Description:
Very few patients with endocrine-resistant, hormone-receptor positive metastatic breast
cancer respond to single agent immunotherapy. Responses to chemotherapy are usually of short
duration. Combining immunotherapy with chemotherapy that has minimal immunosuppressive
effect, it may be possible to achieve higher response rates while keeping the
immune-associated pattern of long durations of response.
This will be a single-center phase 1b study to evaluate the tumor response and appropriate
dose of a chemo-immunotherapy regime consisting of treatment with pegylated liposomal
doxorubicin (PLD) and pembrolizumab-based in endocrine-resistant breast cancer (ERBC)
patients.
Up to 15 female patients, ages 18 and above, with pathological diagnosis of breast cancer,
estrogen receptor (ER) positive, human epidermal growth factor receptor 2 (HER2-) negative
subtype, stage III non-operable, or stage IV disease, who have received at least two lines of
hormonal therapy, one of which included aromatase inhibitors will be eligible for enrollment
to this single arm study.
Title
- Brief Title: Phase 1b Study of Pegylated Liposomal Doxorubicin and Pembrolizumab in Endocrine-resistant Breast Cancer
- Official Title: A Phase 1b Study of Combination Chemo-immunotherapy With Pegylated Liposomal Doxorubicin (Doxil/Caelyx) and Pembrolizumab (Keytruda) in Metastatic Endocrine-resistant Breast Cancer
Clinical Trial IDs
- ORG STUDY ID:
310-17-SZMC
- NCT ID:
NCT03591276
Conditions
Interventions
Drug | Synonyms | Arms |
---|
Chemotherapy Drugs, Cancer | Immunotherapy Antibodies, Cancer | Pembrolizumab and PLD |
Purpose
Very few patients with endocrine-resistant, hormone-receptor positive metastatic breast
cancer respond to single agent immunotherapy. Responses to chemotherapy are usually of short
duration. Combining immunotherapy with chemotherapy that has minimal immunosuppressive
effect, it may be possible to achieve higher response rates while keeping the
immune-associated pattern of long durations of response.
This will be a single-center phase 1b study to evaluate the tumor response and appropriate
dose of a chemo-immunotherapy regime consisting of treatment with pegylated liposomal
doxorubicin (PLD) and pembrolizumab-based in endocrine-resistant breast cancer (ERBC)
patients.
Up to 15 female patients, ages 18 and above, with pathological diagnosis of breast cancer,
estrogen receptor (ER) positive, human epidermal growth factor receptor 2 (HER2-) negative
subtype, stage III non-operable, or stage IV disease, who have received at least two lines of
hormonal therapy, one of which included aromatase inhibitors will be eligible for enrollment
to this single arm study.
Detailed Description
This will be a single-center phase 1b study to evaluate the tumor response and appropriate
dose of combined treatment with pembrolizumab and pegylated liposomal doxorubicin (PLD) in
endocrine-resistant breast cancer (ERBC) patients.
Female patients, ages 18 and above, with pathological diagnosis of breast cancer, estrogen
receptor (ER) positive, human epidermal growth factor receptor 2 (HER2-) negative subtype,
stage III non-operable, or stage IV disease, who have received at least two lines of hormonal
therapy, one of which included aromatase inhibitors will be eligible for enrollment to the
study.
The total number of patients in the study will be 15 patients. The study diagram is shown in
Figure 1. After signing the informed consent, eligible subjects will be successively
assigned, in order of accrual, to a dosing cohort. Six subjects will be enrolled in the Start
Cohort (Cohort S1), and receive: intravenous (IV) pembrolizumab 200 mg flat dose with IV
pegylated liposomal doxorubicin (PLD) 30 mg/m2, every 3 weeks. Toxicity will be graded by the
National Cancer Institute Common Terminology Criteria for Adverse Events Ver. 4.0
(NCI-CTCAE).
If during the first 2 cycles of treatment (the first 6 weeks) in the Start Cohort (Cohort
S1), up to one subject out of the 6 in the cohort will develop a dose-limiting toxicity (DLT;
defined as grade-4 hematological adverse events (AEs), or grade 3 non-hematological AEs
[stomatitis, hand and foot syndrome] in the first 2 cycles), the drug combination's safety
profile will be deemed acceptable and up to 9 more subjects will be recruited in the cohort
(Expanded Start Cohort S1) and will receive the same dose to help establish the rate of Tumor
Response and to confirm safety.
If during the first 2 cycles of treatment in the Start Cohort (Cohort S1) a DLT will be
observed in 2 or more patients out of the initial 6 patients enrolled into this cohort,
Cohort S1 will be discontinued, and a Reduced Dose Cohort (Cohort R1), will be accrued where
the dose of PLD will be reduced by 20% to 24 mg/m2 (IV pembrolizumab 200 mg flat dose with IV
PLD 24 mg/m2 every 3 weeks). Initially, 6 patients will be accrued to Cohort R1. If during
the first 2 cycles of treatment (the first 6 weeks) in the Reduced Dose Cohort (Cohort R1),
up to one subject out of the 6 in the cohort will develop a DLT, the drug combination's
safety profile will be deemed acceptable and up to 7 more subjects will be recruited in the
cohort (Expanded Reduced Cohort R1) to help establish the rate of Tumor Response and to
confirm safety of the reduced dose.
If during the first 2 cycles of treatment in Cohort R1, a DLT would be again observed in 2 or
more subjects, the study will be terminated (refer to Figure 1 for the study diagram).
Note: Only the first 2 cycles will be considered for safety clearance of any Cohort. If an
additional DLT occurs in the 3rd cycle, the dose will be individually modified if the
affected patient has stable disease (SD) or partial response/complete response (PR/CR), and
the patient will continue to the extended phase of the study.
The 3 first cycles of treatment (first 9 weeks) constitute the main phase of the study during
which most of the study objectives will be reached (safe dose clearance, tumor response rate
characterization of DLT's, pharmacokinetic [PK] analysis of PLD). Patients will return to the
study center on days 7 and 14 of cycles 1, 2 and 3, for monitoring assessments and for
clinical laboratory evaluations. Blood samples will be collected on study visits for
measurement of PLD concentrations at various time points during cycle 1. For each subject,
subsequent dosing will take place 21 days after the previous treatment, provided patients are
deemed fit to be dosed again.
For responding or stable patients, the extended phase of the study consists of 9 additional
cycles (27 more weeks) during which further safety information, duration of response,
progression-free survival (PFS) time, and other pertinent data will be collected. During both
phases of the study and beyond, information on survival and post-study treatments will be
collected until death. Information on potentially predictive biomarkers of treatment response
(and duration of response) will be gathered all along the study.
All patients receiving two or more cycles will be followed-up for survival until death. Study
treatment may continue until disease progression, unacceptable toxicity, patient refusal,
patient loss to follow up, or termination of the study by the Sponsor or Investigator,
whichever comes first. Pembrolizumab may be continued beyond disease progression. PLD will
not be continued beyond disease progression.
Trial Arms
Name | Type | Description | Interventions |
---|
Pembrolizumab and PLD | Experimental | Cohort S1: IV pembrolizumab 200 mg flat dose with IV PLD 30 mg/m2 every 3 weeks.
Reduced Dose Cohort (R1)*: IV pembrolizumab 200 mg flat dose with IV PLD 24 mg/m2 every 3 weeks.
*Subjects will be recruited into the R1 cohort only if DLT is reported in 2 or more subjects during the first 2 cycles of treatment in the first 6 patients of the S1 cohort. | - Chemotherapy Drugs, Cancer
|
Eligibility Criteria
Inclusion Criteria:
1. Have pathological diagnosis of breast cancer, ER positive (%ER+ cells≥1%, Allred score
≥3), Her2 negative subtype, locally advanced (stage III non-operable), or metastatic
(stage IV) disease.
2. Have measurable disease on computed tomography (CT) or positron emission
tomography-computed tomography (PET-CT) scan.
2. Be 18 years of age on day of signing informed consent. 3. Have measurable disease based
on RECIST 1.1. 4. Have Eastern Cooperative Oncology Group (ECOG) Performance Status 0 or 1.
5. Have an estimated life expectancy of at least 3 months. 6. Demonstrate adequate organ
function as defined in Table 1. All screening labs should be performed within 10 days of
treatment initiation.
7. Have received at least two lines of hormonal therapy, one of which had included
aromatase inhibitors.
8. May have received none or up to 2 lines of chemotherapy (excluding any chemotherapy
given in adjuvant or pre-operative-neoadjuvant settings).
9. Have a ≥21-day treatment-free interval from chemotherapeutic treatment. 10. Female
subjects of childbearing potential should have a negative urine or serum pregnancy within
72 hours prior to receiving the first dose of study medication. If the urine test is
positive or cannot be confirmed as negative, a serum pregnancy test will be required.
11. Female subjects of childbearing potential (Section 5.7.2) must be willing to use an
adequate method of contraception as outlined in Section 5.7.2, for the course of the study
through 120 days after the last dose of study medication.
Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception
for the subject.
12. Understanding of study procedures and willingness to comply throughout the entire
course of the study and to provide written informed consent.
Exclusion Criteria:
1. Has known hypersensitivity to the study drugs or to any of their excipients.
2. Has congestive heart failure (New York Heart Association [NYHA] Class IV) or left
ventricular ejection fraction (LVEF) ≤40%.
3. Has chronic obstructive pulmonary disease (COPD) >Stage 3 (forced expiratory volume in
1 second [FEV1] <50%, forced expiratory volume 1/forced vital capacity [FEV1/FVC]
<70%).
4. Has cirrhosis (Child-Pugh Class C score).
5. Has serum albumin level < 2.5 g/dl.
6. Has a known history of HIV (HIV 1/2 antibodies).
7. Has known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA
[qualitative] is detected).
8. Has evidence of active bleeding or bleeding diathesis.
9. Concomitant use of any other chemotherapy (except for PLD) or hormonal therapy during
the study
10. Uncontrolled ascites (defined as 2 or more palliative taps within 30 days of
screening).
11. Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent.
12. Continuous steroid treatment for other than brain metastases requiring daily
corticosteroid dose ≥ 10 mg prednisone or corticosteroid-equivalent per day.
13. Anthracycline treatment (doxorubicin, epirubicin, mitoxantrone, PLD) in metastatic
setting.
14. Less than 6 months from last treatment with anthracyclines in adjuvant or neo-adjuvant
setting.
15. Use of any investigational drug within 28 days prior to study entry.
16. Diagnosis of any other malignancy within 5 years prior to registration, except for
adequately treated basal cell or squamous cell skin cancer, superficial melanoma, or
carcinoma in situ of the breast or of the cervix.
17. Severe gastrointestinal conditions such as clinical or radiological evidence of bowel
obstruction within 4 weeks prior to study entry, or uncontrolled diarrhea in the last
4 weeks prior to enrollment.
18. Is currently participating and receiving study therapy or has participated in a study
of an investigational agent and received study therapy or used an investigational
device within 4 weeks of the first dose of treatment.
19. Has a diagnosis of immunodeficiency or is receiving any immunosuppressive therapy
(except for prednisone ≤10 mg/day or equivalent) within 7 days prior to the first dose
of trial treatment.
20. Has a known history of active Bacillus Tuberculosis.
21. Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study
Day 1 or has not recovered (i.e., ≤ Grade 1 or at baseline) from AEs due to agents
administered more than 4 weeks earlier.
22. Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy
within 3 weeks prior to study Day 1 or has not recovered (i.e., ≤ Grade 1 or at
baseline) from AEs due to a previously administered agent.
Note: Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and may
qualify for the study.
Note: If the subject underwent major surgery, she must have recovered adequately from
the toxicity and/or complications from the intervention prior to starting therapy.
23. Has a known additional malignancy that is progressing or requires active treatment.
Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the
skin or melanoma that have undergone potentially curative therapy or in situ cervical
or bladder cancer.
24. Has known active central nervous system metastases and/or carcinomatous meningitis.
Subjects with previously treated brain metastases are eligible for recruitment
provided they are stable (without evidence of progression by imaging for at least four
weeks prior to the first dose of trial treatment and any neurologic symptoms have
returned to baseline), have no evidence of new or enlarging brain metastases, and may
be receiving dexamethasone at a dose ≤4 mg/day prior to trial treatment. This
exception does not include carcinomatous meningitis which is excluded regardless of
clinical stability.
25. Has active autoimmune disease that has required systemic treatment in the past 2 years
(i.e. with use of disease modifying agents, corticosteroids or immunosuppressive
drugs). Replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a
form of systemic treatment.
26. Has a known history of, or any evidence of active, non-infectious pneumonitis.
27. Has an active serious infection or an active infection requiring systemic therapy.
28. Has a history or current evidence of any condition, therapy, or laboratory abnormality
that might confound the results of the trial, interfere with the subject's
participation for the full duration of the trial, or is not in the best interest of
the subject to participate, in the opinion of the treating investigator.
29. Has a known psychiatric or substance abuse disorders that would interfere with
cooperation with the requirements of the trial.
30. Is pregnant or breastfeeding, or expecting to conceive children within the projected
duration of the trial, starting with the pre-screening or screening visit through 120
days after the last dose of trial treatment.
31. Has received a live vaccine within 30 days of planned start of study therapy. Note:
Seasonal influenza vaccines for injection are generally inactivated flu vaccines and
are allowed; however intranasal influenza vaccines (e.g., Flu-Mist®) are live
attenuated vaccines, and are not allowed.
Maximum Eligible Age: | N/A |
Minimum Eligible Age: | 18 Years |
Eligible Gender: | Female |
Healthy Volunteers: | No |
Primary Outcome Measures
Measure: | To establish a safe dose of PLD when delivered in combination with pembrolizumab |
Time Frame: | At the end of Cycle 2 (day 42), each cyle is 21 days |
Safety Issue: | |
Description: | A dose will be considered safe when the number of Participants With Treatment-Related Adverse Events grades 3 or 4, as assessed by CTCAE v4.0, will be less than 2 per 6-patient cohort. Our hypothesis is that treatment with pembrolizumab will be compatible with the standard recommended dose of PLD, |
Secondary Outcome Measures
Measure: | To evaluate the safety and DLT of the PLD and pembrolizumab combination, as indicated by the number of study participants with treatment-related Adverse Events, and the class of Adverse Events as assessed by CTCAE v4.0. |
Time Frame: | At the end of Cycle 2 (day 42), each cycle is 21 days |
Safety Issue: | |
Description: | The safety profile of PLD and pembrolizumab will be evaluated by the number of study participants with treatment-related Adverse Events, and the class of Adverse Events as assessed by CTCAE v4.0. Our hypothesis is that it will remain unchanged when given in combination, as compared to what expected for each drug alone. |
Measure: | To characterize the PK of PLD when delivered in combination with pembrolizumab, by measuring and comparing the Area under the curve (AUC) for doxorubicin (liposomal) obtained during Cycles 1 and 3. |
Time Frame: | During Cycle 1 (between days 1 and 22), and Cycle 3 (between days 42 and 63), each cycle is 21 days |
Safety Issue: | |
Description: | The PK of PLD will be evaluated by quantitation of doxorubicin (liposomal) in plasma samples and calculation of the AUC. Hypothesis: The PK profile of PLD may be modified by pembrolizumab during the course of therapy due to indirect effects on the mononuclear-phagocyte system (MPS) which plays an important role in PLD clearance. This will translate into a decrease or increase of AUC when the results of the 1st and 3rd cycles are compared. |
Details
Phase: | Phase 1/Phase 2 |
Primary Purpose: | Interventional |
Overall Status: | Recruiting |
Lead Sponsor: | Shaare Zedek Medical Center |
Trial Keywords
- metastatic breast cancer
- immune check point inhibitors
- chemotherapy
- liposomal doxorubicin
- pharmacokinetics
- Anti-PD1 antibodies
Last Updated
October 23, 2020