Study to Identify the Impact of Denosumab on the Immune System in Patients With HER2 Negative Breast Cancer

Study Overview
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Brief Summary
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The aim of this prospective, randomized, multicenter, open-label, explorative phase II study is to identify the impact of (neo)adjuvant denosumab on the systemic immunity and local immunologic microenvironment in postmenopausal patients with HER2 negative non-metastatic primary breast cancer.

Detailed Description
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In this study, postmenopausal patients with stage T1c + grade 3, stage II or III, HER2-negative breast cancer, which are planned to undergo surgery followed by adjuvant AC-T chemotherapy, are randomized between no denosumab, denosumab low dosing and denosumab high dosing. Denosumab administration will start one week before surgery and continue until the last chemotherapy cycle.

Official Title
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Explorative Trial to Identify the Impact of Denosumab on the Systemic Immunity and Local Immunologic Microenvironment in Postmenopausal Patients With HER2 Negative Breast Cancer

Conditions
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Breast Neoplasms

Intervention / Treatment
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* Drug: Denosumab 120 mg
* Drug: Denosumab 60 mg


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Postmenopausal, defined as 1 year without menstrual activity, previous bilateral oophorectomy, age older than 60 years or baseline FSH >20 U/l and estradiol <110 pmol/l. Clinical stage T1c + grade 3, stage II or III breast cancer amenable to adjuvant AC-T combination chemotherapy. Measurable disease (breast and/or lymph nodes). Histological proven HER2-negative breast cancer in the core biopsy material. WHO 0-2. Adequate bone marrow function (within 4 weeks prior to randomization): WBC≥3.0x109/l, neutrophils ≥1.5 x 109/l, platelets ≥100 x 109/l. Adequate liver function (within 4 weeks prior to randomization): bilirubin ≤1.5 X upper limit of normal (UNL) range, ALAT and/or ASAT ≤2.5 x UNL, Alkaline Phosphatase ≤5 x UNL. Adequate renal function (within 4 weeks prior to randomization): the calculated creatinine clearance should be ≥50 ml/min. Albumin-adjusted serum calcium > 2.0 mmol/L (8.0mg/dL) Accessible for treatment and follow-up. Written informed consent. Exclusion Criteria: Evidence of distant metastases (M1). History of breast cancer. Prior chemotherapy or radiation therapy. Previous malignancy within 5 years, with exception of a history of a previous basal cell carcinoma of the skin or pre-invasive carcinoma of the cervix. Prior or current bisphosphonate or denosumab usage. Serious other diseases as recent (last 6 months) myocardial infarction, clinical signs of cardiac failure or clinically significant arrhythmias. Current active dental problems including dental abscess or infection of the jawbone (maxilla or mandible), non-healed dental or oral surgery, a current or prior diagnosis of osteonecrosis of the jaw or planned invasive dental procedures for the course of the study. Known hypersensitivity reaction to any of the components of the treatment. Medical or psychological condition which in the opinion of the investigator would not permit the patient to complete the study or sign meaningful informed consent.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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Female

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: Basic Science
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: No denosumab<br>All patients undergo surgery followed by adjuvant chemotherapy. Patients in this study arm are not additionally treated with denosumab. | |
| Experimental: Denosumab 120 mg<br>All patients undergo surgery followed by adjuvant chemotherapy. Patients in this study arm are additionally treated with denosumab 120 mg every 3 weeks. First denosumab gift is before surgery, last denosumab gift is together with the last cycle of chemotherapy. | Drug: Denosumab 120 mg<br>* Denosumab 120 mg every 3 weeks.<br>* Other names: Xgeva;|
| Experimental: Denosumab 60 mg<br>All patients undergo surgery followed by adjuvant chemotherapy. Patients in this study arm are additionally treated with denosumab 60 mg every 6 months. First denosumab gift is before surgery, last denosumab gift is together with the last cycle of chemotherapy. | Drug: Denosumab 60 mg<br>* Denosumab 60 mg every 6 months.<br>* Other names: Prolia;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in intratumoral T-cell (CD4, CD8 and Treg) numbers and function between the baseline biopsy and the surgical specimen. | The change will be determined by use of IHC and immunofluorescent stainings. | The change can be determined after the surgical specimen is obtained, which is around two weeks after enrolment. | 
| Change in myeloid cell (M1/M2 Macrophage, MDSC, DC) numbers and function between the baseline biopsy and the surgical specimen. | The change will be determined by use of IHC and immunofluorescent stainings. | The change can be determined after the surgical specimen is obtained, which is around two weeks after enrolment. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Shift in activated T effector cell levels. | Shifts will be determined by comparing PBMCs (using flow cytometry) before start treatment, at day of surgery before surgery and 7 days after last chemotherapy administration. | Measurements will be done in PBMCs from before start treatment, day of surgery and 7 days after last chemotherapy administration, which will be around 8 months after enrolment. | 
| Shift in regulatory T-cell levels. | Shifts will be determined by comparing PBMCs (using flow cytometry) before start treatment, at day of surgery before surgery and 7 days after last chemotherapy administration. | Measurements will be done in PBMCs from before start treatment, day of surgery and 7 days after last chemotherapy administration, which will be around 8 months after enrolment. | 
| Change in functional response of T-cells. | Changes will be determined by comparing PBMCs (using stimulation tests) before start treatment, at day of surgery before surgery and 7 days after last chemotherapy administration. | Measurements will be done in PBMCs from before start treatment, day of surgery and 7 days after last chemotherapy administration, which will be around 8 months after enrolment. | 
| Change in mature and immature myeloid cells (M1/M2 macrophage, MDSC, DC). | Shifts will be determined by comparing PBMCs (using flow cytometry) before start treatment, at day of surgery before surgery and 7 days after last chemotherapy administration. | Measurements will be done in PBMCs from before start treatment, day of surgery and 7 days after last chemotherapy administration, which will be around 8 months after enrolment. | 
| Shift in myeloid cell function. | Shifts will be determined by comparing PBMCs (using triggering tests) before start treatment, at day of surgery before surgery and 7 days after last chemotherapy administration. | Measurements will be done in PBMCs from before start treatment, day of surgery and 7 days after last chemotherapy administration, which will be around 8 months after enrolment. | 
| Change in stimulation capacity APCs. | Changes will be determined by comparing PBMCs (using restimulation tests) before start treatment, at day of surgery before surgery and 7 days after last chemotherapy administration. | Measurements will be done in PBMCs from before start treatment, day of surgery and 7 days after last chemotherapy administration, which will be around 8 months after enrolment. | 
| Change in serum levels of RANKL and OPG. | Changes will be determined by comparing serum before start treatment, at day of surgery before surgery and 7 days after last chemotherapy administration, using ELISA. | Measurements will be done in serum from before start treatment, day of surgery and 7 days after last chemotherapy administration, which will be around 8 months after enrolment. | 
| Change in serum cytokine levels (TNF-alpha, interleukines, IFN gamma). | Changes will be determined by comparing serum before start treatment, at day of surgery before surgery and 7 days after last chemotherapy administration, using luminex. | Measurements will be done in serum from before start treatment, day of surgery and 7 days after last chemotherapy administration, which will be around 8 months after enrolment. | 
| Correlation of tumor measurements with serum measurements. | Measurements in tumor and serum will be correlated. | Measurements will be done in tumor material and serum from before start treatment, day of surgery and 7 days after last chemotherapy administration, which will be around 8 months after enrolment and tumor material from baseline and surgery. | 
| Correlation of tumor measurements with PBMCs measurements. | Measurements in tumor and PBMCs will be correlated. | Measurements will be done in tumor material and PBMCs from before start treatment, day of surgery and 7 days after last chemotherapy administration, which will be around 8 months after enrolment and tumor material from baseline and surgery. | 
| Correlation of serum measurements and PBMCs measurements. | Measurements in serum and PBMCs will be correlated. | Measurements will be done in PBMCs/serum from before start treatment, day of surgery and 7 days after last chemotherapy administration, which will be around 8 months after enrolment and tumor material from baseline and surgery. | 
| Toxicity according to NCI CTCAE v4.03. | Toxicities are graded according to NCI CTCAE v4.03. | Toxicity will be assessed from start treatment up to 30 days following the last dose of treatment. | 
| Difference in descriptive event free survival (EFS) at 3 years based on immune response. | After 3 years of follow up, differences in EFS based on immune response will be determined. | EFS will be determined after 3 years. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Breast cancer, Denosumab, Chemotherapy, Immunity, Immune system, PERIDENO