arrhythmias requiring treatment i.e., atrial tachycardia with a heart rate ≥ 100/bpm at rest, significant ventricular arrhythmia (ventricular tachycardia) or highergrade AV-block, Angina pectoris within the last 6 months requiring anti-anginal medication, Clinically significant valvular heart disease, Evidence of myocardial infarction on electrocardiogram (ECG), Poorly controlled hypertension (e.g., systolic > 180 mmHg or diastolic > 100 mmHg). Inadequate organ function including but not confined to: hepatic impairment as defined by bilirubin > 1.5 x ULN pulmonary disease (severe dyspnea at rest requiring oxygen therapy) Abnormal blood values: Platelet count below 100,000/mm3 AST/ALT > 1.5 x ULN Hypokalaemia > CTCAE grade 1 Neutropenia > CTCAE grade 1 Anaemia > CTCAE grade 1 Administration of a live, attenuated vaccine within 4 weeks before cycle 1 day 1 or anticipation that such a vaccine will be required during the study Treatment with systemic immunosuppressive medications (including but not limited to interferons, IL-2) within 28 days or 5 half-lives of the drug, whichever is longer, prior to randomization. Treatment with systemic immunosuppressive medications (including but not limited to Prednisone, Cyclophosphamide, Azathioprine, Methotrexate, Thalidomide, and anti-tumor necrosis [anti-TNF] factor agents) within 14 days prior to screening or anticipation of need for systemic immunosuppressive medications during the study Patients with prior allogeneic stem cell or solid organ transplantation Active or history of autoimmune disease or immune deficiency, including but not limited to myasthenia gravis, myositis, autoimmune hepatitis, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, antiphospholipid syndrome, Wegener granulomatosis, Sjögren syndrome, Guillain-Barré syndrome, or multiple sclerosis with the following exceptions: Patients with a history of autoimmune-related hypothyroidism on a stable dose of thyroid replacement hormone may be eligible for this study. Patients with controlled Type 1 diabetes mellitus on a stable dose of insulin regimen may be eligible for this study. Patients with eczema, psoriasis, lichen simplex chronicus, or vitiligo with dermatologic manifestations only (e.g., patients with psoriatic arthritis are excluded) are permitted provided all of following conditions are met: Rash must cover < 10% of body surface area; Disease is well controlled at baseline and requires only low-potency topical corticosteroids; No occurrence of acute exacerbations of the underlying condition requiring psoralen plus ultraviolet A radiation, Methotrexate, retinoids, biologic agents, oral calcineurin inhibitors, or high-potency or oral Corticosteroids within the previous 12 months. History of idiopathic pulmonary fibrosis, organizing pneumonia (e.g., bronchiolitis obliterans), drug-induced pneumonitis, idiopathic pneumonitis, or evidence of active pneumonitis on screening chest CT scan. History of HIV infection, hepatitis B or hepatitis C infection. Patients with significant cardiovascular disease Patients with inadequate hematological and end-organ function Patients receiving therapeutic anti-coagulants Stage N3, as soon as 21 patients with stage N3 are randomized

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Arm A<br>2 weeks Atezolizumab monotherapy before biopsy, followed by a 12-week therapy with Paclitaxel + Carboplatin+ Atezolizumab every 3 weeks for 4 cycles. This will be followed by Epirubicin + Cyclophosphamide + Atezolizumab every 3 weeks for 4 cycles. | Drug: Atezolizumab 840 MG in 14 ML Injection<br>* 840 mg Day 1 for two weeks<br>* Other names: Tecentriq;Drug: Atezolizumab 1200 MG in 20 ML Injection<br>* 1200 mg Day 1 every 3 weeks for 8 cycles<br>* Other names: Tecentriq;Drug: Carboplatin<br>* Dosing according to Area Under the Curve of 2 Intravenous weekly x 12 cycles<br>Drug: Paclitaxel<br>* Paclitaxel 80 mg/m² IV weekly x 12 cycles<br>Drug: Epirubicin<br>* 90 mg/m2, day 1 for 4 cycles (12 weeks)<br>Drug: Cyclophosphamide<br>* 600 mg/m2, day 1 for 4 cycles (12 weeks)<br>Procedure: Biopsy Arm A<br>* 1st Biopsy two weeks after Baseline visit. 2nd Biopsy after two weeks of Carboplatin + Paclitaxel + Atezolizumab therapy. 3rd Biopsy with tumor size greater 10 mm in diameter.<br>Procedure: Surgery<br>* After completion of 27-28 weeks (Arm B) or 29-30 weeks (Arm A) of neoadjuvant treatment, surgery is planned for all patients.<br>|
| Active Comparator: Arm B<br>12-week therapy with Paclitaxel + Carboplatin + Atezolizumab every 3 weeks for 4 cycles. This will be followed by Epirubicin + Cyclophosphamide + Atezolizumab every 3 weeks for 4 cycles. | Drug: Atezolizumab 1200 MG in 20 ML Injection<br>* 1200 mg Day 1 every 3 weeks for 8 cycles<br>* Other names: Tecentriq;Drug: Carboplatin<br>* Dosing according to Area Under the Curve of 2 Intravenous weekly x 12 cycles<br>Drug: Paclitaxel<br>* Paclitaxel 80 mg/m² IV weekly x 12 cycles<br>Drug: Epirubicin<br>* 90 mg/m2, day 1 for 4 cycles (12 weeks)<br>Drug: Cyclophosphamide<br>* 600 mg/m2, day 1 for 4 cycles (12 weeks)<br>Procedure: Biopsy Arm B<br>* 1st Biopsy after two weeks of Carboplatin + Paclitaxel + Atezolizumab therapy. 2nd Biopsy with tumor size greater 10mm in diameter.<br>Procedure: Surgery<br>* After completion of 27-28 weeks (Arm B) or 29-30 weeks (Arm A) of neoadjuvant treatment, surgery is planned for all patients.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pathological complete response (ypT0/is, ypN0) | Pathological Complete Response defined as no residual invasive tumor cells in the breast and in the lymph nodes (ypT0/is, ypN0) | after 29-30 weeks in Arm A and after 27-28 weeks in Arm B. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Safety Measures | Safety (incidence, relationship, seriousness, and severity of all AEs, SAEs, AESIs coded by medical dictionary for regulatory activities (MedDRA), summarized by Preferred Term and System Organ Class and graded according to common terminology criteria of adverse events (CTCAE V5.0) | from date of randomization up to 59 months | 
| Pathological Complete Response (ypT0/is, ypN0) (ER/PR expression of <1%) | Pathological complete response defined as no residual invasive tumor cells in the breast and in the lymph nodes (ypT0/is, ypN0) in patients with an ER/PR expression of <1% and an ER/PR expression of 1% to 10%. | after 29-30 weeks in Arm A and after 27-28 weeks in Arm B | 
| Pathological Complete Response (ypT0, ypN0) | Pathological complete response defined as no tumor cells (invasive and no non-invasive) in the breast but also in the lymph nodes (ypN0, ypT0) | after 29-30 weeks in Arm A and after 27-28 weeks in Arm B. | 
| Near Pathological Complete Response (Near pCR) | Near pCR defined as residual tumor <5 mm in the breast irrespective of in situ and lymph nodes status | after 29-30 weeks in Arm A and after 27-28 weeks in Arm B. | 
| Pathological Complete Response (no invasive tumor) | Pathological Complete Response defined as no invasive tumor in the breast, irrespective of lymph node status | after 29-30 weeks in Arm A and after 27-28 weeks in Arm B. | 
| Decrease of Ki-67 expression as continuous predictor | Decrease of Ki-67 expression versus baseline after 14/28 days (+/- 2 days) of treatment as continuous predictor | after 14/28 days (+/- 2 days) of treatment | 
| Tumor-infiltrating lymphocytes (TILs) | TILs after 14/28 days (+/- 2 days) of treatment as continuous predictor | after 14/28 days (+/- 2 days) of treatment | 
| Complete Cell Cycle Arrest (CCCA) | CCCA: Ki-67 expression ≤ 2.7% after 14/28 days (+/- 2 days) of treatment | after 14/28 days (+/- 2 days) of treatment | 
| Low cellularity | Low cellularity: < 500 tumor cells after 14/28 days (+/- 2 days) of treatment | after 14/28 days (+/- 2 days) of treatment | 
| Decrease of Ki-67 expression | Decrease of Ki-67 expression versus baseline by 30% or more after 14/28 days (+/- 2 days) of treatment | after 14/28 days (+/- 2 days) of treatment | 
| Tumor-infiltrating lymphocytes (TILs) ≥ 60% | TILs ≥ 60% after 14/28 days (+/- 2 days) of treatment | after 14/28 days (+/- 2 days) of treatment | 
| Combined early response | Combined early response defined by CCCA (Ki-67 expression < 2.7%) or low cellularity or decrease of Ki-67 expression (versus baseline) by 30% or more or TILs ≥ 60% | after 14/28 days (+/- 2 days) of treatment | 
| Disease free survival (DFS) | Disease free survival (DFS) defined as time from the first date of no disease [i.e. date of surgery] to the first occurrence of disease recurrence or death from any cause | from randomization up to 59 months until date of occurrence of no disease to the first occurrence of disease recurrence or death from any cause | 
| Overall survival (OS) | Overall survival (OS) defined as length of time from randomization to death from any cause | from randomization up to 59 months until date of death from any cause | 
| Event free survival (EFS) | Event free survival (EFS) defined as length of time after randomization till death from any cause, failure to achieve remission after induction therapy, relapse in any site, or second malignancy | from randomization up to 59 months until date of death from any cause, failure to achieve remission after induction therapy, relapse in any site, or second malignancy | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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TNBC, Immunotherapy