Targeting Triple Negative BREAst Cancer Metabolism With a Combination of Chemoimmunotherapy and a FASTing-like Approach in the Preoperative Setting: the BREAKFAST 2 Trial

Breast Cancer Clinical Trial

— BREAKFAST-2  

Official title:

Targeting Triple Negative BREAst Cancer Metabolism With a Combination of Chemoimmunotherapy and a FASTing-like Approach in the Preoperative Setting: the BREAKFAST 2 Trial

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT05763992
• Other study ID #: INT214/22
• Status: Recruiting
• Phase: Phase 2
• Start date: May 15, 2023
• Est. completion date: May 15, 2026

Study information

• Verified date: December 2022
• Source: Fondazione IRCCS Istituto Nazionale dei Tumori, Milano
• Contact: Claudio Vernieri, MD, PhD
• Phone: 0223903066
• Email: claudio.vernieri[@]istitutotumori.mi.it; claudio.vernieri[@]ifom.eu
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Italian, multicenter, open-label, two-arm, comparative, randomized phase II study investigating if the addition of the experimental metabolic intervention consisting in cycles of Fasting-Like Approach, as administered every three weeks up to a maximum of 8 consecutive cycles, is able to increase the anticancer activity of standard preoperative chemo-immunotherapy in patients with localized invasive Triple Negative Breast Cancer.

Description:

TNBC is the most aggressive subtype of breast cancer. TNBC patients who achieve pCR during neoadjuvant chemo-immunotherapy have significantly lower rates of disease recurrence or death. Preclinical studies indicate that combining nutrient starvation, in the form of cycles of FLA, with anthracycline- or platinum-based chemotherapy remarkably increases the therapeutic index of chemotherapy against murine and human models of breast cancer, including models of TNBC. In particular, the chemotherapy-fasting/FLA combination increases the anticancer activity of chemotherapy, while reducing treatment-related adverse events (AEs). Moreover, the FLA has demonstrated potent and desirable immunomodulatory effects both in in vivo studies and in patients with cancer, and the activation of antitumor immunity is a crucial mediator of the anticancer effects of the FLA, either alone or in combination with chemotherapy. Therefore, there is a strong biological rationale to combine cyclic FLA with ICIs in cancer therapy.

Based on these data, we hypothesize that combining the FLA with standard-of-care, preoperative, anthracycline-taxane-carboplatin chemotherapy plus Pembrolizumab can increase the rate of pCR in a population of patients with stage II-III TNBC.

This is an Italian, multicenter, open-label, two-arm, comparative, randomized phase II study. This study is designed to investigate if the addition if the experimental metabolic intervention consisting in cycles of FLA, as administered every three weeks up to a maximum of 8 consecutive cycles, is able to increase the anticancer activity of standard preoperative chemo-immunotherapy consisting of antracycline-taxane-carboplatin-based chemotherapy plus pembrolizumab in patients with treatment naïve, localized (tumor stage T1c AND nodal stage N1-2, or tumor stage T2-4 AND nodal stage N0-2) invasive Triple Negative Breast Cancer (HER2 negative, ER <1%, PgR <1%). Bilateral and/or multifocal primary tumor is allowed, as well as inflammatory breast cancer, and the tumor with the most advanced T stage should be used to assess the eligibility. If multi-focal/multi-centric disease, TNBC needs to be confirmed for each focus. The primary study endpoint is pathologic complete response (pCR).

Patients will be randomly allocated to one of the following treatment arms:

• Arm A (control arm): 12 consecutive cycles of weekly paclitaxel plus carboplatin (PCb) combined with 4 triweekly cycles of Pembrolizumab, followed by 4 consecutive cycles of triweekly anthracycline (doxorubicin or epirubicin)-cyclophosphamide (AC or EC) chemotherapy combined with 4 triweekly cycles of Pembrolizumab. This combination treatment will be further referred to as "standard treatment".

• Arm B (experimental arm): standard treatment in combination with up to a maximum of 8 consecutive triweekly cycles of 5-day FLA.

Enrolled patients will be randomized in a 1:1 ratio and stratified according to a) disease stage: stage II (T1N1, T2N0, T2N1, T3N0) vs. stage III (T3N1; any T4; any N2); b) patient body mass index (BMI ≥25 kg/m2 vs <25 kg/m2).

After completion of the experimental preoperative protocol, patients will undergo surgery between 14 and 28 days after the last chemotherapy administration.

After surgery, patients will receive 9 additional triweekly pembrolizumab administration at the same dosage, and regardless of the pathologic tumor response (pCR yes vs. no). After surgery, patients may receive local radiotherapy, depending on the pathological stage and according to local and international guidelines.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 145
• Est. completion date: May 15, 2026
• Est. primary completion date: May 15, 2025
• Accepts healthy volunteers: No
• Gender: Female
• Age group: 18 Years to 75 Years

Eligibility

Inclusion Criteria:

1. Female sex

2. Age = 18 and = 75 years.

3. Evidence of a personally signed and dated informed consent document (ICD), signed and dated from the patient of legal representative with or without an impartial witness, indicating that the patient has been informed of all pertinent aspects of the study before enrollment

4. Willingness and ability to comply with the prescribed FLA regimen, the scheduled visits, treatment plans, laboratory tests and other procedures.

5. Histologically confirmed diagnosis of invasive TNBC candidate to neoadjuvant chemo-immunotherapy and subsequent curative surgery. On the basis of International Guidelines, TNBC is defined by absent or minimal (<1%) expression of oestrogen and progesterone receptors at IHC, and absence of HER2 protein over-expression and HER2 gene amplification, as defined as an IHC score of 0, 1+, or an IHC score of 2+ with in situ hybridization (ISH) analysis excluding HER2 gene amplification. The expression of hormone receptors (ER and PgR) and HER2 will be evaluated through immunohistochemistry (IHC), according to International Guidelines47,48

6. Availability of a formalin-fixed, paraffin-embedded (FFPE) block containing tumor tissue, or at least 7 unstained tumor slides.

7. Patients with tumor stage T1c AND nodal stage N1-2, or tumor stage T2-4 AND nodal stage N0-2 according to TNM.

8. Presence of an Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1.

9. Presence of adequate bone marrow and organ function as defined by the following laboratory values:

1. ANC = 1.5 x 103/l

2. platelets = 100 x 103/l

3. hemoglobin = 9.0 g/dl

4. calcium (corrected for serum albumin) within normal limits or = grade 1 according to NCI-CTCAE version 5.0 if not clinically significant

5. potassium within the normal limits, or corrected with supplements

6. creatinine < 1.5 ULN

7. blood uric acid < 10 mg/dl

8. ALT and AST = 2 x ULN

9. total bilirubin < 1.5 ULN except for patients with Gilbert syndrome who may only be included if the total bilirubin is < 3.0 x ULN or direct bilirubin < 1.5 x ULN

10. Fasting glucose = 250 mg/dl.

10. Female patients of childbearing potential must agree to sexual abstinence or to use two highly effective methods of contraception throughout the study and for at least six months after the end of the FLA. Abstinence is only acceptable if it is in line with the preferred and usual lifestyle of the patient. Examples of contraceptive methods with a failure rate of < 1% per year include tubal ligation, male sterilization, hormonal implants, established, proper use of combined oral or injected hormonal contraceptives, and certain intrauterine devices. Alternatively, two methods (e.g., two barrier methods such as a condom and a cervical cap) may be combined to achieve a failure rate of < 1% per year. Barrier methods must always be supplemented with the use of a spermicide. A patient is of childbearing potential if, in the opinion of the Investigator, she is biologically capable of having children and is sexually active.

11. Female patients are not of childbearing potential if they meet at least one of the following criteria:

1. Have undergone a documented hysterectomy and/or bilateral oophorectomy

2. Have medically confirmed ovarian failure

3. Achieved post-menopausal status, defined as: = 12 months of non-therapy-induced amenorrhea or surgically sterile (absence of ovaries); in women <45 years of age FSH level in the postmenopausal range may be used to confirm a post-menopausal state in women not using hormonal contraception or hormonal replacement therapy.

Exclusion Criteria:

1. Prior systemic treatment for breast cancer or other malignancies within 5 years of treatment enrollment, except for adequately treated basal cell or squamous skin cancer or in situ cervical cancer. Other malignancies diagnosed more than 5 years before the diagnosis of breast cancer must have been radically treated without evidence of relapse at the moment of patient enrollment in the trial.

2. Prior treatment with anthracyclines

3. Prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent or with an agent directed to another co-inhibitory T-cell receptor (e.g., CTLA-4, OX-40, CD137)

4. Body mass index (BMI) < 19 kg/m2.

5. History of alcohol abuse.

6. Non-intentional weight loss = 5% in the previous 3 months, unless the patient has a BMI > 22 kg/m2 and weight loss has been lower than 10% at the time of enrollment in the study; or non-intentional weight loss of = 10% in the previous 3 months, unless the patient has a BMI > 25 kg/m2 and weight loss has been lower than 15% at the time of the enrollment in the study. In both cases, weight must have been stable for at least one month before study enrollment.

7. Active pregnancy or breast feeding.

8. Known active B or C hepatitis or human immunodeficiency virus (HIV) infection, or occasional finding of active hepatitis B/C infection during screening tests before chemotherapy initiation, as defined as positive polymerase chain reaction (PCR) testing for HBV-DNA and HCV-RNA and qualitative PCR for HIV-RNA, or requiring active treatment at study enrollment.

9. Serious infections in the previous 4 weeks before the FLA initiation, including, but not limited to, potential hospitalizations for complications of infections, bacteriemia or serious pneumonitis.

10. Active autoimmune diseases requiring systemic treatments (e.g., systemic steroids or immune suppressants). Replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency) is not considered a form of systemic treatment.

11. Active chronic therapy with systemic steroids at a dose = 10 mg per day of prednisone or equivalent at study enrollment.

12. Diagnosis of type 1 or 2 diabetes mellitus requiring pharmacologic therapy (including, but not limited to, insulin or insulin secretagogues), with the exception of metformin. A diagnosis of type 2 diabetes mellitus not requiring pharmacological treatments, or only requiring treatment with metformin, based on the judgment of a diabetologist, is compatible with patient enrollment in the trial.

13. Anamnesis of clinically significant heart disease including:

1. angina pectoris, coronary bypass, symptomatic pericarditis, myocardial infarction in the previous 12 months from the beginning of experimental therapy;

2. congestive heart failure (NYHA III-IV).

14. Anamnesis of clinically meaningful cardiac arrhythmias, such as ventricular tachycardia, chronic atrial fibrillation, complete bundle branch block, high grade atrio-ventricular block like bi-fascicular block, type II Mobitz and third grade atrio-ventricular block, nodal arrhythmias, supra-ventricular arrhythmia.

15. Left ventricular ejection fraction lower than 50% at the cardiac scan with radionuclides or at echocardiography.

16. Previous episodes of symptomatic hypotension leading to loss of consciousness.

17. History of eating disorders (anorexia, bulimia).

18. Baseline plasma fasting glucose = 60 mg/dL.

19. Medical or psychiatric comorbidities rendering the patient not candidate to the clinical trial, according to the investigator's judgement.

20. Other cardiac, liver, lung or renal comorbidities, not specified in the previous inclusion or exclusion criteria, but potentially exposing the patient to a high risk of lactic acidosis.

21. Known history of active TB (Bacillus Tuberculosis).

Related Conditions & MeSH terms

• Breast Cancer
• Breast Neoplasms
• Dietary Exposure
• Fasting
• Triple Negative Breast Cancer
• Triple Negative Breast Neoplasms

Intervention

Dietary Supplement:
• Control diet (ARM A) or Fasting-Like Approach (FLA, ARM B)
Each FLA cycle will consist of 5 consecutive days of a specific FLA scheme, which will be repeated with a three-week interval. The FLA will consist of a plant-based, low-calorie (about 600 Kcal on day 1; about 300 Kcal on day 2 to 5), low-protein, low-carbohydrate diet. The first FLA cycle will start two days prior to the day of first chemo-immunotherapy cycle administration and will continue for two more days after chemotherapy. In the absence of significant contraindications or severe adverse events, subsequent FLA cycles will recur with three-week intervals and will maintain the same timing with respect to chemo-immunotherapy administration.

Locations

Country	Name	City	State
Italy	Fondazione IRCCS Istituto Nazionale dei Tumori	Milan

Sponsors (8)

Lead Sponsor	Collaborator
Fondazione IRCCS Istituto Nazionale dei Tumori, Milano	Azienda Policlinico Umberto I, European Institute of Oncology, Federico II University, Humanitas Clinical and Research Center, Istituto Oncologico Veneto IRCCS, Ospedale "Carlo Poma" - Mantova, Ospedale Policlinico San Martino

Country where clinical trial is conducted

Italy, 

References & Publications (15)

Caffa I, Spagnolo V, Vernieri C, Valdemarin F, Becherini P, Wei M, Brandhorst S, Zucal C, Driehuis E, Ferrando L, Piacente F, Tagliafico A, Cilli M, Mastracci L, Vellone VG, Piazza S, Cremonini AL, Gradaschi R, Mantero C, Passalacqua M, Ballestrero A, Zop — View Citation

Cortazar P, Zhang L, Untch M, Mehta K, Costantino JP, Wolmark N, Bonnefoi H, Cameron D, Gianni L, Valagussa P, Swain SM, Prowell T, Loibl S, Wickerham DL, Bogaerts J, Baselga J, Perou C, Blumenthal G, Blohmer J, Mamounas EP, Bergh J, Semiglazov V, Justice — View Citation

Cortes J, Cescon DW, Rugo HS, Nowecki Z, Im SA, Yusof MM, Gallardo C, Lipatov O, Barrios CH, Holgado E, Iwata H, Masuda N, Otero MT, Gokmen E, Loi S, Guo Z, Zhao J, Aktan G, Karantza V, Schmid P; KEYNOTE-355 Investigators. Pembrolizumab plus chemotherapy — View Citation

Di Tano M, Raucci F, Vernieri C, Caffa I, Buono R, Fanti M, Brandhorst S, Curigliano G, Nencioni A, de Braud F, Longo VD. Synergistic effect of fasting-mimicking diet and vitamin C against KRAS mutated cancers. Nat Commun. 2020 May 11;11(1):2332. doi: 10. — View Citation

Gong Y, Ji P, Yang YS, Xie S, Yu TJ, Xiao Y, Jin ML, Ma D, Guo LW, Pei YC, Chai WJ, Li DQ, Bai F, Bertucci F, Hu X, Jiang YZ, Shao ZM. Metabolic-Pathway-Based Subtyping of Triple-Negative Breast Cancer Reveals Potential Therapeutic Targets. Cell Metab. 20 — View Citation

Kassam F, Enright K, Dent R, Dranitsaris G, Myers J, Flynn C, Fralick M, Kumar R, Clemons M. Survival outcomes for patients with metastatic triple-negative breast cancer: implications for clinical practice and trial design. Clin Breast Cancer. 2009 Feb;9( — View Citation

Ligorio F, Fuca G, Provenzano L, Lobefaro R, Zanenga L, Vingiani A, Belfiore A, Lorenzoni A, Alessi A, Pruneri G, de Braud F, Vernieri C. Exceptional tumour responses to fasting-mimicking diet combined with standard anticancer therapies: A sub-analysis of — View Citation

Mittendorf EA, Zhang H, Barrios CH, Saji S, Jung KH, Hegg R, Koehler A, Sohn J, Iwata H, Telli ML, Ferrario C, Punie K, Penault-Llorca F, Patel S, Duc AN, Liste-Hermoso M, Maiya V, Molinero L, Chui SY, Harbeck N. Neoadjuvant atezolizumab in combination wi — View Citation

Poggio F, Tagliamento M, Ceppi M, Bruzzone M, Conte B, Fregatti P, Punie K, de Azambuja E, Del Mastro L, Lambertini M. Adding a platinum agent to neoadjuvant chemotherapy for triple-negative breast cancer: the end of the debate. Ann Oncol. 2022 Mar;33(3): — View Citation

Salvadori G, Zanardi F, Iannelli F, Lobefaro R, Vernieri C, Longo VD. Fasting-mimicking diet blocks triple-negative breast cancer and cancer stem cell escape. Cell Metab. 2021 Nov 2;33(11):2247-2259.e6. doi: 10.1016/j.cmet.2021.10.008. — View Citation

Schmid P, Cortes J, Pusztai L, McArthur H, Kummel S, Bergh J, Denkert C, Park YH, Hui R, Harbeck N, Takahashi M, Foukakis T, Fasching PA, Cardoso F, Untch M, Jia L, Karantza V, Zhao J, Aktan G, Dent R, O'Shaughnessy J; KEYNOTE-522 Investigators. Pembroliz — View Citation

Sikov WM, Berry DA, Perou CM, Singh B, Cirrincione CT, Tolaney SM, Kuzma CS, Pluard TJ, Somlo G, Port ER, Golshan M, Bellon JR, Collyar D, Hahn OM, Carey LA, Hudis CA, Winer EP. Impact of the addition of carboplatin and/or bevacizumab to neoadjuvant once- — View Citation

Vernieri C, Casola S, Foiani M, Pietrantonio F, de Braud F, Longo V. Targeting Cancer Metabolism: Dietary and Pharmacologic Interventions. Cancer Discov. 2016 Dec;6(12):1315-1333. doi: 10.1158/2159-8290.CD-16-0615. Epub 2016 Nov 21. — View Citation

Vernieri C, Fuca G, Ligorio F, Huber V, Vingiani A, Iannelli F, Raimondi A, Rinchai D, Frige G, Belfiore A, Lalli L, Chiodoni C, Cancila V, Zanardi F, Ajazi A, Cortellino S, Vallacchi V, Squarcina P, Cova A, Pesce S, Frati P, Mall R, Corsetto PA, Rizzo AM — View Citation

Vernieri C, Ligorio F, Zattarin E, Rivoltini L, de Braud F. Fasting-mimicking diet plus chemotherapy in breast cancer treatment. Nat Commun. 2020 Aug 26;11(1):4274. doi: 10.1038/s41467-020-18194-1. — View Citation

* Note: There are 15 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Translational (DNA repair, metabolic, autophagy and immunologic parameters effect on pCR)	Role of key DNA repair, metabolic, autophagy and immunologic pathways in the efficacy of the experimental treatments, defined as the rate of pCR	Surgical specimen (at the time of surgery)
Primary	Rate of Pathologic complete response (pCR)	Absence of residual tumor cells in both breast tissue and axillary lymph nodes (ypT0/ypTis ypN0)	Surgical specimen (at the time of surgery)
Secondary	Disease free survival (DFS)	Time from surgery to tumor recurrence, either local or distant, or patient death from any cause, assessed up to 36 months	Time from surgery to tumor recurrence or patient death, assessed up to 36 months
Secondary	Event-free survival (EFS)	Time from the date of randomization to the first documentation of progressive disease, or patient death from any cause, assessed up to 36 months	From the date of randomization to the first documentation of progressive disease or patient death, assessed up to 36 months
Secondary	Distant metastasis free survival (DMFS)	Time from surgery to the occurrence of distant metastases or patient death from any cause, assessed up to 36 months	From surgery to the occurrence of distant metastases or patient death, assessed up to 36 months
Secondary	Overall Survival (OS)	Time from randomization to the date of death (patients alive at the time of data cut-off and analysis will be censored at their last contact date), assessed up to 60 months	Time from randomization to the date of death, assessed up to 60 months
Secondary	Compliance (Dose-intensity)	Dose of effective drug administrated per unit of time (e.g., mg/m2/week)	From the start to the end of the neoadjuvant treatment (about 6 months)
Secondary	Compliance (Drug dose/time modifications)	Percentage of patients with drug dose and/or time modifications	From the start to the end of the neoadjuvant treatment (about 6 months)
Secondary	Compliance (Dietary regimen modifications)	Percentage of patients with experimental dietary regimen modifications	From the start to the end of the neoadjuvant treatment (about 6 months)
Secondary	Compliance (Withdrawals)	Percentage of premature withdrawals	From the start to the end of the neoadjuvant treatment (about 6 months)
Secondary	Safety (AE)	Incidence, nature, severity and seriousness of AEs, according of NCI-CTCAE, version 5.0	From the start to the end of the neoadjuvant treatment (about 6 months)
Secondary	Safety (Maximum toxicity grade)	Maximum toxicity grade experienced by each patient for each specific toxicity	From the start to the end of the neoadjuvant treatment (about 6 months)
Secondary	Safety (G3-G4 AEs)	Percentage of patients experiencing grade 3-4 toxicity for each specific toxicity	From the start to the end of the neoadjuvant treatment (about 6 months)
Secondary	Safety (SAE)	Patients with at least a SAE	From the start to the end of the neoadjuvant treatment (about 6 months)