Clinical trial NCT03501979: Tucatinib, Trastuzumab, and Capecitabine for the Treatment of HER2+ LMD
Official title: A Phase II Non-randomized Study to Assess the Safety and Efficacy of the Combination of Tucatinib and Trastuzumab and Capecitabine for Treatment of Leptomeningeal Metastases in HER2 Positive Breast Cancer
Study type: INTERVENTIONAL
Overall status: ACTIVE_NOT_RECRUITING
Phase: PHASE2
Conditions: Metastatic Breast Cancer
Leptomeningeal Disease
Keywords: HER2+
metastatic breast cancer
leptomeningeal disease
tucatinib
trastuzumab
capecitabine
Lead sponsor: University of Alabama at Birmingham
Sponsor class: OTHER
Collaborators: name: Translational Breast Cancer Research Consortium
name: Johns Hopkins University
name: Seagen Inc.
name: University of Michigan
name: Georgetown University
name: University of California, San Francisco
name: University of Chicago
name: Indiana University
name: University of Washington
name: University of Texas
First posted: 2018-04-18
Enrollment: 17
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Intervention model description: Subjects will receive combination treatment with tucatinib + trastuzumab + capecitabine every 21 days, which is one cycle. Evaluation will be done every two cycles with an MRI of the brain and spine. Cycles 3 and beyond will be at the discretion of the physician. A scan will be done every four cycles.
Primary purpose: TREATMENT

Brief summary: A phase 2 non-randomized study to assess the safety and efficacy of the combination of tucatinib and trastuzumab with capecitabine for the treatment of leptomeningeal metastases in HER2-neu positive breast cancer.

Detailed description: The purpose of this study is to evaluate a new treatment for patients with HER2+ metastatic breast cancer (MBC) with leptomeningeal disease (LMD). This is a rare and fast-growing form of cancer. Leptomeningeal disease refers to the seeding of tumor cells to the leptomeninges and dissemination in the cerebrospinal fluid.

Currently, there are is no standard of care treatment for LMD. However, we think the combination therapy will be safe and well-tolerated and may also improve survival. Blood and spinal fluid samples will be collected to evaluate the effects on the body and the cancer, which will help provide greater understanding to therapy response in patients.

The study has a two-stage design with the first stage including 15 subjects from up to ten institutions nationwide. If it advances to the second stage based on the number of successes, another 15 subjects will be enrolled.

Eligibility criteria: Inclusion Criteria:

* Men and women, age ≥18 years at time of consent
* Histologically proven metastatic infiltrating carcinoma of the breast that is HER2 positive - Immunohistochemistry (IHC) 3+ and/or Fluorescence in situ hybridization (FISH) ratio \>2.0, or average HER2 copy number \>6.0 signals per cell or per current ASCO-CAP (American Society of Clinical Oncology - College of American Pathologists) or NCCN (National Comprehensive Cancer Network) guidelines. (NOTE: HER2 testing may be performed on primary and/or metastatic site; Any estrogen and progesterone \[ER/PR\] status is allowed.)
* Evidence of leptomeningeal disease (LMD) as diagnosed by a) presence of malignant cells in CSF (+CSF cytology) and/or b) Magnetic Resonance Imaging (MRI) evidence of LMD, plus clinical signs and/or symptoms. NOTE: Measurable extra-CNS disease is not required. Note: Patients who have MRI evidence of focal LMD with negative cytology and no symptoms are not eligible for enrollment.
* Karnofsky Performance Status ≥ 50 or Eastern Cooperative Oncology Group (ECOG) ≤ 3
* Patient is able and willing to undergo study-required testing including:

  1. Contrast-enhanced MRI Note: If patient has implants in place that are MRI incompatible, these must be removed prior to enrollment.
  2. Placement of an Ommaya reservoir (ventricular access device). Note: This is mandatory for the first 15 patients enrolled onto the protocol (first stage). In the second stage, this is strongly recommended per protocol. If a patient cannot or chooses not to undergo Ommaya placement in the second stage, the patient will be allowed to enroll.
  3. Evaluation by medical oncologist at baseline and at every cycle (required)
  4. Evaluation by neurologist/neuro-oncologist at baseline and at every cycle (strongly recommended); if this is not possible at a site, a medical oncologist may per perform the protocol specified evaluations at each visit.
* Patients who are on steroids due to CNS disease or LMD diagnosis should be on a stable dose for at least 5 days prior to registration.
* Prior treatment allowances are as follows:

  1. \>14 days since last dose of any previous endocrine therapy, chemotherapy, trastuzumab or other antibody-based therapy. NOTE: If patients have been previously receiving trastuzumab on a weekly basis (at a dose of 2mg/kg), only a 7 day washout will be required.
  2. \>14 days or five half-lives since previous treatment with any experimental agent, whichever is greater
  3. Cumulative dose of doxorubicin \>360 mg/m2 or previous treatment with another anthracycline with cumulative dose equivalent to \>360 mg/m2 doxorubicin is not allowed.
  4. Patients must not have received any therapy specifically directed at LMD, including prior systemic or intrathecal therapy for LMD.
  5. Radiotherapy:

     * Patients must not have received radiotherapy to the neuroaxis following diagnosis of LMD for the purpose of treating LMD, and may not receive

       * radiotherapy to the neuroaxis concurrently with the study drug;
     * Patients must not have received whole brain radiotherapy for parenchymal metastases within the last 2 weeks (14 days) or focal CNS radiotherapy within 1 week (7 days) prior to first dose of study drug. Note: Radiation for the purpose of palliation in the setting of a painful bone or dural metastasis can be allowed at the discretion of the treating physicians.
* All toxicity related to prior cancer therapies must have resolved to ≤ Grade 1, with the following exceptions: alopecia; neuropathy, which must have resolved to ≤ Grade 2; and CHF, which must have been ≤ Grade 1 in severity at the time of occurrence, and must have resolved completely. Must be without significant systemic illness (e.g. infection unresponsive to treatment after 7 days)
* Adequate hematologic, liver, and renal function, as follows:

  1. Hemoglobin ≥ 9 g/dL
  2. ANC ≥ 1000 cells/μL
  3. Platelets ≥ 100,000/μ
  4. Total bilirubin ≤ 1.5 X upper limit of normal (ULN), unless a known history of Gilbert's disease (≤ 3 X ULN)
  5. Transaminases (AST/SGOT and ALT/SGPT) ≤ 2.5X ULN (\< 5 X ULN if liver metastases are present)
  6. International normalized ratio (INR) and activated partial thromboplastin time (aPTT) ≤ 1.5 X ULN
  7. Creatinine clearance (CrCL) ≥ 50 mL/min
* Left ventricular ejection fraction (LVEF) must be within institutional limits of normal as assessed by ECHO or MUGA documented within 4 weeks prior to enrollment on the study.
* Able to understand the study requirements and document informed consent indicating his/her awareness of the investigational nature and the risks of this study.

Exclusion Criteria:

* Medical, social, or psychosocial factors that, in the opinion of the Investigator, could impact safety or compliance with study procedures.
* Patient is pregnant or is breastfeeding. Note: If female and of child-bearing potential (females who are not surgically sterile or who have had a period in the last 12 months), has negative pregnancy test within 21 days prior to treatment. If a sexually active male or a sexually active female of child- bearing potential, agrees to use dual (two concurrent) forms of medically accepted contraception from the time of consent until 6 months after the last dose.
* History of allergic reactions to compounds of similar chemical or biological composition to capecitabine (Group A only), trastuzumab or tucatinib, except for a history of Grade 1 or Grade 2 infusion related reaction to trastuzumab, that has been successfully managed.
* Known to be HIV positive, or a carrier for Hepatitis B and/or Hepatitis C (whether active disease or not)
* Known liver disease, autoimmune hepatitis, or sclerosing cholangitis
* Inability to swallow pills or any significant gastrointestinal diseases, which would preclude adequate absorption of oral medications
* Use of a strong CYP2C8/CYP3A4 inducer or inhibitor within three elimination half-lives of the inducer or inhibitor prior to the start of study treatment.
* Known impaired cardiac function or clinically significant cardiac disease such as ventricular arrhythmia requiring therapy or congestive heart failure. Note: Patients with hypertension must have controlled disease defined as systolic blood pressure \>150 mmHg and/or diastolic blood pressure \>100 mmHg on antihypertensive medications.
* Myocardial infarction or unstable angina within 6 months prior to the first dose of study drug.
* Patient with known dihydropyrimidine dehydrogenase deficiency
* Previous treatment with tucatinib
* Previous treatment with capecitabine within 12 months prior to study registration
* Prior history of other cancer (except non melanoma skin, cervical intraepithelial neoplasia) with evidence of disease within the last 5 years.

Primary outcomes:
measure: Length of Subject Survival After Starting Study Treatment
timeFrame: Through study completions, an average of 2 years
Secondary outcomes:
measure: Number of Adverse Events
timeFrame: Baseline up to 3 years or until disease progression or unacceptable toxicity or death.
measure: Progression Free Survival
timeFrame: Baseline to 12 weeks
measure: Objective Response in the Central Nervous System (CNS)
timeFrame: Baseline up to 3 years
measure: Clinical Benefit Rate (CBR) in CNS
timeFrame: Baseline to 3 years
measure: Objective Response in Extra-CNS Disease
timeFrame: Baseline up to 3 years
measure: Clinical Benefit Rate (CBR) in Extra-CNS Disease
timeFrame: Baseline to 3 years
measure: Symptom Burden
timeFrame: Beginning at baseline and every 21 days until the end of study up to three years
measure: Quality of Life Assessment
timeFrame: Beginning at baseline and every 42 days until the end of study up to three years
Other outcomes:
Locations:
city: Birmingham
country: United States
facility: University of Alabama at Birmingham
state: Alabama
city: San Francisco
country: United States
facility: UCSF-Mission Bay
state: California
city: Washington
country: United States
facility: MedStar Georgetown University-Lombardi CCC
state: District of Columbia
city: Chicago
country: United States
facility: University of Chicago
state: Illinois
city: Indianapolis
country: United States
facility: Indiana University-Melvin and Bren Simon cancer center
state: Indiana
city: Boston
country: United States
facility: Dana Farber/Harvard Cancer Center-
state: Massachusetts
city: Ann Arbor
country: United States
facility: University of Michigan-
state: Michigan
city: Houston
country: United States
facility: University of Texas MD Anderson Cancer Center
state: Texas
city: Seattle
country: United States
facility: University of Washington Medical Center-Montlake
state: Washington
Study officials:
affiliation: University of Alabama at Birmingham
name: Erica M Stringer-Reasor, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: M.D. Anderson Cancer Center
name: Rashmi K Murthy, MD, MBE
role: STUDY_CHAIR
affiliation: M.D. Anderson Cancer Center
name: Barbara J O'Brien, MD
role: STUDY_CHAIR
References: