Testing the Addition of an Anti-cancer Drug, Berzosertib, to the Usual Treatment (Radiation Therapy) for Chemotherapy-Resistant Triple-Negative and Estrogen and/or Progesterone Receptor Positive, HER2 Negative Breast Cancer
Testing the Addition of an Anti-cancer Drug, Berzosertib, to the Usual Treatment (Radiation Therapy) for Chemotherapy-Resistant Triple-Negative and Estrogen and/or Progesterone Receptor Positive, HER2 Negative Breast Cancer
This phase Ib trial studies the best dose of berzosertib when given together with the usual
 treatment (radiation therapy) in treating patients with triple negative or estrogen receptor
 and/or progesterone receptor positive, HER-2 negative breast cancer. Berzosertib may stop the
 growth of tumor cells by blocking some of the enzymes needed for cell growth. Radiation
 therapy uses high energy rays to kill tumor cells and shrink tumors. Giving M6620 and
 radiation therapy may kill tumor cells more effectively than radiation alone or shrink or
 stabilize breast cancer for longer than radiation therapy alone.
PRIMARY OBJECTIVE:

 I. To determine the recommended phase 2 dose of twice weekly berzosertib administered
 concurrently with conventionally fractionated radiation therapy (RT) to the breast/chest wall
 and regional nodes.

 SECONDARY OBJECTIVES:

 I. To describe the nature of toxicity that develops when an ATR inhibitor is administered
 concurrently with RT for breast cancer using provider assessments.

 II. To assess long-term locoregional control, disease-free survival, distant disease-free
 survival, and overall survival of patients treated with this approach.

 III. To explore symptomatic adverse events and tolerability of berzosertib being administered
 concurrently with RT using patient-reported outcomes (PROs).

 IV. To assess for germline and somatic alterations in deoxyribonucleic acid (DNA) damage
 response and repair genes, including effectors and regulators of homologous recombination
 (HR), in pre-chemotherapy biopsy specimens and post-chemotherapy surgical resection specimens
 using whole exome sequencing (WES), and to correlate HR deficiency with disease-free
 survival.

 V. To identify somatic alterations in circulating cell-free DNA (cfDNA) at baseline,
 mid-treatment, end-of-treatment, and follow-up and to correlate cfDNA with disease-free
 survival.

 EXPLORATORY OBJECTIVES:

 I. To compare the baseline and post-treatment skin microbiome and make exploratory
 correlations with severe provider and patient-reported toxicity.

 II. To assess for germline DNA repair alterations and correlate with severe provider and
 patient-reported toxicity.

 III. To explore dose-volume parameters associated with acute and late toxicity provider and
 patient-reported toxicity following berzosertib administration concurrent with RT.

 IV. To identify circulating tumor cell (CTC) positivity at baseline, mid-treatment,
 end-of-treatment, and follow-up and to correlate CTC positivity or the combination of CTC
 positivity and cfDNA with disease-free survival.

 V. To evaluate pre-treatment and post-treatment differential abundance of peripheral blood
 immune cell populations identified by cytometry by time-of flight (CyTOF).

 VI. To evaluate associations of the pre-treatment and post-treatment peripheral blood immune
 phenotype (as assessed by CyTOF) with disease-free survival, distant disease-free survival
 and overall survival.

 OUTLINE: This is a dose-escalation study of berzosertib.

 Patients receive berzosertib intravenously (IV) over 60 minutes twice weekly (BIW) for 5
 weeks in the absence of disease progression or unacceptable toxicity. Patients also undergo
 RT 5 days a week for 5-6 weeks depending on the type of surgery undergone.

 After completion of study treatment, patients are followed up weekly for 4 weeks, at 12
 months, then yearly for up to 3 years.
Inclusion Criteria:

 -  Patient with non-metastatic, histologically confirmed primary estrogen receptor (ER)
 =< 10%, progesterone receptor (PR) =< 10%, and HER2-negative breast cancer (triple
 negative breast cancer [TNBC]) either using the baseline biopsy specimen or the
 post-neoadjuvant chemotherapy (NAC) residual surgical specimen and RCB2 or RCB3, as
 defined by Symmans et al., 2007, and received neoadjuvant anthracycline and/or
 taxane-based chemotherapy OR Patient has non-metastatic, histologically confirmed
 primary ER > 10% and/or PR > 10%, HER2-negative breast cancer with RCB3 and received
 neoadjuvant anthracycline and/or taxane-based chemotherapy OR Patient has
 locoregionally recurrent TNBC or ER >10% and/or PR >10%, HER2-negative breast cancer.
 Note: Results from any Clinical Laboratory Improvement Act (CLIA)-certified lab are
 acceptable for the purpose of determining study eligibility.

 -  Note: For patients with primary breast cancer, there is no minimum number of
 neoadjuvant cycles required provided the patient received an anthracycline or
 taxane preoperatively. Patients with locoregionally recurrent breast cancer are
 not required to have received preoperative chemotherapy

 -  Patient has undergone total mastectomy or wide local excision with axillary staging,
 and the margins of the resected wide local excision or mastectomy specimens are free
 of invasive tumor and ductal carcinoma in situ (DCIS) or patient has undergone
 axillary surgery for regionally recurrent breast cancer. Unresected axillary level
 III, internal mammary, and supraclavicular nodal disease is permitted.

 -  Note: For patients who have undergone mastectomy, immediate reconstruction is
 allowed

 -  Patients must have completed their final breast surgery, including re-excision of
 margins for invasive cancer and DCIS, within 90 but not fewer than 21 days prior to
 registration unless patient received postoperative chemotherapy in which case patients
 must have completed their adjuvant chemotherapy within 90 days but not fewer than 28
 days prior to registration

 -  The patient must have recovered from surgery with the incision completely healed and
 no signs of infection prior to registration

 -  Patients must be proceeding with breast/chest wall and regional nodal irradiation
 including internal mammary node treatment. For patients with bilateral breast cancer,
 RT must be indicated and administered only to one side

 -  Eastern Cooperative Oncology Group (ECOG) performance status =< 2

 -  Willing to provide tissue and blood samples for correlative research

 -  Leukocytes >= institutional lower limit of normal (LLN)

 -  Absolute neutrophil count >= institutional LLN

 -  Platelets >= institutional LLN

 -  Total bilirubin =< 1.5 x institutional upper limit of normal (ULN)

 -  Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase
 [SGOT])/alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT])
 =< 3 x institutional ULN

 -  Creatinine =< 1.1 mg/dL OR

 -  Glomerular filtration rate (GFR) >= 45 mL/min/1.73 m^2 for patients with creatinine
 levels above 1.1 mg/dL

 -  Human immunodeficiency virus (HIV)-infected patients on effective anti-retroviral
 therapy with undetectable viral load within 6 months are eligible for this trial

 -  For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral
 load must be undetectable on suppressive therapy, if indicated

 -  Patients with a history of hepatitis C virus (HCV) infection must have been treated
 and cured. For patients with HCV infection who are currently on treatment, they are
 eligible if they have an undetectable HCV viral load

 -  Negative urine or serum pregnancy test for individuals of childbearing potential.
 Note: The effects of berzosertib on the developing human fetus are unknown. For this
 reason and because DNA-damage repair inhibitors as well as radiation used in this
 trial are known to be teratogenic, women of child-bearing potential and men must agree
 to use adequate contraception (hormonal or barrier method of birth control;
 abstinence) prior to study entry and for the duration of study participation, and for
 6 months after completion of berzosertib administration. Should a woman become
 pregnant or suspect she is pregnant while she or her partner is participating in this
 study, she should inform her treating physician immediately. Men treated or enrolled
 on this protocol must also agree to use adequate contraception prior to the study, for
 the duration of study participation, and 6 months after completion of berzosertib
 administration

 -  Ability to understand and the willingness to sign a written informed consent document

 Exclusion Criteria:

 -  Patients who have had chemotherapy within 4 weeks prior to entering the study

 -  Prior RT to the ipsilateral chest wall or ipsilateral breast or thorax. Individuals
 with prior RT to the contralateral breast or chest wall are eligible

 -  Patients who have not recovered from adverse events due to prior anti-cancer therapy
 (i.e., have residual toxicities > grade 1) with the exception of alopecia and grade
 1-2 taxane-induced neuropathy which will be permitted

 -  Patients who are receiving any other investigational agents or concomitant
 anti-neoplastic treatment, except endocrine therapies and bisphosphonates which are
 permitted without restriction even during protocol treatment. Postoperative
 chemotherapy is allowed but must be discontinued >28 days prior to registration

 -  History of allergic reactions attributed to compounds of similar chemical or biologic
 composition to berzosertib

 -  Berzosertib is primarily metabolized by CYP3A4; therefore, concomitant administration
 with strong inhibitors of CYP3A4 (e.g., ketoconazole, itraconazole, clarithromycin,
 ritonavir, indinavir, nelfinavir, and saquinavir) or inducers of CYP3A4 (e.g.,
 rifampin, phenytoin, carbamazepine, phenobarbital, St. John's wort) should be avoided.
 Patients requiring any medications or substances that are strong inhibitors or
 inducers of CYP3A during the course of the study and for 14 days prior to enrollment
 are ineligible. Because the lists of these agents are constantly changing, it is
 important to regularly consult a frequently-updated medical reference. As part of the
 enrollment/informed consent procedures, the patient will be counseled on the risk of
 interactions with other agents, and what to do if new medications need to be
 prescribed or if the patient is considering a new over-the-counter medicine or herbal
 product

 -  Patients with uncontrolled intercurrent illness. This includes but is not limited to,
 ongoing uncontrolled serious infection requiring IV antibiotics at the time of
 registration, symptomatic congestive heart failure, unstable angina pectoris,
 symptomatic/uncontrolled cardiac arrhythmia, or psychiatric illness/social situations
 that would limit compliance with study requirements.

 -  Active systemic lupus, scleroderma, or dermatomyositis with a CPK level above normal

 -  Pregnant women are excluded from this study because berzosertib as a DNA damage repair
 inhibitor may have the potential for teratogenic or abortifacient. Because there is an
 unknown but potential risk for adverse events in nursing infants secondary to
 treatment of the mother with berzosertib, breastfeeding should be discontinued if the
 mother is treated with berzosertib

 -  Patients with known hereditary syndromes predisposing to radiosensitivity such as Li
 Fraumeni syndrome and ataxia telangiectasia are excluded from the study. Patients with
 mutations in breast cancer predisposition genes such as BRCA1, BRCA2, PALB2, CHEK2,
 and ATM are eligible

 -  Patients with a prior or concurrent malignancy, excluding non-melanoma skin cancers
 and non-invasive cancers whose natural history or treatment does not have the
 potential to interfere with the safety or efficacy assessment of the investigational
 regimen