This is a Phase 2, multicenter, single-arm study to determine the safety and efficacy of
BKM120 plus capecitabine in breast cancer patients with brain metastases. 40 patients will be
included, who have either ER+/HER2-, HER2+ or triple negative breast cancer..
The Graded Prognostic Assessment (GPA) is a recently developed, validated prognostic score
for patients with brain metastases. The Graded Prognostic Assessment will be utilized to
evaluate efficacy in this clinical study.
Capecitabine is a prodrug which is enzymatically converted to 5-fluorouracil in its tumor
target where it inhibits DNA synthesis and slows tumor growth. It is currently FDA approved
for both colorectal and breast cancer. BMK120 is a pan phosphatidylinositol-3-kinase
inhibitor being developed under IND# 102,823 by Novartis Corporation. As of September 2012
over 600 patients had been enrolled in fourteen separate Novartis sponsored monotherapy or
combination therapy clinical studies of BMK120.
Phosphatidylinositol-3-kinase (PI3K) signaling regulates diverse cellular functions including
cell proliferation, survival, translational regulation of protein synthesis, glucose
metabolism, cell migration, and angiogenesis. PI3K signaling also serves a central role in
the pathogenesis of numerous cancers.
Constitutive activation of PI3K signaling is known to be a critical step in mediating the
transforming potential of oncogenes and tumor suppressors in many tumor types. Resistance to
a variety of therapeutic interventions, including hormonal therapy, anti-HER2 therapies and
chemotherapy can also be linked to constitutive activation of the PI3K pathway.
Preliminary data suggest that activation of the PI3K pathway is a predictor of a poor
prognostic outcome in many cancer types. Thus, as a pan-PI3K inhibitor, BMK120 may provide a
therapeutic benefit to patients with MBC. Both capecitabine and BMK120 have previously shown
activity in patients with MBC. Like capecitabine, BMK120 is also effective in crossing the
blood brain barrier making it a preferred candidate for its evaluation in patients with MBC.
Trastuzumab is a monoclonal antibody that targets the HER2 receptor which is overexpressed or
amplified in approximately 20-25% of breast cancers. The clinical benefit of trastuzumab in
women with metastatic breast cancer has been demonstrated in two pivotal studies.
Current clinical experience with BMK120 has shown that its most frequent adverse events (AEs)
include fatigue, decreased appetite, diarrhea, hyperglycemia, nausea, rash and mood
alteration disorders. Therefore patients will be closely monitored for fasting plasma glucose
(FPG) HbA1c, and insulin C-peptide. Patients will also be frequently and routinely evaluated
for mood disorders and disturbances. The remaining most frequent AEs will be detected by
regular, frequent monitoring with symptomatic treatment to be provided as required.
Inclusion Criteria:
1. Age ≥ 18 years
2. Female
3. Histologically and/or cytologically confirmed diagnosis of inoperable metastatic
breast cancer
4. ER+/HER2- OR HER2+ OR triple-negative breast cancer, assessed as ER-, PgR-, and
HER2-negative by local laboratory testing; HER2 negative status (based on most
recently analyzed biopsy) is defined as IHC status of 0, 1+ or 2+ (if IHC 2+, a
negative FISH test is required, ie, HER2 FISH ratio < 2.0); ER-negative and
PR-negative status is defined as ER and PgR <10% nuclei positive by IHC. HER2-positive
status is defined as 3+ staining in ≥10% of cells by immunohistochemistry or a
HER2/CEP17 ratio ≥2 or an average of ≥6 HER2 gene copies per cell by in situ
hybridization (ISH)
5. At least one CNS lesion that is at least 5mm in size in at least one dimension in the
setting of prior WBRT
- Prior WBRT is required and may have been administered at any time in patient's
treatment history. Patients in the primary analysis will not have evidence of
progression of disease following WBRT. However, patients whose brain metastases
have progressed following WBRT are eligible. Patients must have completed WBRT at
least 3 weeks prior to study entry.
- Prior SRS is allowed, but previous treatment of the 5mm target CNS lesion with
SRS is not permitted
6. ECOG performance status ≤ 2
7. Adequate bone marrow function as shown by: ANC ≥ 1.5 x 109/L, Platelets ≥ 100 x 109/L,
Hb >9 g/dL
8. Total calcium (corrected for serum albumin) within normal limits (biphosphonate use
for malignant hypercalcemia control is not allowed)
9. Magnesium ≥ the lower limit of normal
10. Potassium within normal limits for the institution
11. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) within normal
range (or ≤ 3.0 x upper limit of normal (ULN) if liver metastases are present)
12. Serum bilirubin within normal range (or ≤ 1.5 x ULN if liver metastases are present;
or total bilirubin ≤ 3.0 x ULN with direct bilirubin within normal range in patients
with known Gilbert Syndrome)
13. Serum creatinine ≤ 1.5 x ULN or 24-hour clearance ≥ 50 mL/min
14. Serum amylase ≤ ULN
15. Serum lipase ≤ ULN
16. Fasting plasma glucose ≤ 120 mg/dL (6.7 mmol/L)
17. Negative serum pregnancy test within 72 hours before starting study treatment in women
with childbearing potential
18. INR ≤ 2
19. Life expectancy > 12 weeks
20. Available tissue (blocks and/or slides) samples unless discussed in advance with study
principal investigator
21. Patient is able to swallow and retain oral medication
22. Signed most recent patient informed consent form
23. Signed Patient Authorization Form
Exclusion Criteria:
1. Patient received prior treatment with a P13K inhibitor.
2. Patient with known hypersensitivity to BKM120, capecitabine, or their excipients.
3. Patient has evidence of impending herniation on baseline brain imaging.
4. Patient has evidence of diffuse leptomeningeal disease on brain MRI or by previously
documented CSF.
5. Patient has acute or chronic liver, renal disease or pancreatitis (liver metastases
are allowed)
6. Patients has a mood disorder as judged by the Investigator or a psychiatrist, or as a
result of patient's mood assessment questionnaire (PHQ-9 and/or GAD-7):
- Medically documented history of or active major depressive episode, bipolar
disorder (I or II), obsessive-compulsive disorder, schizophrenia, a history of
suicidal attempt or ideation, or homicidal ideation (immediate risk of doing harm
to others) or patients with active severe personality disorders (defined
according to DSM- IV) are not eligible. Note: for patients with psychotropic
treatments ongoing at baseline, the dose and the schedule should not be modified
within the previous 6 weeks prior to start of study drug.
- ≥ CTCAE grade 3 anxiety
- Meets the cut-off score of ≥ 12 in the PHQ-9 or a cut-off of ≥ 15 in the GAD-7
mood scale, respectively, or selects a positive response of "1, 2, or 3" to
question number 9 regarding potential for suicidal thoughts in the PHQ-9
(independent of the total score of the PHQ-9)
7. Patients has diarrhea ≥ CTCAE grade 2
8. Patients with uncontrolled hypertension defined as systolic blood pressure 170 or
greater or diastolic blood pressure over 100.
9. Patient has active cardiac disease including any of the following:
- Left ventricular ejection fraction (LVEF) < 50% as determined by Multiple Gated
acquisition (MUGA) scan or echocardiogram (ECHO)
- QTc > 480 msec on screening ECG (using the QTcF formula)
- Angina pectoris that requires the use of anti-anginal medication
- Ventricular arrhythmias except for benign premature ventricular contractions
- Supraventricular and nodal arrhythmias requiring a pacemaker or not controlled
with medication
- Conduction abnormality requiring a pacemaker
- Valvular disease with document compromise in cardiac function
- Symptomatic pericarditis
10. Patient has a history of cardiac dysfunction including any of the following:
- Myocardial infarction within the last 6 months, documented by persistent elevated
cardiac enzymes or persistent regional wall abnormalities on assessment of LVEF
function
- History of documented congestive heart failure (New York Heart Association
functional classification III-IV)
- Documented cardiomyopathy
11. Patient has poorly controlled diabetes mellitus or steroid-induced diabetes mellitus
12. Patient has other concurrent severe and/or uncontrolled concomitant medical conditions
(e.g., active or uncontrolled infection) that could cause unacceptable safety risks or
compromise compliance with the protocol
- Significant symptomatic deterioration of lung function. If clinically indicated,
pulmonary function tests including measures of predicted lung volumes, DLco, O2
saturation at rest on room air should be considered to exclude pneumonitis or
pulmonary infiltrates.
13. Impairment of gastrointestinal (GI) function or GI disease that may significantly
alter the absorption of BKM120 (e.g., ulcerative diseases, uncontrolled nausea,
vomiting, diarrhea, malabsorption syndrome, or small bowel resection). Patients with
unresolved diarrhea will be excluded as previously indicated
14. Patient was treated with any hematopoietic colony-stimulating growth factors (e.g.,
G-CSF, GM-CSF) ≤ 2 weeks prior to starting study drug. Erythropoietin or darbepoetin
therapy, if initiated at least 2 weeks prior to enrollment, may be continued
15. Patient is currently receiving treatment with medication with a known risk to prolong
the QT interval or inducing Torsades de Pointes and the treatment cannot either be
discontinued or switched to a different medication prior to starting study drug.
16. Patients receiving chronic treatment with steroids or another immunosuppressive agent.
Patients must have been off all corticosteroids (except for physiologic doses of
hydrocortisone as replacement therapy) for at least 2 weeks prior to study entry.
- Note: Single doses, or topical applications (e.g. rash), inhaled sprays (e.g.
obstructive airways diseases), eye drops or local injections (e.g.
intra-articular) are allowed.
17. Patient has taken herbal medications and certain fruits within 7 days prior to
starting study drug. Herbal medications include, but are not limited to St. John's
wort, Kava, ephedra (ma huang), gingko biloba, dehydroepiandrosterone (DHEA), yohimbe,
saw palmetto, and ginseng. Fruits include the CYP3A inhibitors Seville oranges,
grapefruit, pummelos, or exotic citrus fruits. Regular orange juice is permitted.
18. Patient is currently treated with drugs known to be moderate and strong inhibitors or
inducers of isoenzyme CYP3A, and the treatment cannot be discontinued or switched to a
different medication prior to starting study drug. Please refer to Table 4-8 for a
list of prohibited inhibitors and inducers of CYP3A (Please note that co-treatment
with weak inhibitors of CYP3A is allowed).
19. Patient received chemotherapy or targeted anticancer therapy ≤ 3 weeks (6 weeks for
nitrosourea, antibodies or mitomycin-C) prior to starting study drug, and have related
side effects must recover to a grade 1 or less before starting the trial
20. Patient received any continuous or intermittent small molecule therapeutics (excluding
monoclonal antibodies) with ≤ 5 effective half lives prior to starting study drug or
who have not recovered from side effects of such therapy
21. Patient received wide field radiotherapy ≤ 4 weeks or limited field radiation for
palliation ≤ 2 weeks prior to starting study drug or who have not recovered from side
effects of such therapy
22. Patient underwent major surgery ≤ 2 weeks prior to starting study drug or who have not
recovered from side effects of such therapy.
23. Patient is currently taking therapeutic doses of warfarin sodium or any other
coumadin-derivative anticoagulant.
24. Patient is pregnant or breast feeding or is of reproductive potential and not
employing an effective method of birth control.
- Note: Double barrier contraceptives must be used through the trial by both sexes.
Oral, implantable, or injectable contraceptives may be affected by cytochrome
P450 interactions, and are therefore not considered effective for this study.
Women of child-bearing potential, defined as sexually mature women who have not
undergone a hysterectomy or who have not been naturally postmenopausal for at
least 12 consecutive months (i.e., who has had menses any time in the preceding
12 consecutive months), must have a negative serum pregnancy test ≤ 72 hours
prior to initiating treatment.
- Note: Women are considered post-menopausal and not of child bearing potential if
they have had 12 months of natural (spontaneous) amenorrhea with an appropriate
clinical profile (e.g. age appropriate, history of vasomotor symptoms) or six
months of spontaneous amenorrhea with serum FSH levels > 40 mIU/mL [for US only:
and estradiol < 20 pg/mL] or have had surgical bilateral oophorectomy (with or
without hysterectomy) at least six weeks ago. In the case of oophorectomy alone,
only when the reproductive status of the woman has been confirmed by follow up
hormone level assessment is she considered not of child bearing potential.
- Note: Women of child-bearing potential, defined as all women physiologically
capable of becoming pregnant, must use highly effective contraception during
treatment for 4 weeks (5 T1/2) after stopping treatment. The highly effective
contraception is defined as either:
i. True abstinence: When this is in line with the preferred and usual lifestyle
of the subject. Periodic abstinence (e.g., calendar, ovulation, symptothermal,
post-ovulation methods) and withdrawal are not acceptable methods of
contraception.
ii. Sterilization: have had surgical bilateral oophorectomy (with or without
hysterectomy) or tubal ligation at least six weeks ago. In case of oophorectomy alone,
only when the reproductive status of the woman has been confirmed by follow up hormone
level assessment.
iii. Male partner sterilization (with the appropriate post-vasectomy documentation of
the absence of sperm in the ejaculate). For female subjects on the study, the
vasectomised male partner should be the sole partner for that patient.
iv. Use of a combination of any two of the following (a+b):
1. Placement of an intrauterine device (IUD) or intrauterine system (IUS)
2. Barrier methods of contraception: Condom or Occlusive cap (diaphragm or
cervical/vault caps) with spermicidal foam/gel/film/cream/vaginal suppository
- Oral contraception, injected or implanted hormonal methods are not allowed
as BKM120 potentially decreases the effectiveness of hormonal
contraceptives.
25. Patient has known diagnosis of human immunodeficiency virus (HIV) infection
26. Patient has history of another malignancy within 5 years, except cured basal cell
carcinoma of the skin or excised carcinoma in situ of the cervix
27. Patient is unable or unwilling to abide by the study protocol or cooperate fully with
the investigator
28. Patient is concurrently using other approved or investigational antineoplastic agent.
29. Patient taking or needing enzyme-inducing anti-epileptic medication.
30. Patient has an acute viral hepatitis or a history of chronic or active HBV or HCV
infection
