Fulvestrant (F)+Placebo vs F+Palbociclib First Line for Postmenopausal Hormone Receptor+ Advanced Breast Cancer (FLIPPER)

Phase II Study to Compare Fulvestrant (F) 500mg Plus Placebo vs F 500mg Plus Palbociclib as First Line Treatment for Postmenopausal Women With Hormone Receptor Positive Advanced Breast Cancer Sensitive to Endocrine Therapy. GEICAM/2014-12

This is an international, multicentre, double-blind, controlled, randomized phase II study comparing the efficacy and safety of fulvestrant in combination with palbociclib versus fulvestrant plus placebo in postmenopausal women with HR-positive/HER2-negative metastatic breast cancer who have received ≥5 years of endocrine therapy in the adjuvant setting as treatment for early disease and remained disease free for > 12 months following its completion or have "de novo" metastatic disease.

Study Overview

• Status: Active, not recruiting
• Conditions: Breast Neoplasms
• Intervention / Treatment: Drug: PD-0332991 (Palbociclib); Drug: Fulvestrant; Drug: Placebo

Detailed Description

Patients must have at least one lesion (measurable and/or non-measurable) that can be accurately assessed at baseline and is suitable for repeated assessment by CT, MRI or plan x-ray. Patients with bone-only disease must have a lytic or mixed (lytic + blastic) lesion, which has not been previously irradiated and can be accurately assessed by CT/MRI or x-ray. Approximately 190 patients will be randomized 1:1 between the experimental arm (approximately 95 patients treated with fulvestrant plus palbociclib) and the control arm (approximately 95 patients treated with fulvestrant plus placebo).

Primary Objective:

• To compare the efficacy of fulvestrant in combination with palbociclib versus fulvestrant plus placebo in terms of the rate of Progression-Free Survival (PFS) at 1 year in postmenopausal women with HR-positive/HER2-negative metastatic breast cancer previously treated with endocrine therapy for at least 5 years and remaining disease free for more than 12 months following its completion or have "de novo" metastatic disease

• Study Type: Interventional
• Enrollment (Actual): 189
• Phase: Phase 2

Contacts and Locations

Study Locations

• Ireland
  • Cork, Ireland
    • Bon Secours Hospital
  • Dublin, Ireland
    • Beaumont Hospital
  • Dublin, Ireland
    • Mater Misericordiae University Hospital
  • Galway, Ireland
    • Galway University Hospital
  • Waterford, Ireland
    • University Hospital Waterford
• Spain
  • A Coruña, Spain, 15009
    • Centro Oncologico de Galicia
  • Barcelona, Spain, 08003
    • Hospital Del Mar
  • Barcelona, Spain, 08916
    • Hospital Universitario Germans Trias i Pujol
  • Barcelona, Spain, 08026
    • Hospital de La Santa Creu Y Sant Pau
  • Córdoba, Spain, 14004
    • Hospital Universitario Reina Sofia
  • Jaen, Spain, 23007
    • Complejo Hospitalario de Jaén
  • Leon, Spain, 24080
    • Complejo Asistencial Universitario de León
  • Madrid, Spain, 28034
    • Hospital Universitario Ramon y Cajal
  • Madrid, Spain, 28040
    • Hospital Clinico Universitario San Carlos
  • Madrid, Spain, 28492
    • Hospital Universitario de Fuenlabrada
  • Málaga, Spain, 29011
    • Hospital Regional Universitario de Malaga
  • Sevilla, Spain, 41013
    • Hospital Universitario Virgen del Rocio
  • Sevilla, Spain, 41009
    • Hospital Universitario Virgen de la Macarena
  • Sevilla, Spain, 41014
    • Hospital Universitario de Valme
  • Sevilla, Spain, 41013
    • Hospital Quirón Sagrado Corazón de Sevilla
  • Valencia, Spain, 46010
    • Hospital Clínico Universitario de Valencia
  • Valencia, Spain, 46014
    • Hospital General Universitario Valencia
  • Valencia, Spain, 46026
    • Hospital Universitario i Politècnic La Fé
  • Zaragoza, Spain, 50009
    • Hospital Universitario Miguel Servet
  • Asturias
    • Oviedo, Asturias, Spain, 33011
      • Hospital Universitario Central de Asturias
  • Baleares
    • Palma De Mallorca, Baleares, Spain, 07198
      • Hospital Son Llàtzer
    • Palma de Mallorca, Baleares, Spain, 07120
      • Hospital Universitari Son Espases
  • Barcelona
    • Terrassa, Barcelona, Spain, 08221
      • Hospital Universitario Mútua Terrassa
  • Madrid
    • Parla, Madrid, Spain, 28981
      • Hospital Universitario Infanta Cristina
    • Pozuelo de Alarcón, Madrid, Spain, 28223
      • Hospital Universitario Quiron de Madrid
  • Pontevedra
    • Vigo, Pontevedra, Spain, 36204
      • Complejo Hospitalario Universitario Vigo
  • Tarragona
    • Reus, Tarragona, Spain, 43204
      • Hospital Universitario Sant Joan Reus

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

1. The patient has signed and dated the informed consent document and it has been obtained before conducting any procedure specifically for the study.
2. Availability of a tumor tissue sample, archival (primary tumour) or from the metastatic lesions (preferable) for the central ER, PgR and HER2 testing.
3. Histological/cytological confirmation of breast cancer with evidence of metastatic disease (loco-regional or distant), not amenable to resection or radiation therapy with curative intent.
4. Documented positive hormone receptor status (> or = 1% of tumour cells with oestrogen receptor [ER] and/or progesterone receptor [PgR] expression) based on central testing on the most recent tumour biopsy.
5. Documented HER2-negative tumour based on central testing on the most recent tumour biopsy. HER2-negative tumour is determined as immunohistochemistry score 0/1+ or negative by in situ hybridization (FISH/CISH/SISH) defined as a HER2/CEP17 ratio <2 or for single probe assessment a HER2 copy number <4.
6. Patients must have received at least 5 years of endocrine therapy in the adjuvant setting as treatment for early disease and remained disease free for more than 12 months following its completion or have "de novo" metastatic disease. Patients that have been scheduled 5 years with adjuvant endocrine therapy and stopped treatment, by patient's own decision, after completing at least 3 years of treatment, can be also be included as long as they have remained free of disease 3 years after discontinuing the endocrine therapy.
7. Patients must have at least one lesion (measurable and/or non-measurable) that can be accurately assessed at baseline and is suitable for repeated assessment by CT, MRI, plan x-ray or physical examination. Clinical lesions will only be considered measurable when they are superficial and ≥10mm diameter as assessed using callipers (e.g. skin nodules). Patients with bone-only disease must have a lytic or mixed (lytic + blastic) lesion, which has not been previously irradiated and can be accurately assessed by CT/MRI according to RECIST version 1.1.

8. Postmenopausal patient, defined as a woman fulfilling any one of the following criteria (based on the NCCN definition of menopause [National Comprehensive Cancer Network 2008]):

   • Prior bilateral oophorectomy.
   • Age > 60 years.
   • Age ≤ 60 years and with amenorrhea for 12 or more months in the absence of chemotherapy, tamoxifen, toremifene, or ovarian suppression and follicle stimulating hormone and estradiol in the postmenopausal range.
9. Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) 0, 1 or 2.
10. At least 18 years of age.
11. Life expectancy ≥ 12 weeks.

12. Adequate organ and bone marrow function:

    • ANC ≥ 1,500/mm3 (1.5x109/L);
    • Platelets ≥ 100,000/mm3 (100x109/L);
    • Haemoglobin (Hgb) ≥ 9g/dL (90g/L);
    • Serum creatinine ≤ 1.5xUpper Limit of Normal (ULN) or estimated creatinine clearance ≥ 60ml/min as calculated using the method standard for the institution;
    • Total serum bilirubin ≤ 1.5xULN (<3xULN if Gilbert´s disease);
    • AST and/or ALT ≤ 3xULN (≤5xULN if liver metastases present);
    • Alkaline Phosphatase (AP) ≤ 2.5xULN (≤5xULN if bone or liver metastases present).
13. Patients consent to biological sample provision for biomarker exploratory analysis.
14. Willingness and ability to comply with scheduled visits, treatment plan, laboratory tests and other study procedures.

Exclusion Criteria:

1. Prior systemic therapy for metastatic disease. Note: patients with a local recurrent disease treated with surgery (R0) and receiving a "second hormonal adjuvant therapy for five years" will be allowed, provided they have remained disease free for more than 12 months following its completion.
2. Have "de novo" locally advanced disease.
3. Current use of food or drugs known to be potent CYP3A4 inhibitors, drugs known to be potent CYP3A4 inducers, and drugs that are known to prolong the QT interval.
4. Presence of life-threatening metastatic visceral disease, defined as extensive hepatic involvement, or any degree of brain or leptomeningeal involvement (past or present), or symptomatic pulmonary lymphangitis spread, or any known bone marrow infiltration due to breast cancer. Patients with discrete pulmonary parenchymal metastases are eligible, provided their respiratory function is not significantly compromised as a result of disease.
5. Treatment with a non-approved or experimental drug within 4 weeks before randomization.
6. Prior treatment with any CDK4/6 inhibitor or fulvestrant.
7. Current or prior malignancy within previous 5 years (other than breast cancer or adequately treated basal cell or squamous cell carcinoma of the skin or in-situ carcinoma of the cervix).

8. History of:

   • Bleeding diathesis (i.e., disseminated intravascular coagulation [DIC], clotting factor deficiency) or long-term (>6 months) anticoagulant therapy (other than antiplatelet therapy and low dose coumarin derivatives provided that the International Normalised Ratio (INR) is less than 1.6). Hypersensitivity to active or inactive excipients of fulvestrant, palbociclib/placebo or castor oil.
   • Any severe concomitant condition which makes it undesirable for the patient to participate in the trial or which would jeopardize compliance with the trial protocol, e.g. uncontrolled cardiac disease or uncontrolled diabetes mellitus.
9. QTc interval > 480msec, family or personal history of long or short QT syndrome, Brugada syndrome or known history of QTc prolongation or Torsade de Pointes.
10. Uncontrolled electrolyte disorders that can compound the effects of a QTc-prolonging drug (eg, hypocalcaemia, hypokalaemia, hypomagnesaemia).
11. Impairment of gastro-intestinal (GI) function or GI disease that may significantly alter the absorption of palbociclib, such as history of GI surgery which may result in intestinal blind loops and patients with clinically significant gastro-paresis, short bowel syndrome, unresolved nausea, vomiting, active inflammatory bowel disease or diarrhoea of CTCAE grade > 1.
12. Prior hematopoietic stem cell or bone marrow transplantation.
13. Known human immunodeficiency virus infection.
14. Other severe acute or chronic medical or psychiatric condition or laboratory abnormality that may increase the risk associated with study participation or investigational product administration or may interfere with the interpretation of study results and, in the judgment of the investigator, would make the patient inappropriate for entry into this study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: PD-0332991(Palbociclib)+fulvestrant(FaslodexTM); Fulvestrant 500mg, on days 1, 15 (±3 days) of Cycle 1, and then on Day 1 of each subsequent 28 day cycle (±3 days) in combination with Palbociclib, 125 mg, orally once daily from day 1 to day 21 followed by 7 days off treatment on every 28 days cycles.	Drug: PD-0332991 (Palbociclib); Palbociclib, 125 mg, orally once daily from day 1 to day 21 followed by 7 days off treatment on every 28 days cycles. Patients will continue to receive their assigned treatment until objective disease progression, clinical progression (under investigator criteria), unacceptable toxicity, death or withdrawal of consent, whichever occurs first; Other Names: Ibrance; Drug: Fulvestrant; Fulvestrant 500mg, two 5ml intramuscular injections (one in each buttock), on days 1, 15 (±3 days) of Cycle 1, and then on Day 1 of each subsequent 28 day cycle (±3 days) Patients will continue to receive their assigned treatment until objective disease progression, clinical progression (under investigator criteria), unacceptable toxicity, death or withdrawal of consent, whichever occurs first; Other Names: Faslodex
Active Comparator: Placebo+fulvestrant(FaslodexTM); Fulvestrant 500mg on days 1, 15 (±3 days) of Cycle 1, and then on Day 1 of each subsequent 28 day cycle (±3 days) in combination with Placebo orally once daily from day 1 to day 21 followed by 7 days off treatment on every 28 days cycles.	Drug: Fulvestrant; Fulvestrant 500mg, two 5ml intramuscular injections (one in each buttock), on days 1, 15 (±3 days) of Cycle 1, and then on Day 1 of each subsequent 28 day cycle (±3 days) Patients will continue to receive their assigned treatment until objective disease progression, clinical progression (under investigator criteria), unacceptable toxicity, death or withdrawal of consent, whichever occurs first; Other Names: Faslodex; Drug: Placebo; Placebo orally once daily from day 1 to day 21 followed by 7 days off treatment on every 28 days cycles. Patients will continue to receive their assigned treatment until objective disease progression, clinical progression (under investigator criteria), unacceptable toxicity, death or withdrawal of consent, whichever occurs firs

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Efficacy in terms of the rate of Progression-Free Survival (PFS)	assessed according to Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 by the investigator	at 1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Progression-Free Survival (PFS)	the time from the date of randomization to the first documented progressive disease, using RECIST version 1.1, or death from any cause, whichever occurs first	an average of 40-44 months since FPFV (approximately Ago2019)
Objective Response Rate (ORR)	the percentage of patients with a complete or partial response out of the patients who had measurable disease at baseline.	at 1 year and to be updated with further analyses
Clinical Benefit Rate (CBR)	Complete Response (CR) plus Partial Response (PR) plus stable disease (SD) lasting ≥ 24 weeks (+/- 2 weeks) according to RECIST version 1.1.	at 1 year and to be updated with further analyses
Overall Survival (OS).	the time from the date of randomization to the date of death from any cause.	an average of 40-44 months since FPFV(approximately Ago2019). A formal analysis will be performed when at least 60% of patients have died (2021)
1 year and 2 year survival probabilities	the percentage of patients without death from any cause out of the randomised patients (calculated using the Kaplan-Meier technique).	1 year and 2 year
Incidence of adverse events occurring during the study, and their relatedness to the study drug/medications (safety and tolerability).	Safety will be assessed by standard clinical and laboratory tests. Adverse events will be graded according to NCI-CTCAE version 4.0	at 1 year and to be updated with further analyses
Patient reported outcomes of health-related quality of life based on EORTC QLQ-C30 Global Health Status/Quality of Life and Physical Function	Generic aspects of quality of life will be assessed. Changes (mean score) from baseline and time to deterioration will be analyzed.Health Status/QoL and Physical Function and EORTC QLQ-BR23 Breast Module from baseline	at 1 year and to be updated with further analyses
Patient reported outcomes of health-related quality of life based on EORTC QLQ-BR23 Breast Module.	Disease-specific treatment measurements will be assessed. Changes (mean score) from baseline and time to deterioration will be analyzed.	at 1 year and to be updated with further analyses

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Biomarker analyses	Identify promising biomarkers of response to fulvestrant plus palbociclib and fulvestrant plus placebo.; Identify promising biomarkers of primary resistance to fulvestrant plus palbociclib and fulvestrant plus placebo.; Identify promising biomarkers of acquired resistance to fulvestrant plus palbociclib and fulvestrant plus placebo.; Identify promising biomarkers to monitor response to fulvestrant plus palbociclib and fulvestrant plus placebo	Up to 5 years

Collaborators and Investigators

• Sponsor: Spanish Breast Cancer Research Group
• Collaborators: AstraZeneca
• Investigators: Study Director: Study Director, Hospital Del Mar

Publications and helpful links

General Publications

• Albanell J, Martinez MT, Ramos M, O'Connor M, de la Cruz-Merino L, Santaballa A, Martinez-Janez N, Moreno F, Fernandez I, Alarcon J, Virizuela JA, de la Haba-Rodriguez J, Sanchez-Rovira P, Gonzalez-Cortijo L, Margeli M, Sanchez-Munoz A, Anton A, Casas M, Bezares S, Rojo F. Randomized phase II study of fulvestrant plus palbociclib or placebo in endocrine-sensitive, hormone receptor-positive/HER2-advanced breast cancer: GEICAM/2014-12 (FLIPPER). Eur J Cancer. 2022 Jan;161:26-37. doi: 10.1016/j.ejca.2021.11.010. Epub 2021 Dec 11.

Study record dates

Study Major Dates

• Study Start (Actual): February 17, 2016
• Primary Completion (Actual): January 11, 2020
• Study Completion (Anticipated): December 1, 2023

Study Registration Dates

• First Submitted: January 5, 2016
• First Submitted That Met QC Criteria: February 18, 2016
• First Posted (Estimate): February 24, 2016

Study Record Updates

• Last Update Posted (Actual): February 5, 2020
• Last Update Submitted That Met QC Criteria: February 3, 2020
• Last Verified: February 1, 2020

More Information

Terms related to this study

• Keywords: breast cancer; metastases; hormone receptor positive; postmenopausal; palbociclib; fulvestrant
• Additional Relevant MeSH Terms: Skin Diseases; Neoplasms; Neoplasms by Site; Breast Diseases; Breast Neoplasms; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Antineoplastic Agents; Hormones, Hormone Substitutes, and Hormone Antagonists; Antineoplastic Agents, Hormonal; Protein Kinase Inhibitors; Hormone Antagonists; Estrogen Antagonists; Estrogen Receptor Antagonists; Fulvestrant; Palbociclib
• Other Study ID Numbers: GEICAM/2014-12; 2015-002437-21 (EudraCT Number)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO