Description:
This is an open label, randomized, multicenter study evaluating the activity of lasofoxifene
relative to fulvestrant for the treatment of pre- and postmenopausal women with locally
advanced or metastatic ER+/HER2- breast cancer with an acquired ESR1 mutation and who have
disease progression on an aromatase inhibitor (AI) in combination with a cyclin dependent
kinase (CDK) 4/6 inhibitor.
The primary objective is to evaluate the progression free survival (PFS) of 5 mg lasofoxifene
relative to fulvestrant for the treatment of pre- and postmenopausal women with locally
advanced or metastatic estrogen receptor positive (ER+)/human epidermal growth factor 2
negative (HER2-) breast cancer with an estrogen receptor 1 (ESR1) mutation.
The secondary objectives are to evaluate:
1. Clinical benefit rate (CBR) and Objective Response Rate (ORR)
2. Duration of response
3. Time to response
4. Overall Survival (OS)
5. Pharmacokinetics of lasofoxifene
6. Quality of life (QoL): Quality of Life (QoL): vaginal assessment scale (VAS) and vulvar
assessment scale (VuAS) questionnaires
7. Safety of lasofoxifene
8. Response to various ESR1 mutation (Y537S, Y537C, D538G, E380Q, S463P, V534E, P535H,
L536H, L536P, L536R, L536Q, or Y537N).
Title
- Brief Title: Evaluation of Lasofoxifene Versus Fulvestrant in Advanced or Metastatic ER+/HER2- Breast Cancer With an ESR1 Mutation
- Official Title: An Open-Label, Randomized, Multicenter Study Evaluating the Activity of Lasofoxifene Relative to Fulvestrant for the Treatment of Pre- and Postmenopausal Women With Locally Advanced or Metastatic ER+/HER2- Breast Cancer With an ESR1 Mutation
Clinical Trial IDs
- ORG STUDY ID:
SMX 18001
- NCT ID:
NCT03781063
Conditions
- Locally Advanced or Metastatic Breast Cancer
Interventions
Drug | Synonyms | Arms |
---|
Lasofoxifene | | Lasofoxifene |
Fulvestrant | | Fulvestrant |
Purpose
This is an open label, randomized, multicenter study evaluating the activity of lasofoxifene
relative to fulvestrant for the treatment of pre- and postmenopausal women with locally
advanced or metastatic ER+/HER2- breast cancer with an acquired ESR1 mutation and who have
disease progression on an aromatase inhibitor (AI) in combination with a cyclin dependent
kinase (CDK) 4/6 inhibitor.
The primary objective is to evaluate the progression free survival (PFS) of 5 mg lasofoxifene
relative to fulvestrant for the treatment of pre- and postmenopausal women with locally
advanced or metastatic estrogen receptor positive (ER+)/human epidermal growth factor 2
negative (HER2-) breast cancer with an estrogen receptor 1 (ESR1) mutation.
The secondary objectives are to evaluate:
1. Clinical benefit rate (CBR) and Objective Response Rate (ORR)
2. Duration of response
3. Time to response
4. Overall Survival (OS)
5. Pharmacokinetics of lasofoxifene
6. Quality of life (QoL): Quality of Life (QoL): vaginal assessment scale (VAS) and vulvar
assessment scale (VuAS) questionnaires
7. Safety of lasofoxifene
8. Response to various ESR1 mutation (Y537S, Y537C, D538G, E380Q, S463P, V534E, P535H,
L536H, L536P, L536R, L536Q, or Y537N).
Detailed Description
Lasofoxifene is a potent SERM that has demonstrated in non-clinical models to prevent and
treat breast cancer. In a large clinical osteoporosis trial, lasofoxifene reduced the
incidence of ER+ breast cancer, which most likely represents a beneficial effect on
clinically undetectable breast cancer. The clinical and non-clinical results are not
unexpected based on the results seen with tamoxifen and fulvestrant as the mechanisms of
action are similar. Moreover, the safety profile of lasofoxifene is well established in
postmenopausal women and therefore a clinical trial investigating lasofoxifene for the
treatment of breast cancer is scientifically justifiable.
Subjects with ESR1 mutations have endocrine resistance and shorter time to progression when
treated with currently approved endocrine therapy. There is an unmet medical need for
endocrine agents that can provide greater efficacy in this population. Non-clinical in vitro
and in vivo studies with lasofoxifene have demonstrated efficacy. If this benefit translates
to subjects with ESR1 mutated breast cancer cells, an important treatment option beyond
fulvestrant will be available. The population being recruited in this trial are subjects with
advanced breast cancer who have been treated with an AI in combination with a
cyclin-dependent kinase (CDK) 4/6 inhibitor and who have an ESR1 mutation. The efficacy of
endocrine agents in this population has never been prospectively studied. For this reason,
this study will evaluate lasofoxifene in a randomized Phase 2 trial against a comparator to
better evaluate the magnitude of the effect as well as to provide data to estimate the Phase
3 sample size.
In both non-clinical and clinical studies, fulvestrant has shown activity in ESR1 mutated
breast cancer cells and will be used as the comparator in this Phase 2 study to better
determine the relative clinical efficacy of lasofoxifene. The FDA approved fulvestrant dose
will be used.
A major limiting factor in the administration of fulvestrant is its poor solubility requiring
IM injection. The volume of administration limits the dose that can be administered. Initial
clinical trials administered 250 mg of fulvestrant in 5 cc of castor oil as a single
injection once monthly. Because the IM injections were well tolerated, loading and higher
doses were investigated. This was found to have acceptable tolerability and resulted in
greater efficacy. Limited by the volume of administration higher doses of fulvestrant cannot
be investigated further.
Once the subject has consented to participate in the study, screening tests will be performed
within 30 days of enrollment.
All subjects meeting the eligibility criteria will be first stratified into those with
visceral metastasis and those without visceral metastasis. Each of these stratified groups
will then be further stratified into those with the Y537S ESR1 mutation and those without
this particular mutation. Each of the stratified groups will then be randomized 1:1 to
receive either 5 mg/d of oral lasofoxifene or fulvestrant 500 mg intramuscular (IM) on Days
1, 15, and 29, then every 4 weeks thereafter. Treatment will continue until radiographic or
clinical evidence of disease progression. Enrolled subjects will be seen every 2 weeks for
the first month of treatment and then monthly until progression. Efficacy assessments will be
done every 8 weeks.
For subjects randomized to lasofoxifene, blood samples will be drawn to assess the population
PK. Serum samples will be collected at each visit starting at Visit 0 (Day 1) through
Final/ET visit to measure serum lasofoxifene concentration at time points outlined below.
Serum samples for PK analysis will be collected before the time that the next lasofoxifene
dose is ingested. The actual time and date of dosing on the previous day as well as dosing on
the visit day, and the PK blood sampling time/date must be recorded for all subjects.
Pharmacokinetic samples are to be collected before clinical lab blood sampling.
A maximum of 100 subjects will be randomized and it is expected that all subjects enrolled in
the study will be treated until documented disease progression. It is estimated that full
recruitment into the study will occur within 12 to 18 months with another 12 months of follow
up before the primary outcome measure is analyzed.
Trial Arms
Name | Type | Description | Interventions |
---|
Lasofoxifene | Experimental | 5 mg/d of oral lasofoxifene | |
Fulvestrant | Active Comparator | 500 mg fulvestrant intramuscular (IM) | |
Eligibility Criteria
Inclusion Criteria:
1. Pre- or postmenopausal.
Postmenopausal women are defined as:
1. ≥60 years of age with no vaginal bleeding over the prior year, or
2. <60 years with "premature menopause" or "premature ovarian failure" manifest
itself with secondary amenorrhea for at least 1 year and follicle stimulating
hormone (FSH) and estradiol levels in the postmenopausal range according to
institutional standards, or
3. surgical menopause with bilateral oophorectomy. Note: premenopausal women who
meet all of the other entry criteria must be maintained on ovarian suppression
(such as Lupron) during the study and subjects counseled to use appropriate
contraception to prevent pregnancy.
2. If possible, a biopsy of metastatic breast cancer tissue will be obtained to provide
histological or cytological confirmation of ER+ and HER2- disease as assessed by a
local laboratory, according to the American Society of Clinical Oncology/College of
American Pathologists (ASCO/CAP) guidelines, using slides, paraffin blocks, or
paraffin samples. If a biopsy is not possible, the ER and HER2 status from the tissue
obtained at the time of the original diagnosis must confirm that the subject's cancer
is ER+ and HER2-.
3. Locally advanced or metastatic breast cancer with radiological or clinical evidence of
progression on an AI in combination with a CDK 4/6 inhibitor for advanced breast
cancer with demonstrated prior sensitivity to endocrine therapy (recurrence or
progression after at least 12 months of treatment in the metastatic setting).
4. Locally advanced or metastatic breast cancer with either measurable (according to
RECIST 1.1) or non-measurable lesions.
5. At least one or more of the following point ESR1 mutations as assessed in cell-free
circulating tumor DNA (ctDNA) obtained from a blood (plasma) or tissue sample: Y537S,
Y537C, D538G, E380Q, S463P, V534E, P535H, L536H, L536P, L536R, L536Q, or Y537N. The
ctDNA sample collection must be obtained within 30 days prior to randomization to
determine eligibility and baseline. Note: a prior genomic test confirming that the
subject has an ESR1 mutation can be used to determine eligibility; however, an ESR1
sample must also be collected within 30 days of randomization.
6. Subjects who have not received cytotoxic chemotherapy or those who have received one
cytotoxic chemotherapy regimen in the neo-adjuvant or adjuvant setting prior to entry
into the trial and/or no more than one chemotherapy regimen for metastatic breast
cancer. Subjects must be free of all chemotherapy acute toxicity excluding alopecia
and Grade II peripheral neuropathy before study entry.
7. ECOG performance score of 0 or 1.
8. Adequate organ function as shown by:
1. absolute neutrophil count (ANC) >/=1,500 cells/mm3
2. platelet count ≤100,000 cells/mm3
3. hemoglobin >/=9.0 g/dl
4. ALT and AST levels ≤2.5 upper limit of normal (ULN) or ≤5 in the presence of
visceral metastasis
5. total serum bilirubin ≤1.5 X ULN (≤ 3 X ULN for subjects known to have Gilbert
Syndrome)
6. alkaline phosphatase level ≤ 2.5 X ULN
7. creatinine clearance of 40 ml/min or greater as calculated by the Cockcroft-Gault
formula
8. International normalized ratio (INR), activated partial thromboplastin (aPTT), or
partial thromboplastin time (PTT) <2.0 X ULN.
9. Able to swallow tablets.
10. Able to understand and voluntarily sign a written informed consent before any
screening procedures.
Exclusion Criteria:
1. Prior use of everolimus or other mammalian target of rapamycin (mTOR) inhibitor or
phosphoinositide 3-kinase inhibitor (PI3K) inhibitors is excluded unless discontinued
to reasons other than disease progression.
2. Presence of brain metastasis.
3. Lymphangitic carcinomatosis involving the lung.
4. Impending visceral crisis in need of cytotoxic chemotherapy as assessed by the
investigator.
5. Radiotherapy within 30 days prior to randomization except in case of localized
radiotherapy for analgesic purposes or for lytic lesions at risk of fracture, which
can then be completed within 7 days prior to randomization. Subjects must have
recovered from radiotherapy toxicities prior to randomization.
6. History of long QTC syndrome or a QTC of >480 ms.
7. History of a pulmonary embolus (PE) or deep vein thrombosis (DVT) within the last 6
months or any known thrombophilia. Subjects stable on anti-coagulants for maintenance
are eligible as long as the DVT and/or PE occurred >6 months prior to enrollment and
there is no evidence for active thrombosis. The use of low dose ASA is permitted.
8. Any significant co-morbidity that would impact the study or the subject's safety.
9. History of a positive human immunodeficiency virus (HIV), hepatitis B virus (HBV) or
hepatitis C virus (HCV) at Screening. Subjects cured of hepatitis C (no viral load)
are eligible.
10. History of malignancy within the past 5 years (excluding breast cancer), except basal
cell or squamous cell carcinoma of the skin curatively treated by surgery, or early
stage cervical cancer.
11. History of vaginal bleeding over the last year unless it is documented that the
bleeding was due to non-uterine causes (e.g. vaginal atrophy).
12. Uncontrolled hypertension defined as sitting systolic pressure >160 mm Hg or diastolic
pressure >100 mm Hg at Screening.
13. History of non-compliance to medical regimens.
14. Unwilling or unable to comply with the protocol.
15. Current participation in any clinical research trial involving an investigational drug
or device within the last 30 days.
Maximum Eligible Age: | N/A |
Minimum Eligible Age: | 18 Years |
Eligible Gender: | Female |
Healthy Volunteers: | No |
Primary Outcome Measures
Measure: | Progression-Free Survival (PFS) |
Time Frame: | through study completion, an average of 1 year |
Safety Issue: | |
Description: | PFS is defined as the interval from the date of randomization to the earlier date of first documented radiographic progression or death due to any cause |
Secondary Outcome Measures
Measure: | Clinical Benefit Rate (CBR) |
Time Frame: | through study completion, an average of 1 year |
Safety Issue: | |
Description: | CBR is defined as the percentage of all subjects with a complete or partial response; or stable disease for >/=24 weeks. |
Measure: | Objective Response Rate (ORR) |
Time Frame: | through study completion, an average of 1 year |
Safety Issue: | |
Description: | ORR is defined as the percentage of subjects with either a complete response (CR) or a partial response (PR) as assessed by the RECIST 1.1 criteria. |
Measure: | Overall Survival (OS) |
Time Frame: | through study completion, an average of 1 year |
Safety Issue: | |
Description: | OS is defined as time from randomization to death due to any cause. |
Measure: | Incidence of Adverse Events (AEs) and Serious AEs |
Time Frame: | through study completion, an average of 1 year |
Safety Issue: | |
Description: | The type, severity (graded by Common Terminology Criteria for Adverse Events [CTCAE version 5.0]), course, duration, seriousness, and relationship to study treatment will be assess at each visit |
Details
Phase: | Phase 2 |
Primary Purpose: | Interventional |
Overall Status: | Active, not recruiting |
Lead Sponsor: | Sermonix Pharmaceuticals Inc. |
Trial Keywords
- Locally Advanced Breast Cancer
- Metastatic Breast Cancer
- Lasofoxifene
- Fulvestrant
- ER+/HER2
- ESR1 mutation
Last Updated
August 26, 2021