Description:
This is an open-label, multi-center, phase I study designed to assess the maximum tolerated
dose of ribociclib and belinostat in combination. The trial will open with a dose escalation
followed by an expansion cohort at the identified dose. Dose escalation will be open to the
enrollment of patients diagnosed with triple-negative breast cancer or ovarian cancer. Dose
expansion will only be open to patients diagnosed with triple-negative breast cancer.
Title
- Brief Title: Ribociclib&Belinostat In Patients w Metastatic Triple Neg Breast Cancer & Recurrent Ovarian Cancer w Response Prediction By Genomics
- Official Title: A Phase I/Ib Trial of the CDK4/6 Antagonist Ribociclib And The HDAC Inhibitor Belinostat In Patients With Metastatic Triple Negative Breast Cancer And Recurrent Ovarian Cancer With Response Prediction By Genomics (CHARGE)
Clinical Trial IDs
- ORG STUDY ID:
HCI130492
- NCT ID:
NCT04315233
Conditions
- Metastatic Breast Cancer
- Recurrent Ovarian Carcinoma
Interventions
Drug | Synonyms | Arms |
---|
Ribociclib | | Treatment: all patients |
Belinostat | | Treatment: all patients |
Purpose
This is an open-label, multi-center, phase I study designed to assess the maximum tolerated
dose of ribociclib and belinostat in combination. The trial will open with a dose escalation
followed by an expansion cohort at the identified dose. Dose escalation will be open to the
enrollment of patients diagnosed with triple-negative breast cancer or ovarian cancer. Dose
expansion will only be open to patients diagnosed with triple-negative breast cancer.
Detailed Description
We hypothesize that ribociclib plus belinostat will be a well-tolerated and demonstrate
activity in women with metastatic triple-negative breast or recurrent ovarian cancers.
This trial combines two targeted agents, a CDK inhibitor and a lysine deacetylase (DAC)
inhibitor for use as the first targeted treatment for metastatic triple-negative breast
cancer. This in itself would be a leap forward for women who currently endure sequential
treatment with cytotoxic chemotherapies. However, we will also be using samples from this
trial in NIH-funded research on clonal evolution and geographic heterogeneity in breast
cancer. Blockade of CDK4/6 and of lysine deacetylases (DAC) are both promising treatments for
breast cancer. DAC inhibitors have been shown to have single-agent activity against
triple-negative breast cancer in vivo, possibly through decreasing EMT, decreasing migration,
and decreasing metastasis [6, 7] CDK4/6 inhibitor monotherapy causes cell cycle arrest and
tumor regression in triple-negative breast cancer models. [8, 9] However, neither approach
has been successfully translated into clinical use as a monotherapy.
There are several lines of evidence demonstrating that inhibiting DAC increases the
sensitivity of breast cancer to CDK4/6 inhibition. Recently, we showed that inhibitors of
cell cycle progression, including CDKN1A, CDKN1C, CDKN2B, and CDKN2D, are increased by DAC
inhibition in breast cancer cell lines, including triple-negative cell lines. [10] Others
have shown cell cycle arrest by DAC inhibitors due to increases in p21 or decreases in CDK2
and cyclin A. [11-13] We also see an increase in RB1 expression in breast cancer cell lines.
In the TCGA breast cancer analysis, RB1 was frequently down-regulated but not mutated or lost
in triple-negative breast cancer. [14] Therefore, we hypothesized that DAC inhibition would
increase the sensitivity of breast cancer to CDK4/6 inhibition. We first tested this
hypothesis in a small panel of cell lines. We showed and published that all showed synergy
between a CDK4/6 inhibitor (PD-0322991) and DAC inhibitors. [10] Since then, we have tested
the combination of the DAC inhibitor vorinostat and the CDK4/6 inhibitor PD-322991 in a
larger panel of cell lines and have shown at least additivity in most triple-negative cell
lines. Indeed, it seems that those cancers least sensitive to CDK4/6 inhibition may benefit
the most from co-treatment with a DAC inhibitor.
Recently, we investigated ribociclib and belinostat in six triple-negative breast cancer cell
lines. All 6 cell lines showed growth inhibition with belinostat and panobinostat. Synergy
was seen in four of the six cell lines at multiple doses.
We have also recently completed an analysis on a window of opportunity trial of the DAC
inhibitor high-dose valproic acid, in breast cancer.[15] In that study, women were treated
with valproic acid for one week before definitive therapy began. Fifty percent of women with
triple-negative breast cancers had a significant decrease in Ki-67 with one week of valproic
acid, providing proof of principle biologic activity of DAC inhibition in triple-negative
breast cancer. (By contrast, no HER2 positive tumor had a decrease in Ki-67 with valproic
acid treatment.) Given the genomic similarities between serous ovarian cancer and
triple-negative breast cancer seen in the TCGA and pan-cancer analyses [16], we have chosen
to include ovarian cancers in the dose-escalation component to increase accrual rate but not
in the dose-expansion.
Neither CDK4/6 inhibition nor DAC inhibition have a well-defined predictive biomarker to
determine which cancers will respond and which will not. Because of the complex genomic
effects of inhibition of the 11 DACs and the multiple targets of DACs, including histones,
p53, etc, it is unlikely that a single gene or protein alteration will predict sensitivity.
We have published a method for predicting sensitivity to targeted drugs using genome-wide
gene expression analysis. [17] After demonstrating proof of principle by accurately
predicting sensitivity to vemurafenib, we developed a genomic biomarker for the DAC inhibitor
valproic acid. We then validated that this biomarker predicted sensitivity in vitro and in
vivo. In the window of opportunity discussed above, our genomic signature had an AUC of 0.66
for predicting decreased Ki-67 with one week of treatment with valproic acid. We will develop
a similar multi-gene gene expression based biomarker for the combination of ribociclib and
belinostat.
Trial Arms
Name | Type | Description | Interventions |
---|
Treatment: all patients | Experimental | Ribociclib and belinostat will be given at escalating doses and on multiple administration schedules throughout the dose escalation component of the study. The MTD identified in the dose escalation component will be used to define the dose and administration schedule used in the dose expansion. | |
Eligibility Criteria
Inclusion Criteria:
For dose escalation cohorts only:
- Pathologically confirmed breast cancer with the following features:
- Measurable disease by RECIST 1.1;
- ER and PR ≤ 1% by immunohistochemistry;
- Her-2/neu negative (0 or 1+ by immunohistochemistry OR not-amplified by CAP/ASCO
standards);
- Metastatic or unresectable and locally advanced and not amenable to treatment with
curative intent, in the opinion of the enrolling investigator.
OR --Pathologically confirmed serous ovarian cancer that is recurrent and is unresectable,
in the opinion of the enrolling investigator.
For dose expansion cohort only:
- Pathologically confirmed breast cancer with the following features:
- Measurable disease by RECIST 1.1;
- ER and PR ≤ 1% by immunohistochemistry;
- Her-2/neu negative (0 or 1+ by immunohistochemistry OR not-amplified by CAP/ASCO
standards);
- Metastatic or unresectable and locally advanced and not amenable to treatment with
curative intent, in the opinion of the enrolling investigator.
For all patients:
- Age ≥ 18.
- ECOG performance Status ≤ 2.
- Able to swallow pills.
- Adequate organ function as defined as:
- Hematologic:
- ANC > 1,500/mm3
- Platelets > 100,000/mm3
- Hemoglobin > 9g/dL
- Hepatic:
- Serum bilirubin levels ≤1.5 mg/dL. Higher levels are acceptable if these can
be attributed to active hemolysis or ineffective erythropoiesis. Bilirubin
above 1.5mg/dL due to Gilbert's is still excluded.
- Serum aspartate transaminase (AST) and serum alanine transaminase (ALT) ≤
2.5 X upper limit of normal.
- AST(SGOT)/ALT(SGPT) ≤ 5 × institutional ULN for patients with liver
metastasis.
- Alkaline phosphatase < 2.5 X upper limit of normal, unless bone metastasis
is present in the absence of liver metastasis
- Renal:
- Serum creatinine levels ≤1.5 mg/dL
- Patient must have the following laboratory values within normal limits or
corrected to within normal limits with supplements before the first dose of
study medication:
- Potassium
- Magnesium
- Total Calcium (corrected for serum albumin)
- Coagulation ---INR ≤1.5 (unless the patient is receiving anticoagulants and the
INR is within the therapeutic range of intended use for that anticoagulant within
7 days prior to the first dose of study drug)
- Presence of ≥ 1 metastatic sites of disease that can be safely accessed for biopsy and
patient willingness to undergo fresh tissue biopsies of up to 3 lesions.
- Negative serum or urine pregnancy test at screening for women of childbearing
potential.
- Agrees to continue use of approved birth control for at least 6 months after receiving
the last dose of study drugs. See section 7.3 for list of approved birth control
methods.
- Able to provide informed consent and have signed an approved consent form that
conforms to federal and institutional guidelines.
Exclusion Criteria:
- Previous use of CDK 4/6 or HDAC inhibitors for cancer treatment
- Major surgery, radiotherapy, anticancer therapy, or investigational agents ≤ 4 weeks
of treatment day 1 or ≤5 half-lives, whichever is shorter.
- Patients with new or progressive brain metastases (active brain metastases) or
leptomeningeal disease unless determined by the treating physician that immediate CNS
specific treatment is not required and is unlikely to be required during the first
cycle of therapy.
- Medical condition that in the opinion of the enrolling investigator would require the
use of valproic acid within ≤ 5 days of the first dose of belinostat or while on
study.
- Active infection requiring systemic therapy.
- History of allergy or hypersensitivity to belinostat, ribociclib, or their binders.
- Uncontrolled arrhythmia, congestive heart failure or angina. Patients who have had a
myocardial infarction, symptomatic pericarditis, or cardiac surgery should be at least
6 months from the event and free of active symptoms
- Known left ventricular ejection fraction < 50%. (Echocardiogram is not required for
study entry)
- Clinically significant cardiac arrhythmias (e.g., ventricular tachycardia), complete
left bundle branch block, high-grade AV block (e.g., bifascicular block, Mobitz type
II and third degree AV block)
- Congenital long QT syndrome.
- Baseline QTcF>450 msec. The heart rate on the qualifying ECG must be between 50 and 90
BPM.
- Concurrent use of medication known to inhibit UGT1A1. Patients currently taking these
medications must have discontinued ≥7 days prior to treatment day 1.
- Concurrent use of herbal supplements, unless approved by the prinicipal investigator.
Patients currently taking herbal supplements must have discontinued ≥ 7 days prior to
treatment day 1.
- Concurrent use of medication with a known risk of inducing Torsades de Pointes (on the
known risk list of crediblemeds.org) that cannot be discontinued or switched to a
different medication ≥ 7 days prior to starting the study drug.
- Unresolved diarrhea ≥ Grade 2, per CTCAE v5.0.
- Use of any of the following substances ≤ 7 days prior to the start of the treatment:
- Known strong and moderate inducers or inhibitors of CYP3A4/5, including
grapefruit, grapefruit hybrids, pomelos, star-fruit, and Seville oranges.
- Medications that have a narrow therapeutic window and are predominantly
metabolized through CYP3A4/5.
- Patient is currently receiving warfarin or other coumarin derived anti-coagulant, for
treatment, prophylaxis or otherwise.
--Note: Therapy with heparin, low molecular weight heparin (LMWH), an oral factor Xa
inhibitor, an oral direct thrombin inhibitor, or fondaparinux is allowed.
- Impaired GI function that may alter absorption of medicines, such as uncontrolled
inflammatory bowel disease, uncontrolled vomiting, or major stomach or small bowel
resection.
- Pregnant or breast feeding
- Women of child-bearing potential defined as all women physiologically capable of
becoming pregnant or men whose female partner is of child-bearing potential, unless
they are using highly effective methods of contraception during the study treatment
and for 6 months after stopping the treatment. Highly effective contraception methods
include:
- Total abstinence (when this is in line with the preferred and usual lifestyle of
the patient. Periodic abstinence (e.g., calendar, ovulation, symptothermal,
post-ovulation methods) and withdrawal are not acceptable methods of
contraception
- Female sterilization (have had surgical bilateral oophorectomy with or without
hysterectomy), total hysterectomy or tubal ligation at least 6 weeks before
taking study treatment. In case of oophorectomy alone, only when the reproductive
status of the woman has been confirmed by follow up hormone level assessment
- Male partner sterilization (at least 6 months prior to screening). For female
patients on the study, the vasectomized male partner should be the sole partner
for that patient and the success of the vasectomy must be medically confirmed as
per local practice.
- Placement of an intrauterine device (IUD).
- Use of hormonal contraception plus a barrier contraceptive.
- Known HIV infection with a detectable viral load within 6 months of the anticipated
start of treatment.
Note: Patients on effective anti-retroviral therapy with an undetectable viral load within
6 months of the anticipated start of treatment are eligible for this trial.
- Known chronic hepatitis B virus (HBV) or hepatitis C virus infection with a detectable
viral load.
--Note: Patients with an undetectable HBV viral load on appropriate suppressive
therapy are eligible. Patients with an undetectable HCV viral load are eligible.
- Malignancy other than breast carcinoma or ovarian cancer (dose escalation) anticipated
to need systemic treatment within 1 year in the opinion of the enrolling investigator.
Maximum Eligible Age: | N/A |
Minimum Eligible Age: | 18 Years |
Eligible Gender: | All |
Healthy Volunteers: | No |
Primary Outcome Measures
Measure: | MTD of ribociclib and belinostat combination |
Time Frame: | C1D1 to C2D1 (each cycle is 28 days) |
Safety Issue: | |
Description: | incidence of DLTs during the defined DLT period |
Secondary Outcome Measures
Measure: | frequency and characterization of AEs and SAEs |
Time Frame: | 36 months |
Safety Issue: | |
Description: | safety of ribociclib and belinostat combination |
Measure: | Progression Free Survival (PFS) |
Time Frame: | 36 months |
Safety Issue: | |
Description: | assess efficacy |
Measure: | Objective Response Rate (ORR) |
Time Frame: | 36 months |
Safety Issue: | |
Description: | assess efficacy |
Details
Phase: | Phase 1 |
Primary Purpose: | Interventional |
Overall Status: | Recruiting |
Lead Sponsor: | University of Utah |
Last Updated
November 10, 2020