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GEICAM-Trial: English Summary - LEA

Multicenter, randomized study to evaluate the efficacy and safety of Bevacizumab in combination with endocrine treatment compared to endocrine treatment alone, in postmenopausal women with advanced or metastatic breast cancer with indication of hormontherapy as first-line treatment

Current Status: open for accrual

LEA (Letrozol/Fulvestrant and Avastin) (GEICAM 2006-11) GBG 51

Trial Design

Muticenter, multinational, randomized, open label, phase III clinical trial.

Treatment

The patients will be randomized to receive one of the following treatment arms:

Group A: 1st line endocrine treatment with letrozole 2.5mg orally/day or fulvestrant 250mg i.m. injection every 4 weeks according to manufactures recommendation

Group B: 1st line endocrine treatment with letrozole or fulvestrant and bevacizumab: 15 mg/Kg i.v. on day 1 every 3 weeks.

In group B, Bevacizumab will be administered every 21 days (day 1 of cycle 2 will be day 22 of the treatment).

The patients will receive the assigned treatment until the progression of the disease, unacceptable toxicity or withdrawal of the consent. Those patients in treatment with bevacizumab who end the study without having progressed will continue to receive the drug out of the study.

Patient population

Inclusion criteria

1. Before starting the specific protocol procedures, the written informed consent must be obtained and documented.
2. Women ≥ 18 years.
3. Capacity to comply with all the protocol requirements.
4. Functional ECOG status of 0 or 1.
5. Life expectancy ≥ 24 weeks.
6. Postmenopausal patients with histologically confirmed breast adenocarcinoma, with measurable or non-measurable, locally advanced or metastatic (stage IV) disease. In the event that the patient only has locally advanced disease, she will not be able to undergo curative local treatment. Patients with metastasis confined to the bone can be chosen, but the disease must be confirmed by radiology, CT scan or NMR if there is any doubt after a single bone scan.
7. Patients with HER2-negative disease evaluated by IHC and FISH/CISH (IHC 0 or 1+, or 2+ and negative FISH). Patients with 3+ by IHC cannot be chosen regardless of the FISH/CISH status and those with positive FISH/CISH (≥ 2 amplifications) cannot be chosen either, regardless of the IHC findings.
8. Positive hormone receptors (estrogen receptor [ER] and/or progesterone receptor [PgR]) evaluated by a local or central laboratory, according to the criteria of the participating institution.
9. Patients who are candidates for receiving first-line treatment with letrozole.
10. Patients may have received (neo)adjuvant chemotherapy, provided that the last dose of the latter was received at least 12 months before randomization. Patients must have recovered from toxicity.
11. The patients are allowed to have received adjuvant radiotherapy, provided that it was completed at least 6 weeks before randomization and the patient has recovered from the reversible acute effects of the radiation. The previous administration of radiotherapy to palliate the pain of bone metastases is authorized, provided that:
    • Not more than 30% of bone marrow has been irradiated.
    • The patient has recovered from the reversible acute effects of the radiation.
    • The patient has at least one metastatic location which has not been irradiated and which may be evaluated for progression, or a clear progression of the bone disease has been objectified after the end of the palliative radiotherapy.
12. The patients may have received previous (neo)adjuvant hormonotherapy provided that they are considered to be candidates to first-line hormonotherapy with letrozole. They may also have received previous adjuvant treatment with an aromatase inhibitor provided that it ended at least 12 months before randomization.
13. The treatment with bisphosphonates is allowed and recommended for patients with bone metastases. Whenever it is possible, the treatment should be started before or within the 4 weeks of starting the study therapy. The patients starting treatment with bisphosphonates must be carefully evaluated so that they do not mask the progression of the disease.
14. In the patients with heart failure risk (e.g. previously treated with ≥ 360mg/m2 of doxorubicin or equivalent doses of other anthracyclines), the LVEF must be determined by means of an echocardiogram or radionuclide ventriculography (MUGA), and it must be ≥ the lower limit of normal.

Exclusion criteria

1. Evolutionary disease requiring an immediate treatment with cytotoxic chemotherapy according to the investigator's judgment.
2. Patients with locally advanced breast cancer who are expected to undergo surgery or curative radiotherapy.
3. Patient in treatment with anticoagulant therapy.
4. Previous chemotherapy for the metastatic disease. Patients may have received neoadjuvant chemotherapy or neoadjuvant hormonotherapy with curative intention as a part or as an alternative to an adjuvant treatment. For the previous neoadjuvant hormonotherapy the same premises than for the adjunvant hormonotherapy are valid.
5. Previous therapy with anti-VEGF or VEGFR tyrosine-kinase inhibitors.
6. History of another pathology that may affect the development of the protocol or the interpretation of results. It is considered that patients who have suffered from a skin carcinoma that is not melanoma, cervical carcinoma in situ or another neoplasia treated with a curative intention and with a disease-free interval exceeding 5 years can be chosen.
7. Evidence of CNS metastasis. A CT scan or brain NMR must be done within the 4 weeks before the randomization in case of suspecting brain metastasis.
8. History of peripheral neurophaty NCI CTCAE grade >2 at the time of randomization.
9. Patients subjected to major surgical procedures, open biopsies or those having significant trauma injuries within the 28 days prior to randomization, or patients who are expected to undergo a major surgical procedure that must necessarily be performed within the course of the study.
10. Minor surgical procedures in the 7 days prior to randomization.
11. Unsuitable bone marrow supply: ANC < 1.5 x 10⁹/L, platelets < 100 x 10⁹/L or Hb < 10 g/dL
12. Impaired liver function: total bilirubin total > 1.5 x ULN, AST and ALT > 2.5 x ULN (> 5 x ULN in patients with liver metastases).
13. Impaired kidney function:
    • Serum creatinine > 2.0 mg/dL or 177 µmol/L.
    • Proteinuria determined by reactive strip ≥ 2+. A 24h determination of proteins in urine will be requested for the patients with ≥ 2+ in the baseline analysis and must have a protein figure ≤ 1 g/24 h.
14. Chronic treatment with oral corticoids (dose ≥ 10 mg/day of methylprednisolone or equivalent): the use of inhaled corticoids is allowed.
15. Chronic treatment with acetylsalicylic acid (> 325 mg/day) or clopidogrel (> 75 mg/day).
16. Uncontrolled arterial hypertension (systolic > 150 mm Hg and/or diastolic > 100 mm Hg) or clinically significant cardiovascular disease: for example CVA (in the 6 months prior to randomization), coronaropathy or history of AMI in the last 6 months, unstable angina, congestive heart failure of grade ≥ II of the New York Heart Association (NYHA) or severe heart arrhythmias which are not controlled with medication or which can potentially interfere with the study treatment.
17. History or evidence of hemorrhagic diathesis or coagulopathy with bleeding risk.
18. History of abdominal fistula, gastrointestinal perforation or intra-abdominal abcess in the 6 months prior to randomization.
19. Active infection requiring i.v. antibiotics at the time of randomization.
20. Unhealed wounds, active peptic ulcer, esophageal varices.
21. Any other disease, psychological or metabolic alteration, found in the physical or laboratory examination, providing reasonable indications for suspecting a disease or complaint for which the use of any of the study drugs are contraindicated, or which may affect the patient's compliance with the routine procedures of the study or which places the patient at a high risk of experiencing complications related to the treatment.
22. Current or recent (within 30 days prior to that start of the study treatment) treatment with another drug under investigation or participation in another investigation study.
23. Known hypersensitivity to any of the study drugs or their components.
24. Hypersensitivity to the products of Chinese hamster ovary cells or to other human or humanized recombinant antibodies.

Main Objective

• To compare the progression-free survival (PFS) between both treatment arms.

Secondary Objectives

To compare the following parameters between both treatment arms:

• Overall survival (OS)
• Time to treatment failure (TTF)
• Better response to treatment (RR)
• Response duration (RD)
• Clinical benefit proportion (CBP = CR + PR + SD > 6 months)
• Safety and tolerance

Tertiary Objectives

• Biomarkers to investigate the efficacy, safety and action mechanism of bevacizumab, and potential interactions between the tumor expression of VEGFA/VEGFR (KDR-1) and hormone receptor processes will be studied.

Primary Endpoint

Any progression of disease or disease related death.

Study Report

As stated previously, both bevacizumab and aromatase inhibitors have shown a high activity and an acceptable and manageable toxicity profile in the treatment of patients with locally advanced or metastatic breast cancer. It has also been suggested that estrogens modulates the angiogenesis induced by VEGF in pathological and physiological conditions. Clinical data suggest, that the downregulation of VEGF may be able to overcome resistance to hormonal therapy and thus improve efficacy to hormonal therapy. Therefore, a combination of endocrine therapy and an antibody against VEGF such as bevacizumab can be more effective than endocrine therapy as a single agent alone. In the neoadjuvant setting the combination of bevacizumab and letrozole has been evaluated in 43 patients demonstrating efficacy and feasibility. In a similar study in metastatic breast cancer by Falkson et al. (ASCO 2008 (58)) patients with different endocrine treatments (letrozol, fulvestrant, exemestane) were treated in combination with BEV to evaluate time to treatment failure as well as safety. The most often used endocrine therapies were letrozol (30%) followed by fulvestrant and exemestane.

This study proposes evaluating the activity and safety profile of the combination of bevacizumab and endocrine treatment compared with endocrine treatment alone, as first-line treatment for postmenopausal women with positive hormone receptor and negative HER2 status. As some patients may have received aromatase inhibitors in the adjuvant setting, fulvestrant, an estrogen receptor downregulator, can also be administered as endocrine therapy according the physicians decision.

Likewise, and in those women who give their specific consent, biomarkers will be investigated for the purpose of aiding and improving the understanding of the efficacy, safety and action mechanism of bevacizumab, and potential interactions between the tumor expression of VEGF-A/VEGFR (KDR-1) and hormone receptor processes will be studied.

Reference

Traina TA, Rugo H, Caravelli j, Yeh B, Panageas K, Bruckner J, et al. Letrozole (L) with bevacizumab is feasible in patients (pts) with hormone receptor-positive metastatic breast cancer (MBC). J Cin Oncol 2006;24(18S):3050(abstr.).

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• Study Group: German Breast Group
• Sponsor: GRUPO ESPAÑOL DE INVESTIGACIÓN EN CÁNCER DE MAMA (GEICAM)
• Study Chairs: Dr. med. habil. S. Loibl, Dr. Miguel Martín, Dr. Juan de la Haba
• Clinical Project Management: Dr. Silvia Gimeno
• Datamanagement / Biometry: Keyur Mehta
• Enrolment period: Q IV 2007 - Q IV 2010
• Estimated Follow up: 24 months
• Proposed accrual: 378

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