Combination Chemotherapy With or Without Bevacizumab in Treating Patients With Nonmetastatic Breast Cancer

Study Overview
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Brief Summary
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RATIONALE: Drugs used in chemotherapy, such as docetaxel, fluorouracil, epirubicin hydrochloride, and cyclophosphamide, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Giving more than one drug (combination chemotherapy) may kill more tumor cells. Monoclonal antibodies, such as bevacizumab, can block tumor growth in different ways. Some block the ability of tumor cells to grow and spread. Others find tumor cells and help kill them or carry tumor-killing substances to them. It is not yet known whether giving combination chemotherapy together with or without bevacizumab is more effective in treating patients with nonmetastatic breast cancer. PURPOSE: This randomized phase III trial is studying how well giving combination chemotherapy works compared with giving combination chemotherapy together with bevacizumab in treating patients with nonmetastatic breast cancer.

Detailed Description
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OBJECTIVES: Primary To compare the efficacy of neoadjuvant therapy comprising docetaxel, fluorouracil, epirubicin hydrochloride, and cyclophosphamide with versus without bevacizumab in patients with HER2-negative nonmetastatic breast cancer. Secondary To assess quality of life of female patients treated with these regimens. OUTLINE: This is a multicenter study. Patients are stratified according to age (≤ 50 years old vs > 50 years old), estrogen receptor status (negative [Allred score 0-2] vs weakly positive [Allred score 3-5] vs strongly positive [Allred score 6-8]), total tumor size* (≤ 50 mm vs > 50 mm), clinical involvement of axillary nodes (yes vs no), and inflammatory/locally advanced disease (T4) (yes vs no). Patients are randomized to 1 of 2 treatment arms. NOTE: *In cases with multifocal disease in one breast, or bilateral disease, the size to be used for the stratification is the sum of the single largest diameter of all measurable tumors. Arm I: Patients receive docetaxel IV on day 1; treatment repeats every 3 weeks for 3 courses. Patients then receive fluorouracil IV, epirubicin hydrochloride IV, and cyclophosphamide IV on day 1 (FEC). Treatment with fluorouracil, epirubicin hydrochloride, and cyclophosphamide repeats every 3 weeks for 3 courses. Arm II: Patients receive bevacizumab IV over 30 to 90 minutes and docetaxel IV on day 1; treatment repeats every 3 weeks for 3 courses. Patients then receive FEC as in arm I. Treatment with FEC repeats every 3 weeks for 3 courses. Patients also receive bevacizumab IV over 30 to 90 minutes and docetaxel IV on day 1 in FEC course 1 only. Within 3-6 weeks after completion of last dose of study therapy, patients in both arms undergo surgery. Within 4-8 weeks after surgery, patients undergo radiotherapy according to standard protocol. Women complete quality-of-life questionnaires (FACT-B and EuroQoL) at baseline and during and after completion of study treatment. After completion of study treatment, patients are followed every 6 months for 2 years and then annually for 3 years.

Official Title
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ARTemis - Avastin Randomized Trial With Neo-Adjuvant Chemotherapy for Patients With Early Breast Cancer

Conditions
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Breast Cancer, Cardiac Toxicity, Perioperative/Postoperative Complications

Intervention / Treatment
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* Biological: bevacizumab
* Drug: cyclophosphamide
* Drug: docetaxel
* Drug: epirubicin hydrochloride
* Drug: fluorouracil
* Procedure: assessment of therapy complications
* Procedure: neoadjuvant therapy
* Procedure: quality-of-life assessment
* Procedure: therapeutic conventional surgery


Participation Criteria
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Eligibility Criteria
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DISEASE CHARACTERISTICS: Histologically confirmed invasive breast cancer HER2-negative disease IHC 0/1 OR IHC 2+ and FISH negative Must meet 1 of the following criteria: Unifocal tumor meeting 1 of the following criteria: T2 or T3 tumors (radiological size > 20 mm) T4 tumor of any size with direct extension to the chest wall or the skin Inflammatory carcinoma with tumor of any size Multifocal tumor meeting the following criteria: The sum of each tumors' maximum diameter must be ≥ 20 mm (total radiological tumor size ≥ 20 mm) Other locally advanced disease meeting 1 of the following criteria: Any T stage with involvement of large or fixed axillary lymph nodes (radiological diameter > 20 mm or clinical N2) and primary breast tumor of any diameter Any T stage with involvement of large or fixed axillary lymph nodes (radiological diameter > 20 mm or clinical N2), without a primary breast tumor identified and the presence of breast cancer in a lymph node must be histopathologically confirmed by lymph node biopsy (tru-cut or whole lymph node) Embedded paraffin tumor block available from pre-chemotherapy biopsy and surgical specimen Bilateral disease allowed No evidence of metastatic disease No prior breast cancer except for ductal carcinoma in situ of the breast surgically cured > 10 years ago Any hormone receptor status PATIENT CHARACTERISTICS: ECOG performance status 0-2 WBC > 3 x 10^9/L Hemoglobin > 10 g/dL Platelet count > 100 x 10^9/L AST/ALT ≤ 1.5 times upper limit of normal (ULN) Alkaline phosphatase ≤ 2 times ULN Bilirubin normal Isolated elevation of bilirubin to ≤ 3 times ULN with a presumptive diagnosis of Gilbert syndrome allowed if AST/ALT and alkaline phosphatase are within normal limits Creatinine ≤ 1.5 times ULN PT and PTT/aPTT ≤ 1.5 times ULN Not pregnant or nursing Negative pregnancy test Fertile patients must use effective barrier contraception Must be fit to receive chemotherapy on this trial, in the opinion of the responsible clinician, as indicated by the following criteria: No clinically significant cardiac abnormalities No myocardial infarction within the past 6 months LVEF normal (at least 50%) by MUGA scan or echocardiogram No prior ischemic heart disease, cerebrovascular disease, peripheral vascular disease, arterial or venous thromboembolic disease, cardiac failure, inflammatory bowel disease, gastroduodenal ulcer, symptomatic diverticulitis, or bleeding diathesis No uncontrolled hypertension (systolic BP > 150 mm Hg or diastolic BP > 90 mm Hg) with or without antihypertensive medication Patients with initial blood pressure elevations are eligible provided initiation or adjustment of antihypertensive medication lowers pressure to meet entry criteria No other previous malignancy except basal cell carcinoma, carcinoma in situ of the cervix, or ductal carcinoma in situ of the breast treated by surgery only and disease-free for 10 years No concurrent medical or psychiatric problem that might prevent completion of treatment or follow-up No presence of active uncontrolled infection No history of nephritic or nephrotic syndrome No traumatic injury within the past 28 days No evidence of other disease that, in the opinion of the investigator, places the patient at high risk of treatment-related complications No nonhealing wound, peptic ulcer, or bone fracture PRIOR CONCURRENT THERAPY: No prior neoadjuvant endocrine therapy No prior chemotherapy or radiotherapy No major surgical procedure within the past 28 days No concurrent full therapeutic dose of anticoagulants or aspirin > 325 mg/day, clopidogrel > 75 mg/day, or corticosteroids

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
Masking: None (Open Label)


Arms and Interventions

| Intervention/Treatment |
| --- |
|Biological: bevacizumab|nan|
|Drug: cyclophosphamide|nan|
|Drug: docetaxel|nan|
|Drug: epirubicin hydrochloride|nan|
|Drug: fluorouracil|nan|
|Procedure: assessment of therapy complications|nan|
|Procedure: neoadjuvant therapy|nan|
|Procedure: quality-of-life assessment|nan|
|Procedure: therapeutic conventional surgery|nan|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Complete pathological response rates (tumor and lymph nodes) |  |  | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Disease-free survival |  |  | 
| Overall survival |  |  | 
| Pathological complete response rate in breast alone |  |  | 
| Radiological response after 3 and 6 courses of chemotherapy |  |  | 
| Rate of breast conservation |  |  | 
| Toxicities, including cardiac safety and surgical complications (wound healing, bleeding, and thrombosis) |  |  | 
| Quality of life |  |  | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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cardiac toxicity, perioperative/postoperative complications, HER2-negative breast cancer, male breast cancer, estrogen receptor-negative breast cancer, estrogen receptor-positive breast cancer, progesterone receptor-negative breast cancer, progesterone receptor-positive breast cancer, stage II breast cancer, stage IIIA breast cancer, stage IIIB breast cancer, inflammatory breast cancer