Fulvestrant and/or Anastrozole in Treating Postmenopausal Patients With Stage II-III Breast Cancer Undergoing Surgery
- Clements University Hospital
Alternate Approaches for Clinical Stage II or III Estrogen Receptor Positive Breast Cancer Neoadjuvant Treatment (ALTERNATE) in Postmenopausal Women: A Phase III Study
This randomized phase III trial has several primary objectives. One primary objective is to compare the efficacy of 3 different endocrine therapies, the estrogen receptor down regulator fulvestrant and the aromatase inhibitor anastrozole, either alone or in combination, in reducing cancer growth before surgery (neoadjuvant) in postmenopausal women with clinical stage II-III estrogen receptor positive and HER2 negative breast cancer. Another primary objective is to evaluate whether patients who achieved a modified PEPI (Preoperative Endocrine Prognostic Index) score of 0, defined by tumor size <5 cm, N0, Ki67<2.7% (by central testing), at surgery post 6 months of neoadjuvant endocrine therapy predict excellent long term outcome, for whom chemotherapy is unnecessary.
Patients will be randomized to one of three treatment groups: anastrozole, fulvestrant or
the combination of anastrozole and fulvestrant. Each cycle is 28 days for a total of 6
cycles. Surgery must be performed between days 15-28 of Cycle 6 in each treatment arm.
Patients who are determined to have an endocrine resistant tumor at week 4 or week 12 will
discontinue endocrine protocol therapy. It is recommended that patients be switched to
After completion of surgery, those with a modified preoperative endocrine prognostic index (PEPI) score of 0 will continue assigned endocrine treatment for 4.5 years and those with a non-zero PEPI score will receive adjuvant chemotherapy +/- endocrine therapy chosen by treating physician.
The primary and secondary objectives for the study are described below.
1. To determine whether fulvestrant administered for 24 weeks as neoadjuvant endocrine treatment decreases the proportion of endocrine resistant tumors** relative to patients treated with anastrozole.
2. To determine whether fulvestrant in combination with anastrozole, administered for 24 weeks as neoadjuvant endocrine treatment, decreases the proportion of endocrine resistant tumors relative to patients treated with anastrozole.
3. To assess whether the 5 year RFS rate among women with a modified preoperative endocrine prognostic index (PEPI) score of 0 following 24 weeks of neoadjuvant anastrozole treatment is at least 95%.
4. To assess whether the 5 year RFS rate among women with a modified PEPI score of 0 following 24 weeks of neoadjuvant fulvestrant, or fulvestrant in combination with anastrozole, is at least 95%. Note that this objective will only be tested if the selected fulvestrant arm was shown to be superior to anastrozole in objective 1 or 2.
Endocrine resistant tumor is defined by any one of the following criteria**:
- Ki67> 10% after 4 weeks on neoadjuvant endocrine therapy
- Ki67> 10% after 12 weeks on neoadjuvant endocrine therapy
- Progressive disease is documented anytime during neoadjuvant endocrine therapy
- Surgical findings at 22-24 weeks post neoadjuvant endocrine therapy are such that:
- pT stage is 3/4
- positive lymph nodes are present or Ki67 > 2.7% (ie modified PEPI score of not being 0)
- Discontinued neoadjuvant endocrine treatment for any reason
1. To assess whether the 5 year RFS rate among women with a preoperative endocrine prognostic index PEPI score of 0 following 24 weeks of neoadjuvant anastrozole treatment is at least 95%.
2. To examine the differences in surgical outcome, clinical and radiological response rates, and safety profile between the fulvestrant arm and the anastrozole arm.
3. To examine the differences in surgical outcome, clinical and radiological response rates, and safety profile between patients randomized to fulvestrant in combination with anastrozole and those randomized to anastrozole.
4. To examine the rate of pathologic complete response (pCR) of 12 weeks of neoadjuvant paclitaxel in patients with endocrine resistant disease following 4 weeks or 12 weeks of neoadjuvant endocrine therapy with either fulvestrant or anastrozole or the combination of fulvestrant and anastrozole.
5. To examine the rate of pathologic complete response (pCR) among those patients with endocrine resistant disease, following 4 weeks or 12 weeks of neoadjuvant endocrine therapy (with either fulvestrant or anastrozole or the combination of fulvestrant and anastrozole), who choose not to receive neoadjuvant paclitaxel, but another standard neoadjuvant taxane and/or anthracycline containing regimen or CMF.
6. To summarize the frequency of severe (NCI CTCAE grade > 3) adverse events encountered with administration of paclitaxel in the neoadjuvant setting.
7. To assess RFS for patients with endocrine resistant tumors defined as: 1) Ki67 > 10% at week 4, 2) Ki67 > 10% at week 12 and 3) modified PEPI score of non-zero on neoadjuvant endocrine therapy, with all three groups combined or separated.
1. Female ≥18 years of age
2. Eastern Cooperative Oncology Group (ECOG) performance status 0-2
3. Postmenopausal, verified by:
- post bilateral surgical oophorectomy or
- no spontaneous menses ≥ 1 year or
- no menses for < 1 year with follicle-stimulating hormone (FSH) and estradiol levels in postmenopausal range, according to institutional standards
4. Pathologic confirmation of invasive breast cancer diagnosed by core needle biopsy
5. Clinical T2-T4c, any N, M0 invasive breast cancer, by AJCC 7th edition clinical staging, with the goal being surgery to complete excision of the tumor in the breast and the lymph node. The extent of disease is a solitary lesion where the lesion is:
- its size can be measured bidimensional by tape, ruler or caliper technique and
- its largest tumor diameter is at least 2.0 cm (that is considered measurable by the WHO criteria)
- Patients with contralateral ductal carcinoma in situ and/or invasive breast cancer are not eligible.
- Patients with multifocal/multi-lesional breast cancer are not eligible if more than one lesion is invasive breast cancer in the same breast.
6. Invasive breast cancer is estrogen receptor positive with an Allred score of 6, 7 or 8 by local institution standard protocol. If an Allred Score is not reported on the diagnostic pathology report, ER positivity in > 66% cells is eligible. If ER positivity is < 66%, the staining intensity (weak, intermediate, strong) is needed to calculate the Allred Score to determine eligibility.
7. Invasive breast cancer is Human Epidermal Growth Factor Receptor 2 (HER2) negative defined as 0 or 1+ by immunohistochemistry (IHC) or with a fluorescence in situ hybridization (FISH) ratio (HER2 gene copy/chromosome 17) < 2 if IHC 2+ by local institution standard protocol.
8. Documentation of mammogram and ultrasound (including ductal carcinoma in situ (DCIS) and invasive cancer) of the diseased breast performed within 42 days prior to registration. Mammogram for the unaffected contralateral breast is required within 12 months prior to registration.
9. Laboratory values ≤ 14 days prior to registration:
1. Absolute Neutrophil Count (ANC) > 1000/mm^3
2. Platelet Count > 100,000/mm^3
3. Total Bilirubin < 1.5 x upper limits of normal (ULN)
4. Creatinine < 1.5 x ULN
5. Serum alanine transaminase (ALT) < 2.5 x ULN
10. Tissue acquisition: Patient must agree to provide the required research biopsies at baseline, week 4 and at surgery for biomarker and correlative studies.
1. Premenopausal status
2. Inflammatory breast cancer defined as clinically significant erythema of the breast and/or documented dermal lymphatic invasion (not direct skin invasion by tumor or peau d' orange without erythema).
3. An excisional biopsy of this breast cancer.
4. Hormone replacement therapy of any type, megestrol acetate, or raloxifene within one week prior to registration.
5. Tumor estrogen receptor (ER) Allred score between 0-5 or HER2 positive by IHC (3+) or amplified by FISH > 2.0.
6. Surgical axillary staging procedure prior to study entry. Note: Fine needle aspiration (FNA) or core needle biopsy of axillary node is permitted.
7. Clinical or radiographic evidence of metastatic disease. Metastatic workup is not required, but is recommended for patients with clinical stage III disease. Note: Isolated ipsilateral supraclavicular node involvement is permitted.
8. Breast implants are contraindicated only if the implant precludes the required research biopsies. Patients who have previously had implants removed within 6 weeks prior to registration are eligible.
9. Treatment for this cancer including surgery, radiation therapy, chemotherapy, biotherapy, hormonal therapy or investigational agent prior to study entry.
10. History of invasive breast cancer or contralateral DCIS.