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A Neoadjuvant Phase II Trial of ZD1839 (Iressa) and Tamoxifen in Inoperable Locally Advanced HER2-Overexpressing, ER-Positive Breast Cancer Patients: Biologic Correlative Study (AZ #1839US/0303)

Phase 2
18 Years
Not Enrolling
Breast Cancer

Thank you

Trial Information

A Neoadjuvant Phase II Trial of ZD1839 (Iressa) and Tamoxifen in Inoperable Locally Advanced HER2-Overexpressing, ER-Positive Breast Cancer Patients: Biologic Correlative Study (AZ #1839US/0303)

Epidermal growth factor receptor (EGFR) is expressed or over-expressed in many human solid
tumors and plays an important role in progression to invasion and metastases. The EGFR
tyrosine kinase is activated by binding of a variety of ligands to the external domain.
Autophosphorylation by the EGFR tyrosine kinase initiates a signaling cascade that feeds
downstream cell cycle control machinery regulating cell proliferation, and these reactions
are a major component in growth factor-induced proliferation of cancer cells.

The Erb-B (HER) receptor family consists of four transmembrane tyrosine kinases:
Erb-B1-epithermal growth factor receptor (EGFR, HER1), Erb-B2/neu (HER2), Erb-B3 (HER3), and
Erb-B4 (HER4). The ectodomain of Erb-B1, Erb-B3, and Erb-B4 interacts with a specific set of
ligand, whereas no ligand has been identified thus far for the Erb-B2 receptor. Nonetheless,
Erb-B2 can be activated by any of the other ligand-activated Erb-B coreceptors. Upon ligand
binding to the active domain of Erb-B1, Erb-B3, or Erb-B4, these receptors preferentially
recruit Erb-B2 into a heterodimeric complex in which the Erb-B2 kinase can modulate receptor
internalization and prolong signal transduction.

Data are now emerging that Erb-B2 modulates cellular p27 and cyclin D1 protein levels
through both Ras/MAP kinase and PI3K/Akt signaling. Reversible interruption of Erb-B2
function by trastuzumab (Herceptin) has been shown to inhibit MAPk and reduce MAPk-mediated
transcription through cyclin D1. In addition, the signaling molecule Akt is important in the
cell survival pathway. Akt inhibits apoptosis and is present in the PI3 kinase pathway,
which is activated by the EGF family and the IGF family. Several biologic arguments support
the use of EGR inhibitors to block HER2 signaling. In HER2-overexpressing cell lines, the
HER2 receptor is constitutively phosphorylated. This suggests that HER2 may be
transactivated through ligand-stimulated EGFR, also present in tumor cells. In addition,
overexpression of HER2 enhances the binding of EGFR ligands to the receptor and potentiates
EGFR signaling. HER2 inactivation has been shown to impair EGFR- mediated transformation,
and conversely EGFR blocking antibodies can augment the growth inhibitory effect of antiHER2
antibodies in cells with high levels of HER2. Taken together, these data suggest that
EGFR/HER2 crosstalk is present in a subset of human tumors and that interruption of EGFR may
reduce HER2 signaling. Cell cycle progression is regulated predominantly by cyclin-dependent
kinases (CDKs), which in turn are controlled by a family of CDK inhibitory proteins that
include P27KIP1 and P21CIP1-WAF1. Pathways involving CDK inhibitors are commonly destructive
in cancer cells. ZD1839 is an orally active, selective EGFR tyrosine kinase inhibitor that
blocks signal transduction pathways implicated in cancer cell proliferation, survival, and
other host-dependent processes promoting cancer growth.

In preclinical studies, ZD1839 causes tumor growth delay in a range of cancer cell lines and
xenografts, and tumor regression has been observed at higher doses. ZD1839 was also shown to
inhibit proliferation in DCIS together with significantly increased apoptosis in these
tissues. Data from these different cell lines and xenografts suggest that ZD1839 may act via
dose-dependent growth inhibition and by increasing apoptosis, and may even potentiate the
activity of cytotoxic chemotherapy.

In one phase II multicenter study, 63 women with metastatic breast cancer who could have had
any number of previous chemotherapy or hormonal regimens were treated with an oral daily
dose of 500 mg of ZD1839 until disease progression, intolerable toxicity, or withdrawal of
consent. Dosage reduction to 250 mg daily was allowed for toxicity. The primary end point
was clinical benefit rate (complete response + partial response [modified ICC/WHO criteria]
+ stable disease) at 6 months. There was 1 partial response and 2 patients with stable
disease for more than 4 months (4 months in 1 patient and 7+ months in the other), for a
total of 4.8% clinical benefit. An additional 4 patients had stable disease lasting 1 to 2
months, and another 2 patients had stable disease lasting 1 month, resulting in an overall
14.3% partial response or stable disease in this heavily pre-treated population; 15% were on
treatment for 4 to 8+ months, and 2 patients stayed on treatment, despite progression,
because of significant bone pain palliation.

Preliminary efficacy and toxicity data from another phase II trial of 22 ER-positive or
ER-negative patients were reported at the same conference. In that study, patients could
have had 1 previous chemotherapy regimen or were experiencing disease progression while on
tamoxifen and were given 500 mg of ZD1839 daily. Two patients had a partial response and 10
had stable disease at 4 weeks. In both trials the toxicity profile was identical to that
seen in patient with NSCLC.

Inclusion Criteria:

1. All patients must be female and must have signed an informed consent form.

2. Primary breast cancers must be human epidermal growth factor receptor (HER2)
overexpressing (2+ or 3+, or both, as determined by immunohistochemistry [IHC]), and
estrogen receptor (ER) positive. Primary breast cancers must be of clinical and/or
radiologic size >4 cm, with or without gross metastatic disease according to the
International Union against Cancer (UICC) modified World Health Organization (WHO)

3. Negative serum pregnancy test (bHCG) within 7 days of starting study, if of
child-bearing potential.

4. Adequate bone marrow function:

- Hematocrit >30%,

- total neutrophil count must be >1.5 x 10^9/L, and

- platelet count >100 x 10^9/L.

5. Renal function tests:

- creatinine within 1.5 times the institution's upper limit of normal (ULN).

6. Liver function tests:

- Total serum bilirubin within ULN,

- liver transaminases within 2.5 x ULN,

- alkaline phosphatase within 5 x ULN.

7. Performance status (WHO scale) <2.

8. Age > 18 years.

Exclusion Criteria:

1. Pregnancy or unwillingness to use a reliable contraceptive method in women of
child-bearing potential.

2. Women who are lactating or breastfeeding.

3. Severe underlying chronic illness or disease.

4. Patients on other investigational drugs while on study will be excluded.

5. Severe or uncontrolled hypertension, history of congestive heart failure, acute
myocardial infarction, or severe coronary arterial disease.

6. No previous or current malignancies at other sites within the preceding 5 years, with
the exception of adequately treated, cone-biopsied in situ carcinoma of the cervix
uteri and basal or squamous cell carcinoma of the skin.

7. Any evidence of ongoing interstitial lung disease.

8. Concomitant use of phenytoin, carbamazepine, rifampicin, barbiturates, or St John's

9. Treatment with a non-approved or investigational drug within 30 days before Day 1 of
study treatment.

10. Known severe hypersensitivity to ZD1839 or any of the excipients of this product.

Type of Study:


Study Design:

Allocation: Non-Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment

Outcome Measure:

mechanisms of the cellular response, markers predicting response, by investigating whether ZD1839 with or without tamoxifen treatment is associated with altered expression of specific biomarkers in cells isolated by core needle biopsy

Outcome Time Frame:

10 years

Safety Issue:


Principal Investigator

Jenny Chang, MD

Investigator Role:

Principal Investigator

Investigator Affiliation:

Baylor Breast Center


United States: Institutional Review Board

Study ID:

H 13546



Start Date:

July 2003

Completion Date:

September 2010

Related Keywords:

  • Breast Cancer
  • Breast
  • Cancer
  • Neoadjuvant
  • HER2
  • Overexpressing
  • Breast Neoplasms



Baylor Breast Center Houston, Texas  77030