- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT07578116
Adding Surgery and Radiation to the Usual Treatment for HER2-Positive Breast Cancer That Had Already Spread at Diagnosis
Randomized Phase III Trial of Multimodality Therapy Versus Standard of Care Systemic Therapy in HER2 Positive (HER2+) De Novo (AJCC Stage IV) Oligometastatic Breast Cancer With Response to Initial Chemotherapy
Study Overview
Status
Conditions
Intervention / Treatment
- Procedure: Biospecimen Collection
- Procedure: Magnetic Resonance Imaging
- Radiation: Radiation Therapy
- Radiation: Stereotactic Body Radiation Therapy
- Procedure: Positron Emission Tomography
- Procedure: Computed Tomography
- Radiation: Stereotactic Radiosurgery
- Procedure: Mammography
- Procedure: Ultrasound Imaging
- Procedure: Echocardiography Test
- Procedure: Biopsy Procedure
- Biological: Pertuzumab
- Biological: Trastuzumab
- Drug: HER2-targeted Therapy
- Procedure: Breast Conservation Treatment
- Drug: Cyclin-Dependent Kinase 4 Inhibitor
- Drug: Cyclin-Dependent Kinase 6 Inhibitor
- Drug: Hormone Therapy
- Radiation: Radiation Boost
- Drug: Taxane Compound
- Procedure: Total Mastectomy
- Biological: Trastuzumab Deruxtecan
- Biological: Trastuzumab Emtansine
Detailed Description
PRIMARY OBJECTIVES:
I. To compare overall survival (OS) between participants with de novo stage IV oligometastatic HER2+ breast cancer who experience at least a partial response (PR) after initial systemic therapy similar to those used in stage III disease with curative intent, and are randomized to a multimodality approach including definitive locoregional therapy with surgery and radiotherapy and ablative intent stereotactic radiotherapy to detectable metastatic lesions followed by additional HER2-directed systemic therapy, similar to those used for residual disease after neoadjuvant therapy, (Cohort A, Arm 1) versus those who are randomized to physician's choice standard of care HER2-directed systemic therapies without local and metastasis directed ablative therapies (Cohort A, Arm 2). (Randomized Cohort A) II. To evaluate the distribution of progression-free survival (PFS) and overall survival (OS) among participants with de novo stage IV oligometastatic HER2+ breast cancer who do not experience a response after systemic therapy. (Observational Cohort B)
SECONDARY OBJECTIVES:
I. To compare progression-free survival (PFS) in Cohort A, Arm 1 (randomized to multimodality therapy) versus Cohort A, Arm 2 (randomized to standard of care HER2-directed systemic therapy). (Randomized Cohort) II. To compare PFS in Cohort A, Arm 1 per protocol (received all multimodality therapy as planned) versus Cohort A, Arm 2. (Randomized Cohort) III. To compare OS in Cohort A, Arm 1 per protocol (received all multimodality therapy as planned) versus Cohort A, Arm 2. (Randomized Cohort) IV. To assess duration of standard of care first line systemic therapy received from time of response assessment in Cohort B. (Observational Cohort)
BANKING OBJECTIVE:
I. To bank specimens for future correlative studies.
OUTLINE:
STEP 1: Patients receive physician's choice of HER2-targeted systemic therapy according to National Comprehensive Cancer Network (NCCN)/American Society of Clinical Oncology (ASCO) guidelines until completion of at least 12 weeks (4 cycles) or up to 24 weeks (8 cycles) of HER2-targeted therapy prior to Step 2 registration. Patients with brain metastases may also undergo stereotactic radiosurgery (SRS)/stereotactic radiotherapy (SRT) at the discretion of the treating physician.
STEP 2: Patients with partial or complete response in the breast following completion of Step 1 are assigned to Cohort A. Patients with clinically stable or progressive disease following completion of Step 1 are assigned to Cohort B.
COHORT A: Patients are randomized to 1 of 2 arms.
ARM 1:
LOCOREGIONAL THERAPY: Patients undergo breast surgery (either breast conserving therapy or total mastectomy) within 4-6 weeks of completion of Step 1 systemic therapy. Within 8 weeks of breast surgery, patients undergo locoregional radiation therapy (RT) to the breast, with or without RT to the breast/chest wall and/or regional lymph nodes, over 5-16 fractions. Patients may undergo RT boost to the lumpectomy bed over 4-5 fractions at the discretion of the treating physician.
STEREOTACTIC BODY RADIATION THERAPY (SBRT): Within 4-6 weeks of completion of locoregional therapy, patients undergo SBRT, with or without concurrent adjuvant therapy (pertuzumab and trastuzumab, or trastuzumab emtansine [T-DM1], or trastuzumab deruxtecan [T-DXd] with or without pertuzumab), to all targetable metastatic lesions every other day for 1, 3, or 5 fractions over a maximum of 3 weeks.
POST-LOCOREGIONAL THERAPY AND SBRT: Following recovery from surgery, patients resume systemic therapy (T-DXd, or T-DM1, or T-DXd with or without pertuzumab, or taxane with trastuzumab and pertuzumab, or trastuzumab with pertuzumab) according to NCCN/ASCO guidelines for at least 1 year in the absence of disease progression or unacceptable toxicity. Patients who are estrogen receptor positive may also receive endocrine therapy, with or without CDK4/6 inhibitors, at the discretion of the treating physician for at least 5 years, in the absence of disease progression or unacceptable toxicity.
ARM 2: Patients continue systemic therapy (T-DXd, or T-DM1, or T-DXd with or without pertuzumab, or taxane with trastuzumab and pertuzumab, or trastuzumab with pertuzumab) according to NCCN/ASCO guidelines for at least 1 year in the absence of disease progression or unacceptable toxicity. Patients may receive locoregional therapy and/or SBRT according to standard of care only if required for palliative purposes.
COHORT B: Patients continue systemic therapy (T-DXd, or T-DM1, or T-DXd with or without pertuzumab, or taxane with trastuzumab and pertuzumab, or trastuzumab with pertuzumab) according to NCCN/ASCO guidelines in the absence of disease progression or unacceptable toxicity.
All patients also undergo echocardiography (ECHO), magnetic resonance imaging (MRI), mammography, ultrasound, computed tomography (CT), and/or positron emission tomography (PET)/CT throughout the trial. Patients may undergo optional biopsy and/or collection of blood samples throughout the trial.
After completion of study treatment, patients registered to Step 2 are followed up for 10 years.
Study Type
Enrollment (Estimated)
Phase
- Phase 3
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
- Adult
- Older Adult
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- REGISTRATION STEP 1 - SCREENING & INITIAL TREATMENT:
Participants must have histologically confirmed de novo metastatic (i.e. American Joint Committee on Cancer [AJCC] stage IV, no prior history of breast cancer) HER2+ breast cancer with 1 to 5 distant metastatic lesions (oligometastatic). Metastatic breast cancer must be histologically confirmed through biopsy of a distant metastatic lesion unless it is not feasible or safe to biopsy a metastatic lesion, then there must be unequivocal evidence of metastasis on imaging and laboratory studies. HER2+ status must be confirmed in the breast tumor and distant metastatic site as defined per NCCN guidelines version 4.2025
- NOTE: If HER2 positivity at metastatic site is equivocal due to limitations in HER2 analysis in bone, or it is not feasible or safe to biopsy the metastatic lesion, then HER2 positivity based on breast tumor only is acceptable. If there is no breast lesion, HER2+ must be confirmed in at least one metastatic site
Participants with brain metastases are eligible if they meet all of the following criteria at baseline:
- There are 5 or fewer intracranial lesions
- Each intracranial lesions is no larger than 2cm in longest dimension
- NOTE: The brain is counted as 1 distant site towards the oligometastatic definition. Brain imaging is not required for participants who have no neurological signs or symptoms suggestive of central nervous system (CNS) involvement; however, assessment of neurological symptoms and brain MRI is strongly encouraged to rule out CNS disease
- Participants must have no known leptomeningeal disease
Participants must meet one of the following criteria prior to Step 1 registration:
- Treatment naïve and planning to initiate standard of care systemic HER2+ targeted treatment OR
Have already initiated standard of care systemic HER2+ targeted treatment and have completed at least one (≥ 1) but no more than three (≤ 3) cycles prior to enrollment, without progression
- NOTE: Standard of care scans for baseline disease assessment must have been performed within 28 days prior to initiation of treatment
- Participants must not be receiving or planning to receive any investigational systemic therapy during study before disease progression
Participants must not have received whole brain irradiation
- NOTE: Participants with up to five brain metastases may have received SRS/SRT either before or after initiation of systemic therapy. If lesions are small and asymptomatic and the participant is receiving CNS penetration they may be managed with observation
- Participants must be ≥ 18 years old at the time of registration
- Participants must have Zubrod performance status of 0-2
- Participants with known human immunodeficiency virus (HIV)-infection must be on effective anti-retroviral therapy and have undetectable viral load test on the most recent test results obtained within 6 months prior to registration
- Participants must be able to safely receive the physician's choice of standard of care systemic HER2+ targeted treatment per the current Food and Drug Administration (FDA)-approved package insert(s), treating physician's discretion, and institutional guidelines
- Participants must be candidates for definitive surgical and radiotherapeutic management of locoregional disease opinion per the discretion of the treating physician
- Participants must be able to receive ablative dose stereotactic body radiation therapy (SBRT) to all metastatic lesions identified at baseline, in the opinion of the treating physician
- Participants must be offered the opportunity to participate in specimen banking
NOTE: As a part of the Oncology Patient Enrollment Network (OPEN) registration process the treating institution's identity is provided in order to ensure that the current (within 365 days) date of institutional review board approval for this study has been entered in the system
- Participants must be informed of the investigational nature of this study and must sign and give informed consent in accordance with institutional and federal guidelines For participants with impaired decision-making capabilities, legally authorized representatives may sign and give informed consent on behalf of study participants in accordance with applicable federal, local, and CIRB regulations
- REGISTRATION STEP 2 - COHORT ASSIGNMENT AND RANDOMIZATION:
- COHORT A: Participants must be registered to Step 2 within 14 days of staging scans performed after completing Step 1 systemic therapy
- COHORT A: Participants must have standard of care (SOC) staging scans and breast imaging performed following 12-24 weeks (minimum of 4 cycles) of initial systemic therapy and within 14 days prior to Step 2 registration
COHORT A: Participants must have experienced partial or complete response in the breast (in the opinion of the treating physician) following 12-24 weeks of initial systemic therapy based on staging scans performed within 14 days prior to Step 2 registration
- Participants with breast lesion(s) at diagnosis must have a clinical response on breast imaging per the treating physician
- Metastatic lesions, as assessed by Response Evaluation Criteria in Solid Tumors (RECIST) and bone response criteria, must have at least stable disease
- Brain metastases treated with SRS/SRT must have at least stable disease as per Response Assessment in Neuro-Oncology Brain Metastases (RANO BM) and must not require steroid treatment
- Participants with no known breast lesions at diagnosis must have at least partial response in the metastatic sites as assessed by RECIST and bone response criteria
- NOTE: The same imaging modality must be used as in Step 1
- COHORT A: Participants must be eligible for definitive surgical and radiotherapeutic management of locoregional disease per the discretion of the treating physician
COHORT A: Participants must not have metastatic lesions that are not amenable to ablative dose stereotactic body radiation therapy (SBRT)
- Lung lesions that completely resolve after systemic therapy will not be targeted with SBRT, as it is not possible to achieve dose build-up
- The development of new sclerotic bone lesions after systemic therapy is not to be interpreted as disease progression, and all such lesions should be targeted with SBRT
- COHORT B: Participants must be registered to Step 2 within 14 days of staging scans performed after completing Step 1 systemic therapy
- COHORT B: Participants must have standard of care (SOC) staging and breast imaging performed following 12-24 weeks (minimum of 4 cycles) of initial systemic therapy and within 14 days prior to Step 2 registration
COHORT B: Participants must experience clinically stable disease or progression following 12-24 weeks (minimum of 4 cycles) of initial systemic therapy and within 14 days prior to Step 2 registration
- Participants must have progression in metastatic lesions as assessed by RECIST and bone response criteria or may have stable disease in metastatic lesions by RECIST and bone response criteria if there is progression or no clinical response in the breast
- Participants with known breast lesion must have progression or no clinical response on breast imaging as per the treating physician
- NOTE: The same modality must be used as in Step 1
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
|---|---|
|
Experimental: Step 1 (HER2-targeted systemic therapy, STS/SRT)
Patients receive physician's choice of HER2-targeted systemic therapy according to NCCN/ASCO guidelines until completion of at least 12 weeks (4 cycles) or up to 24 weeks (8 cycles) of HER2-targeted therapy prior to Step 2 registration.
Patients with brain metastases may also undergo SRS/SRT at the discretion of the treating physician.
All patients also undergo ECHO, MRI, mammography, ultrasound, CT, and/or PET/CT throughout the trial.
Patients may undergo optional biopsy and/or collection of blood samples throughout the trial.
|
Undergo collection of blood samples
Other Names:
Undergo MRI
Other Names:
Undergo PET/CT
Other Names:
Undergo CT and/or PET/CT
Other Names:
Undergo SRS/SRT
Other Names:
Undergo mammography
Other Names:
Undergo ultrasound
Other Names:
Undergo ECHO
Other Names:
Undergo biopsy
Other Names:
Receive HER2-targeted systemic therapy
|
|
Experimental: Step 2 Cohort A, Arm 1 (locoregional, SBRT, systemic therapy)
See Detailed Description.
|
Undergo collection of blood samples
Other Names:
Undergo MRI
Other Names:
Undergo RT
Other Names:
Undergo SBRT
Other Names:
Undergo PET/CT
Other Names:
Undergo CT and/or PET/CT
Other Names:
Undergo mammography
Other Names:
Undergo ultrasound
Other Names:
Undergo ECHO
Other Names:
Undergo biopsy
Other Names:
Given pertuzumab
Other Names:
Given trastuzumab
Other Names:
Undergo breast conserving therapy
Other Names:
Given CDK4/6 inhibitor
Other Names:
Given CDK4/6 inhibitor
Other Names:
Given endocrine therapy
Other Names:
Undergo RT boost
Other Names:
Given taxane therapy
Other Names:
Undergo total mastectomy
Other Names:
Given T-DXd
Other Names:
Given T-DM1
Other Names:
|
|
Experimental: Step 2 Cohort A, Arm 2 (systemic therapy)
Patients continue systemic therapy (T-DXd, or T-DM1, or T-DXd with or without pertuzumab, or taxane with trastuzumab and pertuzumab, or trastuzumab with pertuzumab) according to NCCN/ASCO guidelines for at least 1 year in the absence of disease progression or unacceptable toxicity.
Patients may receive locoregional therapy and/or SBRT according to standard of care only if required for palliative purposes.
All patients also undergo ECHO, MRI, mammography, ultrasound, CT, and/or PET/CT throughout the trial.
Patients may undergo optional biopsy and/or collection of blood samples throughout the trial.
|
Undergo collection of blood samples
Other Names:
Undergo MRI
Other Names:
Undergo RT
Other Names:
Undergo SBRT
Other Names:
Undergo PET/CT
Other Names:
Undergo CT and/or PET/CT
Other Names:
Undergo mammography
Other Names:
Undergo ultrasound
Other Names:
Undergo ECHO
Other Names:
Undergo biopsy
Other Names:
Given pertuzumab
Other Names:
Given trastuzumab
Other Names:
Undergo breast conserving therapy
Other Names:
Undergo RT boost
Other Names:
Given taxane therapy
Other Names:
Undergo total mastectomy
Other Names:
Given T-DXd
Other Names:
Given T-DM1
Other Names:
|
|
Experimental: Step 2 Cohort B (systemic therapy)
Patients continue systemic therapy (T-DXd, or T-DM1, or T-DXd with or without pertuzumab, or taxane with trastuzumab and pertuzumab, or trastuzumab with pertuzumab) according to NCCN/ASCO guidelines in the absence of disease progression or unacceptable toxicity.
All patients also undergo ECHO, MRI, mammography, ultrasound, CT, and/or PET/CT throughout the trial.
Patients may undergo optional biopsy and/or collection of blood samples throughout the trial.
|
Undergo collection of blood samples
Other Names:
Undergo MRI
Other Names:
Undergo PET/CT
Other Names:
Undergo CT and/or PET/CT
Other Names:
Undergo mammography
Other Names:
Undergo ultrasound
Other Names:
Undergo ECHO
Other Names:
Undergo biopsy
Other Names:
Given pertuzumab
Other Names:
Given trastuzumab
Other Names:
Given T-DXd
Other Names:
Given T-DM1
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Overall survival (OS) (Cohort A)
Time Frame: From date of Step 2 registration to date of death, assessed up to 10 years
|
The primary analysis to evaluate the primary objective in the randomized cohort will be an intent-to treat (ITT) comparison of Arm 1 versus Arm 2 using a stratified log-rank test including all randomized, eligible participants.
The hazard ratio and 95% confidence interval (CI) will be estimated by Cox regression including the stratification factors as variables in the model.
Primary analyses will be repeated among individuals with brain metastases to understand whether the effect of the intervention differs in this subgroup.
|
From date of Step 2 registration to date of death, assessed up to 10 years
|
|
Progression-free survival (PFS) (Observational Cohort B)
Time Frame: From date of Step 2 registration to date of first documentation of progression or recurrence or death, assessed at 3 and 5 years
|
In the observational cohort, the primary objective will be evaluated by estimating 3- and 5-year survival and corresponding 95% CIs using the Kaplan-Meier estimator.
All analyses in the observational cohort will be descriptive.
Primary analyses will be repeated among individuals with brain metastases to understand whether the effect of the intervention differs in this subgroup.
|
From date of Step 2 registration to date of first documentation of progression or recurrence or death, assessed at 3 and 5 years
|
|
Overall survival (Observational Cohort B)
Time Frame: From date of Step 2 registration to date of death, assessed at 3 and 5 years
|
In the observational cohort, the primary objective will be evaluated by estimating 3- and 5-year survival and corresponding 95% CIs using the Kaplan-Meier estimator.
All analyses in the observational cohort will be descriptive.
Primary analyses will be repeated among individuals with brain metastases to understand whether the effect of the intervention differs in this subgroup.
|
From date of Step 2 registration to date of death, assessed at 3 and 5 years
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Progression free survival (Cohort A)
Time Frame: From date of Step 2 registration to date of first documentation of progression or recurrence or death, assessed at 3 and 5 years and then up to 10 years
|
The primary analysis will be an ITT comparison of Arm 1 versus Arm 2 using a stratified log-rank test including all randomized, eligible participants.
The hazard ratio and 95% CI will be estimated by Cox regression including the stratification factors as variables in the model.
In addition to the primary analyses, will estimate PFS at 3 years and 5 years in Arm 1 and Arm 2 and corresponding 95% CIs using the Kaplan-Meier estimator.
|
From date of Step 2 registration to date of first documentation of progression or recurrence or death, assessed at 3 and 5 years and then up to 10 years
|
|
Overall survival (Cohort A)
Time Frame: From date of Step 2 registration to date of death, assessed at 3 and 5 years and then up to 10 years
|
The primary analysis will be an ITT comparison of Arm 1 versus Arm 2 using a stratified log-rank test including all randomized, eligible participants.
The hazard ratio and 95% CI will be estimated by Cox regression including the stratification factors as variables in the model.
In addition to the primary analyses, will estimate OS at 3 years and 5 years in Arm 1 and Arm 2 and corresponding 95% CIs using the Kaplan-Meier estimator.
|
From date of Step 2 registration to date of death, assessed at 3 and 5 years and then up to 10 years
|
|
Duration of standard of care first line systemic therapy (Cohort B)
Time Frame: From time of response assessment at end of Step 1 up to 10 years
|
From time of response assessment at end of Step 1 up to 10 years
|
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Primary outcome treatment effect by sex
Time Frame: Up to 10 years
|
Will estimate the primary outcome treatment effect and corresponding 95% CI by sex.
|
Up to 10 years
|
|
Primary outcome treatment effect by race
Time Frame: Up to 10 years
|
Will estimate the primary outcome treatment effect and corresponding 95% CI by race.
|
Up to 10 years
|
|
Primary outcome treatment effect by ethnicity
Time Frame: Up to 10 years
|
Will estimate the primary outcome treatment effect and corresponding 95% CI by ethnicity.
|
Up to 10 years
|
Collaborators and Investigators
Sponsor
Collaborators
Investigators
- Principal Investigator: Mariya Rozenblit, SWOG Cancer Research Network
Study record dates
Study Major Dates
Study Start (Estimated)
Primary Completion (Estimated)
Study Completion (Estimated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Physiological Effects of Drugs
- Hormones, Hormone Substitutes, and Hormone Antagonists
- Peptides
- Amino Acids, Peptides, and Proteins
- Proteins
- Organic Chemicals
- Investigative Techniques
- Therapeutics
- Clinical Laboratory Techniques
- Diagnostic Techniques and Procedures
- Diagnosis
- Surgical Procedures, Operative
- Cytological Techniques
- Cytodiagnosis
- Pharmacologic Actions
- Chemical Actions and Uses
- Hydrocarbons
- Cycloparaffins
- Hydrocarbons, Alicyclic
- Hydrocarbons, Cyclic
- Terpenes
- Physical Phenomena
- Polycyclic Compounds
- Antibodies, Monoclonal, Humanized
- Antibodies, Monoclonal
- Antibodies
- Immunoglobulins
- Immunoproteins
- Blood Proteins
- Serum Globulins
- Globulins
- Cyclodecanes
- Diterpenes
- Fused-Ring Compounds
- Mastectomy
- Diagnostic Techniques, Surgical
- Chemistry Techniques, Analytical
- Macrolides
- Lactones
- Spectrum Analysis
- Stereotaxic Techniques
- Neurosurgical Procedures
- Lactams, Macrocyclic
- Macrocyclic Compounds
- Radiation, Nonionizing
- Maytansine
- Intracellular Signaling Peptides and Proteins
- Ultrasonic Waves
- Sound
- Cell Cycle Proteins
- Tumor Suppressor Proteins
- Neoplasm Proteins
- Cyclin-Dependent Kinase Inhibitor Proteins
- Trastuzumab
- Ado-Trastuzumab Emtansine
- Hormones
- Radiotherapy
- Radiation
- Mastectomy, Segmental
- Biopsy
- Specimen Handling
- pertuzumab
- Magnetic Resonance Spectroscopy
- Radiosurgery
- taxane
- trastuzumab deruxtecan
- Steroids
- High-Energy Shock Waves
- 2C4 antibody
- CT-P6
- PF-05280014
- trastuzumab biosimilar HLX02
- Ogivri
- Ontruzant
- Cyclin-Dependent Kinase Inhibitor p18
- Cyclin-Dependent Kinase Inhibitor p16
- Taxoids
- Mastectomy, Simple
Other Study ID Numbers
- S2511 (Other Identifier: CTEP)
- U10CA180888 (U.S. NIH Grant/Contract)
- NCI-2026-02627 (Registry Identifier: CTRP (Clinical Trial Reporting Program))
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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