Pilot Clinical Trial of Treatment With Bortezomib to Inhibit Homologous Recombination (HR) Followed by Pembrolizumab and Cisplatin in Patients With Chemotherapy-Pretreated Metastatic Triple Negative Breast Cancer
The hypothesis of this pilot trial is that administration of bortezomib will inhibit NHEJ in metastatic TNBC leading at the time of disease progression to metastases that are HR-deficient and sensitive to pembrolizumab and cisplatin therapy. The trial will include in depth analysis of the patients' TNBC genome and phosphoproteome to evaluate HR-proficiency and deficiency, and nuclear proteins that drive NHEJ, before and upon progression with bortezomib therapy.
• A patient will be eligible for inclusion in this study if she meets all of the following criteria:
‣ Female patients ≥18 years of age
⁃ Have a diagnosis of metastatic TNBC previously treated with standard anthracycline, cyclophosphamide, and taxane chemotherapy, unless there was a contraindication to doxorubicin, in which case prior treatment with this agent is not required. NOTE: TNBC defined as ER-negative tumors with \< or = 10% tumor nuclei immunoreactivity, or ER Low Positive as defined by the updated ASCO/CAP guidelines 2020.
⁃ Have not received more than 3 prior chemotherapy regimens for metastatic disease. Prior platinum and/or taxane therapy in the adjuvant or metastatic setting is permitted.
⁃ Have locoregional (eg, breast, chest wall, regional lymphatic) or pulmonary or hepatic metastatic disease that is amenable to core needle biopsy. If a research biopsy from a patient's metastatic disease cannot be safely obtained, a skin biopsy is permitted. If a skin biopsy cannot be safely obtained, patients may still be eligible, per physician discretion.
⁃ Have an Eastern Cooperative Oncology Group (ECOG) performance status of 0-1 (See Appendix I)
⁃ Have adequate hematologic function, defined by:
• Absolute neutrophil count (ANC) \>1500/μL
∙ Platelet count ≥100,000/μL
∙ Hemoglobin ≥9 g/dL or ≥5.6 mmol/L
⁃ Have adequate liver function, defined by:
• AST and ALT ≤2.5 x the upper limit of normal (ULN) or ≤5 x ULN in presence of liver metastases
∙ Total bilirubin ≤1.5 x ULN OR direct bilirubin ≤ULN for patients with total bilirubin levels \>1.5 × ULN
⁃ Have adequate renal function, defined by:
‣ a. Serum creatinine ≤1.5 x ULN or calculated creatinine clearance of ≥30 mL/min
⁃ Have adequate coagulation function, defined by:
• International Normalized Ratio (INR) OR prothrombin time (PT) and activated partial thromboplastin time (aPTT) ≤1.5 × ULN.
∙ If patient is receiving anticoagulant therapy, PT or aPTT must be within therapeutic range of intended use of anticoagulants.
‣ Patients who have a history of brain metastasis are eligible for the study provided that all the following criteria are met:
⁃ Brain metastases which have been treated
• Off-treatment with steroids for 2 weeks before administration of the first dose of bortezomib
• No ongoing requirement for dexamethasone or anti-epileptic drugs
• No clinical or radiological evidence of progression of brain metastases
‣ Patient must be accessible for treatment and follow-up.
‣ All patients must be able to understand the investigational nature of the study and give written informed consent prior to study entry.