A Proof of Concept, Window Trial of the IMmunological Effects of AveLumab and Aspirin in Triple-Negative Breast Cancer
A Proof of Concept, Window Trial of the IMmunological Effects of AveLumab and Aspirin in Triple-Negative Breast Cancer
This research is being done because the investigators are looking for new and better ways to
 treat a type of breast cancer called triple negative breast cancer. This type of breast
 cancer can be more difficult to treat than other types of breast cancer as it does not
 respond to drugs such as hormonal therapies. One type of treatment that looks promising is
 immunotherapy using new drugs called immune checkpoint inhibitors.

 Immune checkpoints help to regulate the immune system and can stop the immune system from
 attacking cancer cells. Immune checkpoint inhibitors block this 'off-switch' and aim to help
 the immune system control the cancer. These drugs have been very effective in other cancers
 such as melanoma and are now being tested in breast cancer.

 In this study patients will receive an immune checkpoint inhibitor called avelumab. Half the
 patients on the study will also receive aspirin tablets for approximately 18 days as the
 investigators wish to compare the effects of avelumab alone versus in combination with
 aspirin.

 Patients will attend hospital approximately five times in order to complete all necessary
 study assessments. The first visit screens patients for suitability, after which a baseline
 visit will collect the first of two breast tissue biopsies. At the third visit a single dose
 of Avelumab will be given via an infusion (a drip in the forearm). Patients will then return
 approximately two weeks later for a second breast tissue biopsy before having a final follow
 up visit another two weeks later. Blood and urine samples will be taken at various visits
 throughout the study to help us learn more about the effects these treatments may have on the
 immune system and on breast cancer cells.
TNBC is an aggressive subtype of breast cancer associated with poor survival and new
 treatments are needed. A key feature of cancer is its ability to go undetected by the immune
 system. Recent developments in cancer research have identified immune checkpoints as a
 possible treatment option as they seem to promote an anti-tumour immune response.

 Some breast cancers have considerable cancer cell infiltration, which has been associated
 with better prognosis. This is where white blood cells have permeated the cancer cell and
 infiltrated the infected cell in an attempt to 'cure' the infected cell. Greater
 immune-sensitivity is thought to correlate with greater cancer cell infiltration therefore
 researchers are looking at ways in which immune-sensitivity can be improved.

 One approach is to target inflammation that is known to play a major role in cancer
 development and progression. Certain proteins can often be abnormally expressed in many
 cancers. In preclinical models the investigators recently demonstrated that the presence of
 certain cancer cell-derived proteins is critical for the growth of tumours formed by
 melanoma, colorectal and breast mouse cancer cell lines. In the mouse preclinical trials it
 indicated that by blocking the cancer cells ability to produce these proteins was associated
 with a marked shift in the inflammatory profile. To test this theory, this study will use
 aspirin as the chosen protein inhibitor and it is speculated that the addition of aspirin
 might enhance the efficacy of the immune checkpoint blockade, avelumab.

 TRIAL AIMS & DESIGN

 The aim of this trial is to determine whether aspirin enhances the efficacy of avelumab by
 promoting a greater anti-cancer immune response. This is a multi-centre study recruiting
 patients with confirmed TNBC from across four trial sites within the United Kingdom. It is
 anticipate that 50 participants will need to be screened in order to successfully enrol 42
 patients onto the trial. Patients will be randomly assigned to one of two arms:-

 -  21 patients into Arm A: Avelumab + Proton Pump Inhibitor (PPI)

 -  21 patients into Arm B: Avelumab + Aspirin + PPI

 The estimated duration of participation for a participant is up to 10 weeks. Each subject
 will be asked to complete 5 study visits. After successfully completing a Screening Visit
 (Visit 1), each eligible subject will attend for a Baseline Visit (Visit 2) and will be
 randomly assigned to treatment ARM A or ARM B. As part of the baseline visit subjects will
 have their first of two breast tumour biopsies. All subjects will commence their PPI
 following the baseline visit, those subjects randomised to ARM B will also commence their
 Aspirin at this time. At visit 3 all subjects will receive their Avelumab infusion. At Visit
 4 (Follow up Visit A) each subject will undergo their second research biopsy and further
 research blood sampling this will be the first of two follow up visits, with Visit 5 (Follow
 up Visit B) concluding the patients participation.

 Visit windows have been used to aid visit planning in the hope that most research
 appointments can take place in line with patients' ordinary care visits so as to reduce any
 burden inflicted on the patient.

 Adverse events (AEs) and Serious Adverse Events (SAEs) will be collected from the time of
 randomisation and will continue to be collected up until Visit 5 (Follow up Visit B). All
 post biopsy treatment will be at the discretion of the subject's treating physician per local
 standard of care.

 PATIENT IDENTIFICATION & SCREENING

 The study will be conducted as a multi-centre trial consisting of four NHS secondary care
 out-paints clinics from across the United Kingdom. Each site has been chosen for their
 expertise in oncology and their ability to identify patients for the trial directly from
 their clinics with each centre treating between 20 to 40 patients per annum; this pool of
 patients will constitute the source of recruitment in the study, PIC sites may also be used.

 Potential participants will be identified by the Principal Investigators multi-disciplinary
 team following recent diagnosis of TNBC. The multidisciplinary team shall be trained on the
 study protocol and required to sign the trial delegation and training log in advance of
 working on the trial or identifying participants. Potential participants will have at least
 24 hours to read the patient information and decide if they would like to participate in the
 study. Participants must have the capacity to provide fully informed consent. Participants
 must not participate in any other therapeutic trials whilst on study treatments, however once
 all study treatments as specified by trial schema are completed, participation in further
 studies will not be affected.

 At the screening visits the following data will be collected:-

 -  Informed consent

 -  Demographics

 -  Medical history

 -  Concomitant medication

 -  Complete Physical examination

 -  Vital Signs

 -  12-lead Electrocardiograph (ECG)

 -  ECOG performance status

 -  Blood tests:-

 -  Biochemistry: AST or ALT, LDH, Alk Phos, total bilirubin, sodium, potassium, urea,
 creatinine, total protein, albumin, adjusted calcium

 -  Haematology: FBC: Hb, Platelets, ANC, WBC, Lymphocytes, basophils, eosinophils

 -  Thyroid Function: Free T4, TSH

 -  Urinalysis

 -  Pregnancy testing

 -  Optional: Microbiome samples kit dispensation (Stool sample, Saliva sample, Nasal Swab)

 -  Baseline tumour assessment

 BASELINE VISIT

 The following assessments will be conducted at the time of this visit:

 -  Adverse Events

 -  Concomitant medication

 -  Vital Signs

 -  ECOG performance status

 -  Eligibility

 -  Randomisation

 -  Research Bloods (Circulating tumour DNA (CtDNA); Plasma for Cytokine Analysis; PBMC
 extraction for immunophenotyping)

 -  Mid-stream Urine sample for prostaglandin

 -  Optional: Microbiome samples kit collection (Stool sample, Saliva sample, Nasal Swab)

 -  Breast Tissue Biopsy

 -  Pre-treatment dispensation (Arm A: PPI OR Arm B: PPI + aspirin)

 -  Diary card training and dispensation

 -  Pre-treatment Reminder Telephone call

 -  TREATMENT & FOLLOW UP VISITS

 Visit 3: I.V visit

 The following assessments will be conducted at the time of this visit:

 -  Assessment of Adverse Events

 -  Concomitant medication

 -  Vital Signs

 -  *Laboratory tests *(Biochemistry, Haematology and Urinalysis only if screening labs were
 >14 day prior to visit 3)

 -  **Pregnancy testing **(only if screen pregnancy test was >14days prior to day Visit 3)

 -  Microbiome samples kit dispensation only (Stool, Saliva, Nasal Swab )

 -  Mid-stream Urine sample for prostaglandin

 -  Diary card - Pre-treatment compliance check (Arm A: PPI, Arm B: PPI + aspirin)

 -  Avelumab (10mg/kg i.v.)

 Visit 4: Follow up A The following assessments will be conducted at the time of this visit

 -  Adverse Events

 -  Concomitant medication

 -  Research Bloods (CtDNA); Plasma for Cytokine Analysis; Immunophenotyping)

 -  Microbiome sample kit collection (Stool sample, Saliva sample, Nasal Swab)

 -  Mid-stream Urine sample for prostaglandin

 -  Breast Tumour Biopsy

 -  Diary card - Pre-treatment compliance check (Arm A: PPI, Arm B: PPI + aspirin)

 Visit 5: Follow up B

 The following assessments will be conducted at the time of this visit:

 -  Adverse Events

 -  Concomitant medication

 -  Symptom Directed Physical examination

 -  Vital Signs (BP, HR, Sp02, Temp)

 -  ECOG performance status

 -  Laboratory blood tests

 -  Biochemistry: AST or ALT, LDH, Alk Phos, total bilirubin, sodium, potassium, urea,
 creatinine, total protein, albumin, adjusted calcium

 -  Haematology: FBC - Hb, Platelets, ANC, WBC, Lymphocytes, basophils, eosinophils

 -  Thyroid Function: Free T4, TSH

 -  Urinalysis

 -  Research Bloods (CtDNA); Plasma for Cytokine Analysis; Immunophenotyping)

 SAFETY REVIEW An Independent Trial Steering Committee (TSC) and Data Monitoring Committee
 (IDMC) is being formed and will review trial safety data as a combined committee group.

 TRANSLATIONAL RESEARCH With consent the following samples will be collected from patients and
 held by the Manchester Cancer Research

 Centre (MCRC) biobank:

 -  Microbiome samples

 -  Research blood samples

 -  Breast Tissue Biopsies

 The MCRC biobank holds a generic research tissue bank ethics approval under their HTA license
 and will release the samples for relevant research, subject to approval by the Biobank's
 Access Committee.
Inclusion Criteria:

 1. Written informed consent, willing and able to comply with the trial protocol for the
 duration of the trial including all treatments and scheduled biopsies.

 2. Female patients, age 18 and over

 3. Histologically confirmed triple negative invasive breast cancer as defined as
 oestrogen receptor (ER) negative, progesterone receptor (PgR) negative (if available,
 otherwise PgR unknown), (as defined by Allred score 0- 2 or <1% of tumour cells
 positive for stain) and HER2 negative (immunohistochemistry 0/1+ or negative by in
 situ hybridization) as determined by local laboratory. Have previously untreated,
 non-metastatic TNBC with a tumour amenable to multiple biopsies including a T stage of
 at least T2. Note multifocal primary tumours are allowed providing at least one tumour
 meets the criteria above. All biopsies should be obtained from the same tumour.

 4. Have previously untreated, non-metastatic TNBC with a tumour amenable to multiple
 biopsies including a T stage of at least T2. Note multifocal primary tumours are
 allowed providing at least one tumour meets the criteria above. All biopsies should be
 obtained from the same tumour.

 5. ECOG performance status 0/1

 6. Women of childbearing potential (WOCBP), defined as not surgically sterilized or not
 post-menopausal for at least 24 months if age ≤55 years or 12 months if age >55 years,
 must have a negative serum or urine pregnancy test (minimum sensitivity 25 IU/L or
 equivalent units of HCG) within 14 days prior to the start of either IMP study
 treatment (Avelumab, and Aspirin if applicable).

 7. Adequate organ function:-

 1. Adequate Hepatic function:

 -  AST and ALT <2.5x ULN

 -  Alkaline phosphatase ≤2 x ULN

 -  Total Bilirubin within normal range i.e. ≤1.5 x ULN. If AST/ALT and Alkaline
 phosphatase are within normal limits then isolated elevation of bilirubin to
 3≤ ULN and a presumptive diagnosis of Gilbert's syndrome is permitted.

 2. Adequate organ function as defined by:

 -  Bone marrow function: Hb ≥100g/L

 -  Absolute neutrophil count ≥1.5 x 109/L

 -  Platelets ≥100 x 109/L

 -  Hemoglobin >9 g/dL

 -  Renal function: Creatinine ≤1.5 x ULN OR > 50ml/min using the
 Cockcroft-Gault formula (appendix 4).

 Exclusion Criteria:

 Patients meeting any of the following criteria must not be enrolled in the study:

 1. Prior systemic anti-cancer treatment (immune therapy, targeted therapy, vaccine
 therapy, or investigational treatment) for triple negative breast cancer.

 2. Current use of a prohibited medication as described in section 7.11.

 3. Malignancy within the last 5 years except: adequately treated non-melanoma skin
 cancer; curatively treated in situ cancer of the cervix, ductal carcinoma in situ
 (DCIS); stage 1, grade I endometrial carcinoma.

 4. Has received a live vaccine within 30 days of the first dose of study treatment.

 NB Seasonal influenza vaccines are generally inactivated flu vaccines and are allowed;
 intranasal influenza vaccines (eg FluMist®) are live attenuated vaccines and are not
 allowed.

 5. Contraindications to aspirin dosing including hypersensitivity to aspirin (eg known
 aspirin sensitive asthma; history of peptic ulcer disease, gastric bleeding or
 cerebrovascular haemorrhages; haemorrhagic diathesis.

 6. Evidence of distant metastases apparent prior to randomisation. Patients who are
 diagnosed with distant metastases during the course of the study can complete study
 procedures if willing to do so.

 7. Significant cardiovascular disease including a history of myocardial infarction, acute
 coronary syndrome or coronary angioplasty/stenting/bypass grafting within the last 6
 months or clinically significant congestive heart failure.

 8. Any other serious or unstable pre-existing medical conditions (aside from malignancy
 exceptions specified above), psychiatric disorders, or other conditions that in the
 opinion of the investigator could interfere with the patient's safety, obtaining
 informed consent, or compliance with study procedures.

 9. Known Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), or Hepatitis C
 Virus (HCV) infection (patients with laboratory evidence of cleared or chronic (not
 active) HBV and HCV infection will be permitted).

 10. Patients with active, known or suspected autoimmune disease. Patients with type 1
 diabetes mellitus, hypothyroidism only requiring hormone replacement, skin or
 rheumatological disorders (such as vitiligo, psoriasis, rheumatoid arthritis or
 alopecia) not requiring systemic treatment, or conditions not expected to recur in the
 absence of an external trigger will be permitted to enrol. Autoimmune conditions such
 as ulcerative colitis that have been definitively treated (e.g. with total colectomy)
 will be permitted to enrol but should be discussed with the CI.

 11. Patients with a condition requiring systemic treatment with either corticosteroids
 (>10 mg daily prednisone equivalent) or other immunosuppressive medications within 14
 days of study drug administration. Inhaled or topical steroids and adrenal replacement
 steroid doses > 10 mg daily prednisone equivalent are permitted in the absence of
 active autoimmune disease.

 12. Patients with interstitial lung disease that is symptomatic or may interfere with the
 detection or management of suspected drug-related pulmonary toxicity.

 13. Patients unable to swallow orally administered medication and patients with
 gastrointestinal disorders likely in to interfere with absorption of the trial
 medication.

 14. Females who are pregnant or breast-feeding.

 15. Active infection requiring systemic treatment.

 16. Current or previous regular use of aspirin (at any dose) or current use of another
 NSAID for any indication (see appendix IV for list of medications not permitted in the
 trial). Regular aspirin use is defined as taking aspirin more than twice in any given
 week for more than 4 consecutive weeks. Current NSAID use is defined as taking any
 NSAID for more than a week in the preceding month. If investigators feel that this
 definition may unfairly exclude a participant, this can be discussed with the CI/MCTU
 and a case by case decision will be made.

 17. Known immediate or delayed hypersensitivity reaction or idiosyncrasy to drugs
 chemically related to the study treatments.