Overcoming Endocrine Resistance in Metastatic Breast Cancer
- Conditions
- Metastatic Breast Cancer
- Interventions
- Registration Number
- NCT02394496
- Lead Sponsor
- Consorzio Oncotech
- Brief Summary
Based on these results it can be envisioned that the majority of endocrine-responsive post-menopausal breast cancer patients will be treated with an AI as adjuvant therapy (front-line, switching or extending) and/or as first-line management of metastatic breast cancer.
- Detailed Description
In presence of ER hypersensitivity even a small amount of ER may be sufficient for sustained growth signalling. On the other hand, ER disruption operated by fulvestrant is not complete, particularly in the initial phase of treatment. From phase III trials, indeed, The invertigators know that with the standard 250mg monthly dose the steady state of circulating drug is reached only after 5-6 injections. This may play a role since, as long as ER downregulation is concerned, a clear dose-response relationship has been reported. In such a situation, fulvestrant efficacy may be partial, particularly because the concomitant AI discharge yields a restoration of physiologic postmenopausal levels of circulating oestrogens. New dosing schedule are currently under investigation both to accelerate the achievement of the steady state (loading dose) and to achieve higher circulating drug levels (high dose) (86).
In this trial the investigators will be using the so-called 'loading dose'.
Further potential strategies to improve fulvestrant efficacy in this setting are:
A) avoid the restoration of circulating oestrogens; B) interfere with molecular mechanisms that produce ER hypersensitivity by targeting the EGFR/ERBB2/ERB3 system.
A) avoid the restoration of circulating oestrogens: this should be achieved by holding the AI treatment. Because some cases of progression upon AIs may be related to an inefficient inhibition of the aromatase it is a logical step to test whether changing AI class (from type I, steroidal, to type II, non steroidal, and vice-versa) (87), may improve fulvestrant efficay. In this view, pts in this trial will be randomized to receive fulvestrant (loading dose) with or without the alternate class AI treatment. Circulating oestrogens levels will be tracked to verify inhibition of aromatase for pts assigned to concurrent AI treatment.
B) Interfere with growth factors-mediated ER hypersensitivity: although fulvestrant is able to overcome the ER hypersensitivity of LTED (88) and produce a growth arrest, this activity may not be complete because of incomplete ER disruption, but also because of a direct stimulation of growth by the hyperactivated EGFR/ERBB2/ERB3 system. Laboratory evidence support this hypothesis. Indeed, breast cancer cell lines exposed to long-term treatment with fulvestrant became insensitive to the drug and restore growth (89). This growth does not appear, however, related to the development of direct resistance to the drug, since ER mediated signalling continue to be efficiently suppressed in these cells; rather it may be driven by the use of alternative growth-stimulating pathway, including the EGFR system. Indeed, it can be abrogated by the EGFR-tyrosine Kinase inhibitor Gefitinib (IRESSA™) and by an MAPK-inhibitor (90). Lapatinib (GW572016) is an orally active small molecule that reversibly inhibits ErbB1 and ErbB2 tyrosine kinases, which in turn blocks phosphorylation and activation of Erk1/2 (p-Erk1/2) and Akt (p-Akt) in ErbB1- and/ or ErbB2-expressing tumor cell lines and xenografts (91-94). Lapatinib elicits cytostatic or cytotoxic antitumor effects depending on the cell type (95;96). Because ErbB2-containing heterodimers exert potent mitogenic signals, simultaneously interrupting both ErbB1 and ErbB2 signaling is an appealing therapeutic approach. Moreover, ErbB3 signaling is also involved in lapatinib action. Indeed ErbB3 is kinase-dead and relies on ErbB2 for transactivation: ErbB2-ErbB3 heterodimers are potent activators of the PI3K-Akt survival pathway (97;98), which can, in turn, inhibited by lapatinib.
Based on its molecular mechanism of action, on its fair toxicity profile and on its promising, although preliminary, activity data, Lapatinib appears an ideal candidate to combine with Fulvestrant in the attempt to improve its efficacy in patients progressing on AIs.
Recruitment & Eligibility
- Status
- UNKNOWN
- Sex
- Female
- Target Recruitment
- 396
- Provision of written informed consent
- Histological/cytological confirmation of breast cancer
- Documented positive hormone receptor status (ER+ve and/or PgR+ve) of primary or metastaic tumor issue, according to the local laboratory parameters
- Postmenopausal women
- Confirmed progression of disease after an adjuvant therapy or a therapy for metastatic disease with an aromatase inhibitors
- Patients demonstrating prior response to AI therapy
- Patients with measurable disease as per RECIST criteria /Patients with bone lesions, lytic or mixed (lytic + sclerotic), in the absence of measurable disease as defined by RECIST criteria.
- May have received prior radiotherapy as treatment for primary or metastatic tumour; however, is not required for study entry;
- Life expectancy of at least 8 months
- WHO performance status 0, 1 or 2
- Patients with a history of other malignancies are eligible if they have been disease-free for at least 5 years and are deemed by the investigator to be at low risk for recurrence.
- Are able to swallow and retain oral medication;
- Are able to complete all screening assessments as outlined in the protocol;
- Patients must have normal organ and marrow function
- Left ventricular ejection fraction (LVEF) within the institutional normal range
- Previous therapy with Fulvestrant and/or Lapatinib;
- Patients with HER 2 overexpressing, either IHC 3+ or FISH +;
- Concurrent non study anti-cancer therapy (
- Have unresolved or unstable, serious toxicity from prior administration
- Have malabsorption syndrome,
- Have a concurrent disease or condition that would make the patient inappropriate for study participation,
- Have an active or uncontrolled infection;
- Have dementia, altered mental status, or any psychiatric condition that would prohibit the understanding or rendering of informed consent;
- Have a known history of uncontrolled or symptomatic angina, arrhythmias, or CHF;
- Receive concurrent treatment with an investigational agent or participate in another clinical trial;
- Receive concurrent treatment with prohibited medications
- Used an investigational drug within 30 days or 5 half-lives, whichever is longer, preceding the first dose of study medication;
- Have a known immediate or delayed hypersensitivity reaction or idiosyncrasy to drugs chemically related to fulvestrant, aromatase inhibitors or lapatinib or excipients.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- CROSSOVER
- Arm && Interventions
Group Intervention Description ARM 1 Placebo Lapatinib Fulvestrant + Placebo Lapatinib ARM 2 Fulvestrant Fulvestrant + Aromatase Inhibitors + Placebo Lapatinib ARM 2 Aromatase Inhibitors Fulvestrant + Aromatase Inhibitors + Placebo Lapatinib ARM 2 Placebo Lapatinib Fulvestrant + Aromatase Inhibitors + Placebo Lapatinib ARM 3 Fulvestrant Fulvestrant + Lapatinib ARM 3 Lapatinib Fulvestrant + Lapatinib ARM 4 Lapatinib Fulvestrant + Lapatinib + Aromatase Inhibitors ARM 4 Aromatase Inhibitors Fulvestrant + Lapatinib + Aromatase Inhibitors ARM 1 Fulvestrant Fulvestrant + Placebo Lapatinib ARM 4 Fulvestrant Fulvestrant + Lapatinib + Aromatase Inhibitors
- Primary Outcome Measures
Name Time Method Progression Free Survival Defined as the time between the first study dose administration and the date of progression of the disease or death from any cause, whichever occurs first assessed up to 12 months Progression free survival (PFS): it is defined as the time between the first study dose administration and the date of progression of the disease or death from any cause, whichever occurs first.
- Secondary Outcome Measures
Name Time Method Clinical Benefit Rate Defined as the time between the first study dose administration and the date of progression of the disease or death from any cause, whichever occurs first assessed up to 6 months Clinical Benefit Rate: it is defined as the sum of rates of PR, CR and SD lasting ≥ 6 months.
Safety as measured by expected and Non-expected toxicity events Defined as the time between the first study dose administration and the date of progression of the disease or death from any cause, whichever occurs first assessed up to 12 months To evaluate expected and Non-expected toxicity events that occur in more than 5% of patients in any of the study group, as reported by the CTC.
Time To Progression Defined as the time between the first study dose administration and the date of progression of the disease or death from any cause, whichever occurs first assessed up to 12 months Time to Progression (TTP): it is defined as the time between the first study dose administration and the date of progression of the disease or cancer-related death, whichever occurs first.
Overall Survival Defined as the time between the first study dose administration and the date of progression of the disease or death from any cause, whichever occurs first assessed up to 12 months Overall survival. (OS): it is defined as the time between the first study dose administration and the date death from any cause.
Response Rate: Defined as the time between the first study dose administration and the date of progression of the disease or death from any cause, whichever occurs first assessed up to 12 months Response Rate: It will be classified according to the RECIST criteria.
Safety assessed by number of Participants with Adverse Events time between the first study dose administration and the date of progression of the disease or death from any cause, whichever occurs first assessed up to 12 months Withdrawals from the treatment plan (causes of withdrawals will be compared per each study group).
Trial Locations
- Locations (69)
Ospedale Sacro Cuore - Don Calabria U.O.C. Oncologia Medica
🇮🇹Negrar, Verona, Italy
Azienda Ospedaliera Treviglio-Caravaggio U.O. Oncologia Medica
🇮🇹Treviglio, Bergamo, Italy
Presidio Ospedaliero di Vallo della Lucania U.O. Oncologia Medica
🇮🇹Vallo Della Lucania, Salerno, Italy
AOVV - Ospedale E. Morelli S.O.C. Medicina Interna - D.H. Oncologico-Ematologico-Internistico
🇮🇹Sondalo, Sondrio, Italy
Ospedale 'Felice Lotti' - Azienda USL 5 di Pisa U.O. di Oncologia Medica
🇮🇹Pontedera, Pisa, Italy
IRCCS - 'Casa Sollievo della Sofferenza' U.O. Oncologia Medica
🇮🇹San Giovanni Rotondo, Foggia, Italy
A.S.U.R. Zona Territoriale 6 Fabriano U.O. Oncologia Medica
🇮🇹Fabriano, Ancona, Italy
Centro di Riferimento Oncologico S.O.C. di Oncologia Medica C
🇮🇹Aviano, Pordenone, Italy
Ospedale Oncologico Regionale - Centro di Riferimento Oncologico di Basilicata U.O. di Oncologia Medica
🇮🇹Rionero in vulture, Potenza, Italy
Azienda Ospedaliera - Ospedale Umberto I U.O. di Medicina e Oncoematologia
🇮🇹Nocera Inferiore, Salerno, Italy
Ospedale 'S. Antonio Abate' U.O. Oncologia
🇮🇹Gallarate, Varese, Italy
Ospedale Civile Renzetti U.O. Oncologia Medica
🇮🇹Lanciano, Chieti, Italy
Ospedale Unico Versilia U.O. Oncologia Medica
🇮🇹Lido Di Camaiore, Lucca, Italy
Ospedale San Sebastiano Day Hospital Oncologico - Divisione Medicina Acuti
🇮🇹Correggio, Reggio Emilia, Italy
Ospedale S. Francesco da Paola U.O. Oncologia Medica
🇮🇹Paola, Cosenza, Italy
Ospedale 'SS. Trinità' U.O. Oncologia Medica
🇮🇹Sora, Frosinone, Italy
Azienda Ospedaliera Busto Arsizio - Presidio Ospedaliero Saronno S.C. Oncologia Medica
🇮🇹Saronno, Varese, Italy
A.O.U. Ospedale Vittorio Emanuele e Ferrarotto U.O. di Oncologia Medica
🇮🇹Catania, Italy
Istituto Tumori 'Giovanni Paolo II' - IRCCS Ospedale Oncologico U.O. Oncologia Medica e Sperimentale
🇮🇹Bari, Italy
Istituto Oncologico Veneto - I.R.C.C.S. U.O. di Oncologia Medica II
🇮🇹Padova, Italy
Ospedale Evangelico Valdese - ASL TO1 U.O. di Oncologia Medica
🇮🇹Torino, Italy
Ospedale Civico San Vincenzo U.O. Oncologia Medica
🇮🇹Taormina, Messina, Italy
Azienda Ospedaliera G. Rummo U.O. di Oncologia Medica
🇮🇹Benevento, Italy
Ospedale Fatebenefratelli 'Sacro Cuore di Gesù' U.O. Oncologia
🇮🇹Benevento, Italy
Ospedale Civile di Campobasso - A. Cardarelli U.O.C. Oncologia Medica
🇮🇹Campobasso, Italy
Azienda Ospedaliera 'Sant'Anna e San Sebastiano' U.O.C. di Oncologia
🇮🇹Caserta, Italy
Presidio Ospedaliero Garibaldi - Nesima S.C. di Oncologia Medica
🇮🇹Catania, Italy
Humanitas Centro Catanese di Oncologia U.O. Oncologia Medica
🇮🇹Catania, Italy
Azienda Ospedaliera S. Anna U.O. di Oncologia Medica
🇮🇹Como, Italy
Arcispedaliera S. Anna di Ferrara U.O. Oncologia Clinica
🇮🇹Ferrara, Italy
I.R.C.C.S. A.O.U. San Martino - I.S.T. S.C. Oncologia Medica A
🇮🇹Genova, Italy
ASRM - Ospedale F. Veneziale - Zona di Isernia U.O. Oncologia
🇮🇹Isernia, Italy
A.S.L. LT - Ospedale Santa Maria Goretti U.O.C. di Oncologia Medica
🇮🇹Latina, Italy
Ospedale Vito Fazzi U.O. di Oncologia
🇮🇹Lecce, Italy
Istituto Europeo di Oncologia (IRCCS) Dipartimento di Medicina - Unità Cure Mediche
🇮🇹Milano, Italy
Istituto Nazionale dei Tumori - Fondazione G. Pascale U.O. Oncologia Medica Senologica
🇮🇹Napoli, Italy
A.O.U.P. 'Paolo Giaccone' U.O.C. di Oncologia Medica
🇮🇹Palermo, Italy
A.R.N.A.S - Ospedale Civico e Benfratelli G. Di Cristina e M. Ascoli Divisione di Oncologia Medica
🇮🇹Palermo, Italy
Fondazione S. Maugeri IRCCS U.O. Oncologia Medica II
🇮🇹Pavia, Italy
IRCCS Policlinico S. Matteo S.C. di Oncologia Medica
🇮🇹Pavia, Italy
Ospedale S. Maria della Misericordia S.C. Oncologia Medica
🇮🇹Perugia, Italy
AUSL di Piacenza - Ospedale U.O. Oncologia Medica
🇮🇹Piacenza, Italy
Azienda Ospedaliera Santa Maria degli Angeli U.O. Oncolgia Medica
🇮🇹Pordenone, Italy
Arcispedale S.Maria Nuova Servizio di Oncologia
🇮🇹Reggio Emilia, Italy
Istituto Regina Elena per lo studio e la cura dei tumori S.C. Oncologia Medica A
🇮🇹Roma, Italy
Policlinico Universitario 'Agostino Gemelli' U.O.C. Ginecologia Oncologica
🇮🇹Roma, Italy
Ospedale Fatebenefratelli San Giovanni Calibita - Isola Tiberina U.O. Oncologia
🇮🇹Roma, Italy
Azienda Ospedaliera S. Andrea - Università La Sapienza U.O.C. Oncologia
🇮🇹Roma, Italy
Ospedale San Pietro Fatebenefratelli Dipartimento di Oncologia - Day Hospital Oncologico
🇮🇹Roma, Italy
Ospedale G. Da Procida - ASL SA U.O. di Oncologia
🇮🇹Salerno, Italy
Azienda Ospedaliera 'San Giovanni di Dio e Ruggi D'Aragona' Struttura Complessa di Oncologia
🇮🇹Salerno, Italy
Azienda Ospedaliera n. 1 - Annunziata Oncologia Medica
🇮🇹Sassari, Italy
Università di Sassari U.O. di Oncologia Medica
🇮🇹Sassari, Italy
Ospedale Civile di Sondrio - Azienda Ospedaliera Valtellina e Valchiavenna S.C. Oncologia Medica
🇮🇹Sondrio, Italy
Presidio San Lazzaro - A.O.U. San Giovanni Battista di Torino (Molinette) S.C. Oncologia Medica II
🇮🇹Torino, Italy
Università degli Studi di Torino - Ospedale S. Anna U.O. di Oncologia Medica
🇮🇹Torino, Italy
Ospedale Mauriziano Umberto I S.C.D.U. Ginecologia e Ostetricia
🇮🇹Torino, Italy
Centro Oncologico A.S.S. N°1 Triestina Centro Sociale Oncologico
🇮🇹Trieste, Italy
A.O.U. ´S. Maria della Misericordia´ Dipartimento di Oncologia
🇮🇹Udine, Italy
Fondazione del Piemonte per l'Oncologia - Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.) Direzione di Oncologia Medica
🇮🇹Candiolo, Torino, Italy
Presidio Ospedaliero 'Antonio Perrino' U.O.C. di Oncologia
🇮🇹Brindisi, Italy
dazione di Ricerca e Cura 'Giovanni Paolo II' U.O. di Ginecologia Oncologia
🇮🇹Campobasso, Italy
A.O.U. 'Maggiore della Carità' S.C. Oncologia
🇮🇹Novara, Italy
Università di Napoli Federico II - Facoltà di Medicina Dipartimento di Medicina Clinica e Chirurgia - Oncologia
🇮🇹Napoli, Italy
Azienda Ospedaliera Cardarelli Divisione Di Oncologia
🇮🇹Napoli, Italy
Azienda Ospedaliera Bianchi - Melacrino - Morelli U.O. di Oncologia Medica
🇮🇹Reggio Calabria, Italy
Presidio Ospedaliero 'Belcolle' U.O.C. Oncologia Medica
🇮🇹Viterbo, Italy
Azienda Ospedaliera Circolo e Fondazione Macchi U.O. di Oncologia Medica
🇮🇹Varese, Italy
Azienda Ospedaliera San Camillo - Forlanini Day Hospital Oncologia Mammella
🇮🇹Roma, Italy