Clinical Trials /

Phase II Trial of Combination Immunotherapy With NeuVax and Trastuzumab in High-risk HER2+ Breast Cancer Patients

NCT02297698

Description:

This will be a multi-center, prospective, randomized, single-blinded, placebo-controlled phase II trial of trastuzumab + nelipepimut-S/GM-CSF versus trastuzumab + GM-CSF alone. Our target study population is high-risk HER2-positive breast cancer patients. High-risk HER2-positive breast cancer patients are defined as: Those with HER2-positive breast cancer, regardless of hormone receptor status, who receive neoadjuvant therapy with an approved regimen that includes trastuzumab and at least four cycles (12 weeks) of taxane-containing chemotherapy, and fail to achieve a pCR. Those with HER2-positive breast cancer, regardless of hormone receptor status, who undergo surgery as a first intervention and are found to have ≥ 4 positive lymph nodes. Those with HER2-positive, hormone receptor negative breast cancer who undergo surgery as a first intervention and are found to have 1-3 positive lymph nodes. Disease-free subjects after standard of care multi-modality therapy will be screened and HLA-typed.

Related Conditions:
  • Breast Carcinoma
Recruiting Status:

Active, not recruiting

Phase:

Phase 2

Trial Eligibility

Document

Title

  • Brief Title: Phase II Trial of Combination Immunotherapy With NeuVax and Trastuzumab in High-risk HER2+ Breast Cancer Patients
  • Official Title: Phase II Trial of Combination Immunotherapy With Nelipepimut-S + GM-CSF (NeuVax™) and Trastuzumab in High-risk HER2+ Breast Cancer Patients

Clinical Trial IDs

  • ORG STUDY ID: 2014-0443
  • NCT ID: NCT02297698

Conditions

  • Breast Cancer

Interventions

DrugSynonymsArms
NeuVax vaccinenelipepimut-STrastuzumab + NeuVax
TrastuzumabHerceptinTrastuzumab + GM-CSF
GM-CSFLeukine, SargramostimTrastuzumab + GM-CSF

Purpose

This will be a multi-center, prospective, randomized, single-blinded, placebo-controlled phase II trial of trastuzumab + nelipepimut-S/GM-CSF versus trastuzumab + GM-CSF alone. Our target study population is high-risk HER2-positive breast cancer patients. High-risk HER2-positive breast cancer patients are defined as: Those with HER2-positive breast cancer, regardless of hormone receptor status, who receive neoadjuvant therapy with an approved regimen that includes trastuzumab and at least four cycles (12 weeks) of taxane-containing chemotherapy, and fail to achieve a pCR. Those with HER2-positive breast cancer, regardless of hormone receptor status, who undergo surgery as a first intervention and are found to have ≥ 4 positive lymph nodes. Those with HER2-positive, hormone receptor negative breast cancer who undergo surgery as a first intervention and are found to have 1-3 positive lymph nodes. Disease-free subjects after standard of care multi-modality therapy will be screened and HLA-typed.

Detailed Description

      In this study, the investigators intend to assess the ability of the combination of
      trastuzumab and the HER2 vaccine nelipepimut-S (administered with the immunoadjuvant GM-CSF)
      given in the adjuvant setting to prevent recurrences in patients with high-risk HER2-positive
      breast cancer. High-risk is defined as those patients that do not achieve a pCR after
      neoadjuvant therapy with an approved regimen that includes trastuzumab and at least four
      cycles (12 weeks) of taxane-containing chemotherapy or those who undergo upfront surgery and
      are found to have greater than or equal to four positive lymph nodes regardless of hormone
      receptor status or 1-3 positive lymph nodes and are hormone receptor negative.

      Following surgery, patients will be screened and HLA-typed (consent #1). Nelipepimut-S is a
      CD8-eliciting peptide vaccine that is restricted to HLA-2+ or HLA-A3+ or HLA-A24+ or HLA-A26+
      patients (approximately 80% of the US population). HLA-A2+/A3+/A24+/orA26+ patients who meet
      all other eligibility criteria will be randomized to receive trastuzumab +
      nelipepimut-S/GM-CSF or trastuzumab + GM-CSF alone (consent #2). The trastuzumab will be
      administered to all patients consistent with current standard of care. Patients randomized to
      the nelipepimut-S/GM-CSF arm will receive vaccinations of nelipepimut-S (1000 mcg) and GM-CSF
      (250 mcg) administered intradermally every three weeks for six total vaccinations, 30-120
      minutes after completion of trastuzumab infusion. The first vaccination will be given with
      the third dose of maintenance trastuzumab administered as monotherapy optimally, but may be
      given with later maintenance doses of trastuzumab, provided there are at least six remaining
      doses of trastuzumab to overlap with the primary vaccine series. Patients randomized to the
      GM-CSF alone arm will receive inoculations of GM-CSF (250 mcg) administered in an identical
      manner to those receiving nelipepimut-S/GM-CSF. Patients will be blinded as to whether they
      are receiving nelipepimut-S/GM-CSF or GM-CSF alone.

      Upon completion of the primary vaccination/inoculation series, booster inoculations (same
      dose and route) will be administered every six months x 4. The first booster inoculation will
      occur 6 months ± 2 weeks after the completion of the PVS, with subsequent boosters timed
      every six months + 2 weeks. Boosters will therefore occur at the following time points after
      completion of the PVS: 6 months ± 2 weeks, 12 months ± 2 weeks, 18 months ± 2 weeks, 24
      months ± 2 weeks. Booster inoculations will occur for patients randomized to receive
      nelipepimut-S/GM-CSF as well as patients randomized to receive GM-CSF alone, and will consist
      of the same treatment drugs and dosing (i.e., nelipepimut-S/GM-CSF patients will be boosted
      with nelipepimut-S/GM-CSF while GM-CSF alone patients will be boosted with GM-CSF alone).
      Patient blinding will be maintained throughout the study.

      Subjects will be followed for safety issues, immunologic response and clinical recurrence.
      Patients will be monitored 48-72 hours after each inoculation for reaction to the inoculation
      as well as documentation of any adverse effects experienced. Immunologic response will be
      monitored primarily by in vivo delayed type hypersensitivity (DTH) reactions but also may be
      documented by other immunologic assays. All patients will be followed for a total of 36
      months from the time of initiation of trastuzumab maintenance therapy to document
      disease-free status.
    

Trial Arms

NameTypeDescriptionInterventions
Trastuzumab + NeuVaxExperimentalPatients randomized to this arm will receive vaccinations of nelipepimut-S (1000 μg) and GM-CSF (250 μg) (NeuVax vaccine) administered intradermally every three weeks for six total vaccinations, 30-120 minutes after completion of trastuzumab infusion. The first vaccination will be given with the third dose of maintenance trastuzumab administered as monotherapy optimally, but may be given with later maintenance doses of trastuzumab, provided there are at least six remaining doses of trastuzumbab to overlap with the PVS. Upon completion of the primary vaccination series (PVS), booster inoculations (same dose and route) will be administered every six months x 4. The first booster inoculation will occur 6 months ± 2 weeks after the completion of the PVS, with subsequent boosters timed every six months + 2 weeks. Boosters will therefore occur at the following time points after completion of the PVS: 6 months ± 2 weeks, 12 months ± 2 weeks, 18 months ± 2 weeks and 24 months ± 2 weeks.
  • NeuVax vaccine
  • Trastuzumab
  • GM-CSF
Trastuzumab + GM-CSFActive ComparatorPatients randomized to this arm will receive inoculations of GM-CSF (250 μg) administered in an identical manner to those receiving nelipepimut-S/GM-CSF (NeuVax). Patients will be blinded as to whether they are receiving nelipepimut-S/GM-CSF or GM-CSF alone. Upon completion of the primary vaccination series (PVS), booster inoculations (same dose and route) will be administered every six months x 4. The first booster inoculation will occur 6 months ± 2 weeks after the completion of the PVS, with subsequent boosters timed every six months + 2 weeks. Boosters will therefore occur at the following time points after completion of the PVS: 6 months ± 2 weeks, 12 months ± 2 weeks, 18 months ± 2 weeks and 24 months ± 2 weeks.
  • Trastuzumab
  • GM-CSF

Eligibility Criteria

        Inclusion criteria:

          -  18 years or older

          -  Eastern Cooperative Oncology Group (ECOG) performance status 0,1

          -  AJCC stage I - III non-inflammatory, HER2-positive (according to ASCO-CAP guidelines
             5) breast cancer

          -  Completed neoadjuvant therapy with an approved regimen that includes trastuzumab and
             at least four cycles (12 weeks) of taxane-containing chemotherapy and underwent
             surgery with final pathology showing evidence of residual disease in the breast or
             axilla (residual ductal carcinoma in situ or microinvasive disease not eligible) or
             underwent surgery as a first intervention and was found to be pathologically
             node-positive: ≥ 4 positive lymph nodes (pN2 or pN3) regardless of hormone receptor
             status or 1-3 positive lymph nodes (pN1) if hormone receptor negative. Patients with
             micrometastases (pN1mi) are not eligible.

          -  Completed an approved regimen of neoadjuvant or adjuvant therapy with an approved
             regimen that includes trastuzumab and at least four cycles (12 weeks) of
             taxane-containing chemotherapy with plan for completion of one year of trastuzumab
             therapy.

          -  Completed appropriate surgical therapy to include:

               1. Total mastectomy and axillary staging with sentinel lymph node dissection or
                  axillary lymph node dissection (level I/II). Patients with a positive sentinel
                  lymph node must have undergone a completion axillary lymph node dissection.

               2. Breast conserving surgery (BCS) and axillary staging with sentinel lymph node
                  dissection or axillary lymph node dissection. Patients undergoing surgery as a
                  first intervention with a positive sentinel lymph node must have undergone a
                  completion axillary dissection level I/II unless they had clinically node
                  negative T1-T2 tumors and fewer than 3 involved lymph nodes. Patients receiving
                  neoadjuvant chemotherapy that have a positive sentinel lymph node must have
                  undergone a completion axillary lymph node dissection.

               3. Completed or receiving appropriate radiation therapy if indicated:

        For patients undergoing total mastectomy surgery as a first intervention, post-mastectomy
        radiation to the chest wall, infraclavicular and supraclavicular areas is required for
        patients with ≥ 4 positive lymph nodes. Radiation to the internal mammary lymph nodes is
        not required per protocol but is allowed at the discretion of the patient's treating
        radiation oncologist. For patients with 1-3 positive lymph nodes, post-mastectomy radiation
        to the chest wall, infraclavicular, supraclavicular, and internal mammary areas is not
        required per protocol but is allowed at the discretion of the patient's treating radiation
        oncologist.

          -  For patients undergoing breast conserving surgery (BCS) as a first intervention, whole
             breast irradiation with or without a boost, and radiation to the infraclavicular and
             supraclavicular areas is required for patients with ≥ 4 positive lymph nodes.
             Radiation to the internal mammary lymph nodes is not required but is allowed at the
             discretion of the patient's treating radiation oncologist. For patients with 1-3
             positive lymph nodes, whole breast irradiation with or without a boost is required.
             Radiation to the infraclavicular, supraclavicular, and internal mammary areas is not
             required per protocol but is allowed at the discretion of the patient's treating
             medical oncologist.

          -  For patient's undergoing mastectomy after neoadjuvant chemotherapy post-mastectomy
             radiation to the chest wall, infraclavicular and supraclavicular areas is required for
             patients presenting with clinical N2 or N3 disease or with ≥ 4 positive lymph nodes
             identified pathologically at the time of surgery. Radiation to the internal mammary
             lymph nodes is not required per protocol but is allowed at the discretion of the
             patient's treating radiation oncologist. For patients with 0-3 positive lymph nodes
             identified pathologically, post-mastectomy radiation to the chest wall,
             infraclavicular, supraclavicular and internal mammary areas is not required per
             protocol but is allowed at the discretion of the patient's treating radiation
             oncologist.

          -  For patient's undergoing BCS after neoadjuvant chemotherapy, whole breast irradiation
             with or without a boost is required. For patients with clinical N2 or N3 disease or
             with ≥ 4 positive lymph nodes identified pathologically at the time of surgery,
             radiation to the infraclavicular and supraclavicular areas is required. Radiation to
             the internal mammary lymph nodes is not required per protocol but is allowed at the
             discretion of the patient's treating radiation oncologist. For patients with 0-3
             positive lymph nodes identified pathologically, radiation to the infraclavicular,
             supraclavicular and internal mammary areas is not required per protocol but is allowed
             at the discretion of the patient's treating radiation oncologist.

               -  HLA-A2+ or HLA-A3+ or HLA-A24+ or HLA-A26+

               -  LVEF >50%, or an LVEF within the normal limits of the institution's specific
                  testing (MUGA or ECHO)

               -  Adequate organ function as determined by the following laboratory values:

                    1. ANC ≥ 1,000/μL

                    2. Platelets ≥ 75,000/μL

                    3. Hgb ≥ 9 g/dL

                    4. Creatinine ≤ 1.5 x upper limit of normal (ULN) of institution's range or
                       Creatinine clearance ≥ 50%

                    5. Total bilirubin ≤ 1.5 ULN of institution's range

                    6. ALT and AST ≤ 1.5 ULN of institution's range

                    7. For women of child-bearing potential, agreement to use adequate birth
                       control (abstinence, hysterectomy, bilateral oophorectomy, bilateral tubal
                       ligation, oral contraception, IUD, or use of condoms or diaphragms)

               -  Signed informed consent

        Exclusion criteria:

          -  AJCC Stage IV breast cancer

          -  NYHA stage 3 or 4 congestive heart failure

          -  Immune deficiency disease or known history of HIV, HBV, HCV

          -  Receiving immunosuppressive therapy including chronic steroids, methotrexate, or other
             known immunosuppressive agents

          -  Pregnancy (assessed by urine HCG)

          -  Breast feeding

          -  Any active autoimmune disease requiring treatment, with the exception of vitiligo

          -  Active pulmonary disease requiring medication to include multiple inhalers (>3
             inhalers including one containing steroids)

          -  Involved in other experimental protocols except with permission of other PI
      
Maximum Eligible Age:N/A
Minimum Eligible Age:18 Years
Eligible Gender:All
Healthy Volunteers:No

Primary Outcome Measures

Measure:Invasive Disease-free survival (DFS)
Time Frame:Initiation of trastuzumab monotherapy through the end of the patient's fifth year of participation in the study.
Safety Issue:
Description:Compare invasive DFS between the two treatment groups from time of initiation of trastuzumab maintenance therapy (trasuzumab monotherapy) to time of invasive local, regional or distant recurrence, new primary, or death due to any cause. Disease state will be determined by the patients' own physicians at the individual study sites during their routine follow-up screening. This will occur for all enrolled patients, regardless of randomization, approximately every three months for the first 24 months after completion of primary therapies and every six months thereafter with clinical exam, and laboratory and radiographic surveillance. The primary outcome measure of the trial is invasive DFS.

Secondary Outcome Measures

Measure:Distant recurrence-free survival (DRFS)
Time Frame:Initiation of trastuzumab monotherapy through the end of the patient's fifth year of participation in the study.
Safety Issue:
Description:DRFS will be assessed as part of the patient's disease state as determined by their physician at the individual study sites during routine follow-up screening. Determination of DRFS will allow for continued follow-up on patients with local or regional recurrence.
Measure:Local and systemic toxicities
Time Frame:From the date of initiation of the vaccine or inoculation series and booster series up to 36 months.
Safety Issue:
Description:Standard local and systemic toxicities will be collected and graded per the NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.03 graded toxicity scale. For both the inoculations during the primary vaccine/inoculation series and the booster inoculations, patients will be monitored closely for one hour after inoculation with questioning, serial exams and vital signs every 15 minutes to observe for a hypersensitivity reaction. Additionally, patients will return to their study site 48-72 hours after inoculation for questioning regarding any systemic toxicity and local injection site reactions. When they return to their study site, the local reaction at the inoculation sites will be examined and measured.
Measure:Evaluate in vivo and in vitro immune responses
Time Frame:From the date of the first inoculation of Trastuzumab monotherapy to the end of the patient's fifth year of participation in the study.
Safety Issue:
Description:Immune responses will be primarily documented using the delayed type hypersensitivity (DTH) reaction and using the dextramer assay to enumerate peptide-specific CTL. Each of these measurements will be performed regardless of randomization. DTH reactions will be measured prior to initiation of the primary vaccine/inoculation series, one month ± 1 week after completion of the primary vaccine/inoculation series, and one month ± 1 week after the final booster inoculation. Dextramer measurements will be performed prior to initiating the primary vaccine/inoculation series as well as one month ± 1 week after completion of the vaccine/inoculation series. Additionally, these assays may be performed pre- and post-each booster. Alternatively, these assayed time points may also be performed all at once on frozen and banked cells.

Details

Phase:Phase 2
Primary Purpose:Interventional
Overall Status:Active, not recruiting
Lead Sponsor:Cancer Insight, LLC

Trial Keywords

  • Breast cancer, NeuVax

Last Updated

January 29, 2021