A pilot randomized, placebo-controlled, double-blind study of omega-3 fatty acids to prevent paclitaxel-associated acute pain syndrome in breast cancer patients: Alliance A22_Pilot2

PURPOSE

Paclitaxel is associated with an acute pain syndrome (P-APS- and chronic chemotherapy-induced peripheral neuropathy (CIPN). P-APS is associated with higher risk of CIPN. Omega-3 fatty acids have well-established anti-inflammatory and neuroprotective properties. The primary purpose of this pilot study was to assess whether omega-3 fatty acids could decrease P-APS and thus CIPN.

METHODS

Patients scheduled to receive weekly paclitaxel for breast cancer were randomized to receive 4 g of omega-3 acid ethyl esters (Lovaza) or placebo, beginning 1 week prior and continued until paclitaxel was stopped. Patients completed acute pain questionnaires at baseline, daily after each treatment, and 1 month after completion of therapy.

RESULTS

Sixty patients (49 evaluable) were randomized to treatment versus placebo. Seventeen (68.0%) patients receiving the omega-3 fatty acids intervention experienced P-APS, compared to 15 (62.5%) of those receiving placebo during the first week of treatment (p = 0.77). Over the full 12-week study, 21 (84.0%) patients receiving the omega-3 fatty acid intervention experienced P-APS, compared to 21 (87.5%) of those receiving placebo (p = 1.0). Secondary outcomes suggested that those in the intervention arm used more over-the-counter analgesics (OR: 1.65, 95% CI: 0.72-3.78, p = 0.23), used more opiates (OR: 2.06, 95% CI: 0.55-7.75, p = 0.28), and experienced higher levels of CIPN (12.8, 95% CI: 7.6-19.4 vs. 8.4, 95% CI: 4.6-13.2, p = 0.21).

CONCLUSIONS

The results of this pilot study do not support further study of the use of omega-3 fatty acids for the prevention of the P-APS and CIPN.

TRIAL REGISTRATION

Number: NCT01821833.

Patient, provider, and nurse preferences regarding patient-reported outcomes (PRO) and side effect management during cancer treatment of minority, rural and economically disadvantaged patients

e18652

Background: Side effects from treatment significantly impact quality of life and patients ability to continue cancer therapy. Patient Reported Outcomes (PRO) tools have been shown to significantly improve multiple key cancer endpoints including overall survival. However, preferences for PRO tool components, such as contact modality, is not well studied in minority, rural and low-income patient populations. As the only National Cancer Institute (NCI) Designated Cancer Center within a 500-mile radius, we care for the urban/rural, multiethnic communities we serve with tremendous cancer health and socioeconomic disparities. This study evaluated patient, provider and nurse perspectives with the goal of optimizing PRO tools for our unique population. Methods: A survey was developed to assess preferred PRO contact modality. Additional survey domains included side effect burden, quality of life, financial hardship and nutritional services accessed. The survey was offered to all patients receiving IV chemotherapy in the center infusion suite from June to August 2020 using the REDCap platform. Providers and nurses (P/N) were surveyed via email. Survey responses were analyzed using SAS 9.4 and compared via chi-square test where appropriate. Results: Ninety patient surveys were collected; 51.1% were minorities (44.4% Hispanic), 35.6% were rural and 40.0% had income < $30,000. All patients had access to a communication device but 12% did not have access to a cell phone of any kind. Device access included 68% smart phone, 20% cell phone, 22% landline, 53% computer, 39% tablet. Patients preferred a response to reported side effects within 0-3 hours (73%) while only 29% of 55 P/N surveyed shared this expectation (p < 0.0001). Almost half (48%) of patients felt side effect management was a moderate or significant issue with 58% experiencing nausea and/or vomiting, 41% diarrhea, 34% weight change, 33% pain, and 22% mucositis. While 72% of patients experienced nutritional related side effects and 95% of P/N preferred to answer nutritional issues by referring to a dietitian, only 9% of patients reported being referred. The majority of patients reported side effect quality of life implications (60.3%) or missed work / were unemployed (82%). Conclusions: In a minority, rural and low-income patient population, 88% of patients had access to a cell phone communication device, with smart phone access in the majority. Patients and P/N reported significantly different expectations regarding side effect management. Our data suggests an underutilization of nutritional referrals by P/N, despite a recognition of value. This study informs the implementation of a PRO tool to address side effects and develop nutritionist referral strategies in minority, rural and low-income patient populations.

Phase 1 trial of a novel, first-in-class G protein-coupled estrogen receptor (GPER) agonist, LNS8801, in patients with advanced or recurrent treatment-refractory solid malignancies

3084

Background: The G protein-coupled estrogen receptor (GPER) is a broadly expressed G protein-coupled receptor that is tumor suppressive. LNS8801 is an oral, highly selective small molecule agonist of GPER. GPER activation results in c-Myc depletion, inhibition of tumor proliferation, and enhancement of tumor immune recognition. Preclinically, LNS8801 demonstrates potent single-agent and combinatorial anti-cancer activity and can overcome established resistance to standard-of-care anti-cancer therapies including immune checkpoint inhibitors. Methods: The primary objective of this phase 1/1B first-in-human, open-label, multicenter study (NCT04130516) was to determine the safety and tolerability and recommended phase 2 dose (RP2D) of LNS8801 in patients (pts) with locally advanced or metastatic solid tumor malignancies, both as monotherapy and in combination with the anti-PD-1 antibody, pembrolizumab. Dose levels were escalated in a 3+3 fashion and included 10, 40 and 125 mg dosed 3/7, 125 mg daily, and 125 and 250 mg twice daily. Dose limiting toxicity (DLT) was defined via NCI CTCAE v5.0 during the first 21 days of treatment. An increase in prolactin over the initial 12 hrs of dosing was measured to assess systemic GPER signaling. Tumor c-Myc expression was measured as a surrogate of treatment-related biologic response. Radiographic response (RECIST v1.1) was evaluated every 8 weeks until progression. Results: 33 pts (19 M/14 F) with median age 58.8 y and 4 (1-9) prior therapies enrolled. Median duration of treatment was 66 d (1–367+). With monotherapy (n = 28), no DLTs, treatment-related SAEs, or treatment-related study discontinuations were observed up through the maximum administered dose (250 mg bid). Possibly related AEs were grade 1 or 2 and did not correlate with dose level. Exposure was above that predicted for efficacy and t1/2 was ̃10 hr at all doses. Of 26 evaluable monotherapy pts, 8 (27%) experienced stable disease (SD) for up to a year. All SD pts had a prolactin response. Among tumors expressing GPER, c-Myc depletion was observed in 100% (5/5) of paired pre and on-treatment biopsies. In the combination cohort (n = 5), 2/2 evaluable pts demonstrated net tumor reductions on initial f/up scans, including one RECIST partial response. Based on PK/PD data, 125 mg daily has provisionally been identified as the monotherapy and combination RP2D. Conclusions: LNS8801 is well tolerated and demonstrates signals of anti-tumor activity when administered both as monotherapy and in combination with pembrolizumab. Confirmation of RP2Ds and updated efficacy data will be presented in June. A phase 2A expansion study to evaluate these RP2Ds in clinical settings of high unmet need is now in development. Clinical trial information: NCT04130516.

Phase I study of SEA-CD40, gemcitabine, nab-paclitaxel, and pembrolizumab in patients (pts) with metastatic pancreatic ductal adenocarcinoma (PDAC) (trial in progress)

TPS451

Background: SEA-CD40 is an investigational non-fucosylated, humanized IgG1 monoclonal antibody directed against CD40, a co-stimulatory receptor expressed on antigen-presenting cells (APCs). Activation of CD40 on APCs upregulates cytokine production and co-stimulatory receptors, enhancing tumor antigen presentation to T cells. Preclinical data indicate that treatment of PDAC with chemotherapy in conjunction with a CD40 agonist could enhance antigen presentation and initiate an antitumor immune response (Byrne KT and Vonderheide RH, Cell Rep 2016;15, 2719–2732). A Phase 1 study (SGNS40-001) is evaluating SEA-CD40 monotherapy and in combination with other agents in pts with advanced solid or hematologic malignancies. A cohort is enrolling to evaluate the combination of SEA-CD40, gemcitabine, nab-paclitaxel, and pembrolizumab in PDAC. Methods: The cohort consists of pts with metastatic PDAC who have had no prior therapy for metastatic disease. Pts must be ≥18 years old, with (neo)adjuvant therapy completed > 4 months prior to enrollment; ECOG status ≤1; adequate renal, hepatic, and hematologic function; and measurable disease per RECIST v 1.1 criteria. A standard regimen of gemcitabine and nab-paclitaxel on Days 1, 8, and 15 of each 28-day cycle is administered with SEA-CD40 IV on Day 3. Pembrolizumab is administered every 42 days starting on Day 8. The primary objective is to evaluate antitumor activity; secondary objectives are to evaluate safety and tolerability and SEA-CD40 and pembrolizumab pharmacokinetics. Efficacy endpoints are confirmed RECIST objective response rate per investigator (primary), disease control rate (response or stable disease ≥16 weeks), duration of response, progression-free survival, and overall survival. Disease is assessed every 8 weeks using RECIST and immune-based RECIST (iRECIST). Treatment continues until unacceptable toxicity, progressive disease per iRECIST, consent withdrawal, or study closure, whichever occurs first. Assessment of dose-limiting toxicity will occur initially in groups of 6 pts to identify the recommended phase 2 dose of SEA-CD40 for the cohort. Enrollment to this cohort began in November 2019. Clinical trial information: NCT02376699.

Results of a phase II randomized trial of cisplatin +/- veliparib in metastatic triple-negative breast cancer (TNBC) and/or germline BRCA-associated breast cancer (SWOG S1416)

1001

Background: PARP inhibitors(i) are effective in BRCA-mutation -associated metastatic breast cancer(MBC). However, there are no studies evaluating PARPi + platin chemotherapy in BRCA wild-type(wt) TNBC. Approximately 1/2 of BRCAwt TNBC demonstrate homologous recombination deficiency (HRD) resulting in a BRCA-like phenotype which might render them sensitive to PARPi. S1416 compared the efficacy of cisplatin plus PARPi veliparib (Vel) or placebo (P) in 3 groups of MBC: gBRCA+; BRCA-like; and non-BRCA-like. Methods: Patients (pts) with metastatic TNBC or g BRCA1/2-associated MBC, who had received < 1 line of prior therapy were treated with cisplatin (75mg/m2) plus Vel or P (300 mg po BID days 1-14), every 3 weeks. All pts underwent central gBRCA testing. A priori established multipronged biomarker panel was used to classify BRCAwt pts into BRCA-like and non-BRCA-like groups, and included myChoice HRD score, somatic BRCA1/2 mutations, BRCA1 methylation and non- BRCA1/2 HR germline mutations. Primary end-point was progression-free survival (PFS) in the three pre-defined groups; secondary end-points included objective response rate (ORR), overall survival (OS), toxicity. Results: 323/335 randomized pts were eligible for efficacy evaluation; 31% had received 1 prior chemotherapy for MBC. 248 pts were classified into the three groups: (1) 37 gBRCA+ (2) 101 BRCA-like; (3) 110 non- BRCA-like. Remaining 75 could not be classified due to missing biomarker information. In the gBRCA+ group (which reached 62% of its projected accrual), numerically better PFS was noted with Vel compared to P (HR=0.64; p=0.26) though this difference was not statistically significant. In BRCA-like group improved PFS was noted with Vel vs P (median PFS 5.7 vs 4.3 months HR=0.58; p=0.023, 1 years PFS 20% vs 7%). Numerically better OS (median OS 13.7 vs 12.1 months, HR=0.66; p=0.14) and ORR (45% vs 35%, p=0.38) were noted with Vel vs P in BRCA-like group. Non-BRCA-like group did not show benefit of veliparib for PFS (HR=0.85; p=0.43) neither did the unclassified group (HR=0.97). Grade 3/4 neutropenia (46% vs 19%) and anemia (23% vs 7%) occurred at higher frequency in Vel arm compared to P. Conclusions: Addition of Vel to cisplatin significantly improved PFS and showed a trend towards improved OS for BRCA-like advanced TNBC. Integral biomarkers used in this study identified a subgroup of BRCAwt TNBC who benefited from addition of PARPi to cisplatin; platinum plus PARPi combination should be explored further in BRCA-like TNBC. Clinical trial information: NCT02595905 .

A pilot randomized, placebo-controlled, double-blind study of omega-3 fatty acids to prevent paclitaxel-associated acute pain syndrome

e24115

Background: Paclitaxel, a widely used chemotherapeutic agent, is associated with an acute pain syndrome (P-APS) and chronic chemotherapy-induced peripheral neuropathy (CIPN). Currently, there is no standard of care for P-APS. Commonly used analgesics, including NSAIDs and narcotics, have considerable toxicity profiles. Omega-3 fatty acids, a common dietary supplement, have well established anti-inflammatory and neuroprotective properties. The primary aim of the study was to assess if omega 3 fatty acids could prevent P-APS. Methods: Patients scheduled to receive weekly paclitaxel (70-90mg/m2) were randomized to receive 4 g of omega-3 acid ethyl esters (Lovaza) or placebo, beginning 1 week prior to starting paclitaxel and continued until paclitaxel was discontinued. Patients completed acute pain questionnaires at baseline, Days 2-7, prior to each subsequent treatment and one month after completion of therapy. The EORTC- QLQ CIPN 20 questionnaire was completed prior to each dose of paclitaxel and 1 month after completion. The primary objective was to compare the effect of omega 3 fatty acids, versus placebo, on the maximum pain score for the week following the 1st treatment and each subsequent paclitaxel treatment, and to compare pain medication use between the 2 arms. The secondary objective was to compare the effect of the intervention on the severity of CIPN. Results: 49 patients were randomized to treatment versus placebo. Linear mixed effects models were applied with the addition of a bootstrap approach to overcome limitations in the distributional assumptions to compare outcomes between treatment groups. Placebo results were similar to the reported natural history of P-APS. There was no significant difference in trends over time between the 2 groups in the maximum pain score at week 1 (p = .14) and over 12 weeks (p = .21). There was also no difference noted in the rates of use of over the counter analgesics (p = .39) and narcotics (p = .46). CIPN results did not differ between the 2 groups (p = .08). Conclusions: The results of this pilot study do not support the use of omega-3 fatty acids for the prevention of paclitaxel-associated pain syndrome. Clinical trial information: NCT01821833 .

SGNLVA-002: Single-arm, open label phase Ib/II study of ladiratuzumab vedotin (LV) in combination with pembrolizumab for first-line treatment of patients with unresectable locally advanced or metastatic triple-negative breast cancer

TPS1110

Background: There are currently no curative treatments for patients with metastatic triple-negative breast cancer (mTNBC), and prognosis for this disease is very poor. Emerging treatment combinations of anti-programmed death ligand 1 (PD-L1) agents with chemotherapy have shown promise in mTNBC. SGN-LIV1A, or ladiratuzumab vedotin (LV), is a novel investigational humanized IgG1 antibody-drug conjugate (ADC) directed against LIV-1, which is highly expressed in breast cancer cells. LV mediates delivery of monomethyl auristatin E (MMAE), which drives antitumor activity through cytotoxic cell killing and induces immunogenic cell death (ICD). Preliminary results from an ongoing phase 1 study of LV monotherapy has shown LV to be well tolerated and to have encouraging antitumor activity in patients with mTNBC. Combining LV and pembrolizumab may result in complementary, as well as synergistic, activity through LV-induced ICD that creates a microenvironment favorable for enhanced anti-PD-L1 activity. Methods: This single-arm, open-label, phase 1b/2 study evaluates the safety and antitumor activity of LV in combination with pembrolizumab as first-line therapy for patients with unresectable locally advanced or mTNBC (NCT03310957, 2017-002289-35). Patients must have measureable disease per RECIST v1.1, an ECOG score of 0 or 1, and no prior cytotoxic or anti-PD-L1 treatment for advanced disease. This study has 2 parts that are enrolling sequentially: a dose-finding phase that starts at LV 2.5 mg/kg + pembrolizumab 200 mg intravenously every three weeks, and a dose expansion phase. The primary objectives are to evaluate the safety/tolerability and objective response rate of LV + pembrolizumab, and identify the recommended phase 2 dose of LV. The secondary objectives are to assess duration of response, disease control rate, progression-free survival, and overall survival. Additional objectives include assessing PD-L1 and LIV-1 expression-response relationship. Study enrollment is ongoing in the US and EU. Clinical trial information: NCT03310957.

Tucatinib, palbociclib, and letrozole in HR+/HER2+ metastatic breast cancer: Report of phase IB safety cohort

1029

Background: Based on preclinical synergy, we are conducting a phase IB/II clinical trial of tucatinib (HER2 small molecule inhibitor, T), palbociclib (CDK4/6 inhibitor, P) and letrozole (aromatase inhibitor, L) in HR+/HER2+ metastatic breast cancer (MBC). Methods: Post-menopausal, or pre-menopausal women on ovarian suppression, with prior ≥2 HER2 inhibitors at any time of disease; ≥1 HER2 inhibitor for MBC or front line bone/soft tissue only disease are eligible provided ≤2 endocrine agents for MBC. Prior CDK4/6 or HER2 small molecule inhibitors are not allowed. Treatment entails T 300 mg BID, P 125 mg/day 21 days on, 7 days off, and L 2.5 mg/day. Safety was assessed using CTCAE v.4.03 with standard definitions for dose limiting toxicity (DLT). Dose reductions of T and / or P for DLTs, and discontinuation of either P or L for toxicity were allowed at any time during the study. Safety thresholds were set as DLTs in ≤7/20 pts for T, ≤15/20 pts for P, or ≤14/20 pts attributable to both T and P. Results: Phase Ib enrolled 20 pts from 11/16/17 to 12/5/18. The median age is 53y (22-70y), median number of prior lines of MBC therapy is 2 (0-5). 70% of pts have visceral disease and 45% CNS disease. Prior treatment includes 100% of pts with trastuzumab and pertuzumab, and 45% of pts with prior TDM-1. One pt required dose reduction of T; 9 (45%) had dose reduction and 2 (10%) discontinued P for DLTs. One pt discontinued L. Safety boundaries were not crossed. The most common grade (G) ≥3 toxicities were neutropenia (G3 55%, G4 15%), diarrhea (G3 20%), infections (G3 20%), thrombocytopenia (G3 10%) and mucositis (G3 10%). The frequency and type of toxicities were consistent with those previously reported for each single agent. PK analysis showed no interaction between P and T. As of 1/4/19, 14 pts (70%) remain on study (5 pts for ≥6 months) and 6 pts removed for progression. No withdrawals for toxicity and no deaths on study. The longest time on study (ongoing) is 10 months for pts without CNS disease, and 6 months for pts with CNS disease. Conclusions: T, P, L combination showed an acceptable safety profile and encouraging antitumor activity. RP2D of T is 300mg PO BID in combination with full doses of P and L. Enrollment in phase II cohort is ongoing. Clinical trial information: NCT03054363.

Circulating biomarkers in patients receiving neoadjuvant chemotherapy combined with sunitinib for locally advanced breast cancer

1089

Background: Biomarkers to guide the use of antiangiogenic therapy are lacking. Circulating endothelial cells (CECs) and their progenitor cells (CEPs) are increased in cancer patients. VCAM is an endothelial protein increased in response to VEGF stimulation, while CAIX is elevated in states of hypoxia; both correlate with tumor aggressiveness. Methods: We examined these circulating biomarkers in a phase II neoadjuvant trial in 63 patients (pts) with locally advanced HER2 negative breast cancer treated with 12 weeks (wks) of paclitaxel (T) plus sunitinib (S) followed by 15 wks of daily oral cyclophosphamide and weekly doxorubicin plus daily G-CSF (AC+G-CSF). Toxicity and clinical outcomes are reported as a separate abstract. Blood was collected at baseline, wk 12 and pre-surgery. For this analysis, responders were defined as patients with a pathologic complete response (pCR) and/or MDACC CPS+EG score ≤ 2 (a validated score combining clinical and pathologic results for predicting survival in the neoadjuvant setting). Plasma VCAM and CAIX levels were measured by ELISA using commercially available validated kits and CEC/CEPs by flow cytometry in our laboratory as previously published. Results: 28 (44%) pts were responders. CECs decreased significantly in response to T+S (p = 0.04) but not further with AC+G-CSF. No significant changes were seen in CEPs. VCAM and CAIX levels increased in pts with baseline levels below the median in response to T+S (VCAM p = 0.0003, CAIX p = 0.009). ER negative tumors had higher levels of plasma VCAM and CAIX at baseline compared to ER positive tumors (VCAM p = 0.01, CAIX p = 0.1). Lower baseline levels of VCAM and CAIX were associated with both response and pCR. VCAM and CAIX levels were correlated at baseline (r = 0.4, p = 0.01). Conclusions: CEC, VCAM, and CAIX levels significantly changed after treatment with T + S. Higher baseline levels of VCAM and CAIX were associated with ER negative tumors and lower response rates. Our results suggest that elevated baseline VCAM and CAIX levels are associated with more aggressive biology, and may correspond to less (not more) favorable outcome with the addition of a targeted antiangiogenic agent. Clinical trial information: NCT00513695.

A phase II study evaluating the safety and efficacy of sunitinib with weekly paclitaxel followed by doxorubicin and daily oral cyclophosphamide plus G-CSF as neoadjuvant chemotherapy (NC) for locally advanced (LABC) or inflammatory breast cancer (IBC)

1090

Background: Sunitinib (S) is an oral tyrosine kinase inhibitor with anti-tumor and anti-angiogenic activity. The primary objective of this trial was to assess the pathologic complete response rate (pCR) in patients (pts) treated with NC consisting of S with weekly paclitaxel (T) followed by doxorubicin and daily oral cyclophosphamide plus G-CSF (AC+G-CSF). Correlative studies including circulating biomarkers are reported separately. Methods: Pts with HER2 negative LABC or IBC were eligible for this multicenter, phase II trial. Pts received S 25 mg po daily with T 80 mg/m2 IV Qweek (wk) x 12 wks, then AC+G-CSF (doxorubicin 24 mg/m2 IV Qwk + oral cyclophosphamide 60 mg/m2po daily + G-CSF 5 mcg/kg SC days 2-7) x 15 wks. pCR in the breast and axilla was assessed at surgery, and the MDACC CPS+EG score (validated score combining clinical and pathologic results for predicting survival in the neoadjuvant setting) was calculated. Results: 70 pts (ages 33-79) were enrolled; 68 received protocol therapy. 37 (53%) had ER and/or PR positive tumors. 2 patients were unevaluable (hypersensitivity to T, toxicity possibly related to S) and 3 withdrew consent prior to surgery. 61 pts reported any grade AE in S+P period. Among grade 3 or 4 AEs, neutropenia was most common in S+P period occurring in 31/68 (46%). pCR in the breast was observed in 27% (17/63, 95% CI 17%-40%) and breast and axilla in 15/63 (24%). In pts with ER positive tumors, pCR rate in breast was 8/34 (24%) and 9/29 (31%) for pts with ER negative tumors. 18 evaluable pts (29%) had CPS+EG scores ≤2, 40 (63%) had CPS+EG scores of ≥3, and 5 had insufficient information to calculate the CPS+EG score. When response was defined as pCR and/or CPS+EG score ≤ 2, 28 pts (44%) were responders. Conclusions: NC with T+S followed by AC+G-CSF was well tolerated. Using a combined definition of response of pCR and/or CPS+EG score ≤2, 28/63 (44%) pts had response; 19/34 (56%) for ER positive and 9/29 (31%) for ER negative disease. The addition of S to NC may result in promising incremental benefit for pts with ER positive breast cancer. Clinical trial information: NCT00513695.