Atezolizumab, Cobimetinib, and Eribulin in Treating Patients With Chemotherapy Resistant Metastatic Inflammatory Breast Cancer
Atezolizumab, Cobimetinib, and Eribulin in Treating Patients With Chemotherapy Resistant Metastatic Inflammatory Breast Cancer
This phase II trial studies how well atezolizumab, cobimetinib, and eribulin work in treating
 patients with inflammatory breast cancer that has spread to other places in the body
 (metastatic). Immunotherapy with monoclonal antibodies, such as atezolizumab, may help the
 body's immune system attack the cancer, and may interfere with the ability of tumor cells to
 grow and spread. Cobimetinib may stop the growth of tumor cells by blocking some of the
 enzymes needed for cell growth. Drugs used in chemotherapy, such as eribulin, work in
 different ways to stop the growth of tumor cells, either by killing the cells, by stopping
 them from dividing, or by stopping them from spreading. Giving atezolizumab, cobimetinib, and
 eribulin may work better in treating patients with inflammatory breast cancer.
PRIMARY OBJECTIVES:

 I. To determine ORR (overall response rate) of metastatic inflammatory breast cancer (BC)
 (mIBC) patients treated with this proposed combinatorial atezolizumab, cobimetinib, and
 eribulin (ACE) therapy via phase II. (ACE, Cohort I) II. To determine ORR (overall response
 rate) for double combination of atezolizumab and eribulin (AE). (AE, cohort II)

 SECONDARY OBJECTIVES:

 I. To further characterize the safety and tolerability of atezolizumab + cobimetinib +
 eribulin.

 II. To further characterize the safety and tolerability of atezolizumab + eribulin.

 III. To determine CBR (clinical benefit rate): (stable disease [SD] + complete response [CR]
 + partial response [PR] >= 24 weeks).

 III. To determine the duration of response (DOR). IV. To determine progression free survival
 (PFS). V. To determine 2 years overall survival (OS).

 EXPLORATORY OBJECTIVES:

 I. To determine the progressive disease (PD) biomarker changes induced by combinatorial
 therapy using liquid and tissue based assays to investigate microenvironment via multiplex
 imaging, proportional study of T cells: CD3, CD8 composition and change, macrophage (M1 and
 M2), PD-L1 expression on circulating tumor cell (CTC).

 II. To determine the immune pathway related biomarker changes induced by combinatorial
 therapy via multiplex serum cytokine assays.

 III. This translational biomarker assays will be done based on collaboration with plasma
 based ribonucleic acid (RNA) sequencing (RNA-seq) in collaboration with Lambowitz laboratory
 (lab) (University of Texas at Austin [UT Austin]), Oncomine next-generation sequencing (NGS)
 study on tumor/circulating tumor deoxyribonucleic acid (ctDNA) with Wistuba lab, and
 bioinformatics with Futreal lab.

 OUTLINE:

 COHORT I: Patients receive atezolizumab intravenously (IV) over about 30-60 minutes every 2
 weeks, cobimetinib orally (PO) daily for 3 weeks on, 1 week off for 4 weeks of the safety
 lead-in course. Patients then receive atezolizumab IV over about 30-60 minutes every 2 weeks,
 cobimetinib PO daily for 3 weeks on, 1 week off, and eribulin IV over 2-5 minutes on days 1
 and 8 of cycles 1-4. Cycles 1-4 repeat every 21 days and subsequent cycles with atezolizumab
 and cobimetinib repeat every 28 days in the absence of disease progression or unacceptable
 toxicity.

 COHORT II: Patients receive atezolizumab IV over about 30-60 minutes every 3 weeks for cycles
 1-6 and every 4 weeks for subsequent cycles, and eribulin IV over 2-5 minutes on days 1 and 8
 of cycles 1-6. Cycles 1-6 repeat every 21 days and subsequent cycles with atezolizumab repeat
 every 28 days in the absence of disease progression or unacceptable toxicity.

 After completion of the study treatment, patients are followed for 3 months and then every 6
 months for 2 years.
Inclusion Criteria:

 -  Signed informed consent form (ICF) and comply with the requirements of the study
 protocol

 -  Eastern Cooperative Oncology Group (ECOG) performance status 0-1

 -  Confirmed diagnosis of inflammatory breast cancer according to international consensus
 criteria: (1) onset: rapid onset of breast erythema, edema, and/or peau d'orange,
 and/or warm breast, with or without an underlying breast mass (2) duration: history of
 such findings no more than 6 months (3) extent: erythema occupying at least 1/3 of
 whole breast (4) pathology: pathologic confirmation of invasive carcinoma

 -  Patients with recurrent or metastatic IBC after standard systemic therapy are
 eligible; patients who have disease progression while receiving standard anthracycline
 or taxane based neoadjuvant therapy are also eligible. a. patients with HER2-positive
 disease must have had at least 2 lines of anti-HER2 therapy, including Perjeta and
 Kadcyla; b. prior eribulin treatment is allowed

 -  At least one metastatic lesion amendable for biopsy (core, punch, or fine needle
 aspiration [FNA]); if the patient only has lymph nodes, these are considered amenable
 but will not be biopsied

 -  At least one site of measurable disease (per Response Evaluation Criteria in Solid
 Tumors [RECIST] 1.1), local or distant

 -  Any estrogen receptor (ER), progesterone receptor (PR), HER2 status

 -  Absolute neutrophil count (ANC) >= 1500 cells/uL (obtained within 14 days prior to the
 first study treatment [PD window day 1])

 -  White blood cell (WBC) counts > 2500/uL (obtained within 14 days prior to the first
 study treatment [PD window, day 1])

 -  Lymphocyte count >= 300/uL (obtained within 14 days prior to the first study treatment
 [PD window day 1])

 -  Platelet count >= 100,000/uL (obtained within 14 days prior to the first study
 treatment [PD window day 1])

 -  Hemoglobin >= 9.0 g/dL (obtained within 14 days prior to the first study treatment [PD
 window day 1])

 -  Total bilirubin =< 1.5 x upper limit of normal (ULN) with the following the exception:
 Patients with known Gilbert disease who have serum bilirubin level =< 3 x ULN may be
 enrolled (obtained within 14 days prior to the first study treatment [PD window, day
 1])

 -  Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 2.5 x ULN with
 the exception: Patients with liver involvement: AST and/or ALT =< 5 x ULN (obtained
 within 14 days prior to the first study treatment [PD window, day 1])

 -  Alkaline phosphatase =< 2.5 x ULN with the exception: Patients with documented liver
 involvement or bone metastases: alkaline phosphatase =< 5 x ULN (obtained within 14
 days prior to the first study treatment [PD window, day 1])

 -  Serum creatinine =< 1.5 x ULN or creatinine clearance >= 50 mL/min on the basis of the
 Cockcroft-Gault glomerular filtration rate estimation (obtained within 14 days prior
 to the first study treatment [PD window, day 1])

 -  For women of childbearing potential or male subjects: agreement to remain abstinent
 (refrain from heterosexual intercourse) or use contraceptive methods that result in a
 failure rate of < 1% per year, during the treatment period and for at least 5 months
 after the last dose of treatment

 -  International normalized ratio (INR) and activated partial thromboplastin time (aPTT)
 =< 1.5 x ULN for patients who do not receive therapeutic anticoagulation

 -  Patients receiving therapeutic anticoagulation (such as low-molecular-weight heparin
 or warfarin) should be on a stable dose

 -  Left ventricular ejection fraction >= 50% measured by multigated acquisition (MUGA)
 scan or echocardiogram

 Exclusion Criteria:

 -  Any approved anticancer therapy for treatment purpose is not allowed, or need to be
 stopped at least 2 weeks prior to initiation of study treatment; however, the
 following are allowed: a. endocrine therapy (selective estrogen receptor modulator
 [SERM], aromatase inhibitor, fulvestrant) b. palliative radiotherapy for bone
 metastases > 1 week prior to study treatment c. stable brain metastasis and
 asymptomatic treated central nervous system (CNS) metastases are allowed, patient must
 show stable disease by CNS radiographic study >= 4 weeks from completion of
 radiotherapy and >= 2 weeks from discontinuation of corticosteroids

 -  Adverse events (AEs) from prior anticancer therapy that have not resolved to grade =<
 1 except for alopecia and neuropathy

 -  Grade 3 or above neuropathy induced from prior treatment, that is not resolved to
 grade 2 or below despite best supportive care

 -  Known clinically significant liver disease, including active viral, alcoholic, or
 other hepatitis; cirrhosis; fatty liver; and inherited liver disease

 -  Pregnancy, lactation, or breastfeeding

 -  Known hypersensitivity to Chinese hamster ovary cell products or other recombinant
 human antibodies

 -  Inability to comply with study and follow-up procedures

 -  Active or history of autoimmune disease or immune deficiency, including, but not
 limited to, myasthenia gravis, myositis, autoimmune hepatitis, systemic lupus
 erythematosus, rheumatoid arthritis, inflammatory bowel disease, antiphospholipid
 antibody syndrome, Wegener granulomatosis, Sjogren's syndrome, Guillain-Barre
 syndrome, or multiple sclerosis, with the following exception: a. patients with a
 history of autoimmune hypothyroidism who are on thyroid replacement hormone are
 eligible for the study; b. patients with controlled type 1 diabetes mellitus who are
 on an insulin regimen are eligible for the study; c. patients with eczema, psoriasis,
 lichen simplex chronicus of vitiligo with dermatologic manifestations only (e.g.,
 patients with psoriatic arthritis would be excluded) are permitted provided that they
 meet the following conditions are met: i. rash must cover < 10% of body surface area.;
 ii. disease is well controlled at baseline and requires only low-potency topical
 corticosteroids; iii. no occurrence of acute exacerbations of the underlying condition
 requiring psoralen plus ultraviolet A radiation, methotrexate, retinoids, biologic
 agents, oral calcineurin inhibitors, or high potency or oral corticosteroids within
 the previous 12 months

 -  Acute exacerbations of underlying condition within the last 12 months (requiring
 psoralen plus ultraviolet A radiation [PUVA], methotrexate, retinoids, biologic
 agents, oral calcineurin inhibitors; high potency or oral steroids)

 -  Known history of idiopathic pulmonary fibrosis, pneumonitis (including drug induced),
 organizing pneumonia (i.e., bronchiolitis obliterans, cryptogenic organizing
 pneumonia, etc.), or evidence of active pneumonitis on screening chest computed
 tomography (CT) scan:

 -  History of radiation pneumonitis in the radiation field (fibrosis) is permitted

 -  Any other diseases, metabolic dysfunction, physical examination finding, or clinical
 laboratory finding giving reasonable suspicion of a disease or condition that
 contraindicates the use of an investigational drug or that may affect the
 interpretation of the results or render the patient at high risk from treatment
 complications

 -  Known history of human immunodeficiency virus (HIV) infection or active hepatitis B
 (chronic or acute) or hepatitis C infection; but: a. patients positive for hepatitis C
 virus (HCV) antibody are eligible only if polymerase chain reaction (PCR) is negative
 for hepatitis C virus (HCV) RNA; b. patients with past or resolved hepatitis B
 infection (defined as having a negative hepatitis B surface antigen [HBsAg] test and a
 positive anti-HBc [antibody to hepatitis B core antigen] antibody test) are eligible,
 but should sample for hepatitis B virus (HBV) DNA and referral to virologist to
 monitor for HBV reactivation

 -  Active tuberculosis based on history, symptoms, physical exam, imaging

 -  Severe infections within 4 weeks prior to study treatment, including but not limited
 to hospitalization for complications of infection, bacteremia, or severe pneumonia

 -  Signs or symptoms of infection within 2 weeks prior to study treatment

 -  Received oral or IV antibiotics within 2 weeks prior to study treatment

 -  Patients receiving prophylactic antibiotics (e.g., for prevention of a urinary
 tract infection or chronic obstructive pulmonary disease) are eligible

 -  Major surgical procedure within 28 days prior to study treatment or anticipation of
 need for a major surgical procedure during the course of the study

 -  Patients must agree not to receive any live, attenuated influenza vaccine (e.g.,
 FluMist) within 28 days prior to receiving study treatment, during treatment or within
 5 months following the last dose of atezolizumab

 -  Malignancies other than the disease under study within 5 years prior to study
 treatment, with the exception of those with a negligible risk of metastasis or death
 and with expected curative outcome (such as adequately treated carcinoma in situ of
 the cervix, basal or squamous cell skin cancer, or ductal carcinoma in situ treated
 surgically with curative intent) or undergoing active surveillance per
 standard-of-care management (e.g., chronic lymphocytic leukemia Rai Stage 0)

 -  COBIMETINIB-SPECIFIC EXCLUSION CRITERIA (ONLY FOR COHORT I):

 -  History of or evidence of retinal pathology on ophthalmologic examination that is
 considered a risk factor for neurosensory retinal detachment/central serous
 chorioretinopathy (CSCR), retinal vein occlusion (RVO), or neovascular macular
 degeneration

 -  Patients will be excluded if they currently have the following risk factors for
 retinal vein occlusion (RVO): (1) uncontrolled glaucoma with intra-ocular pressures >=
 21 mmHg (2) serum cholesterol >= grade 2 (3) hypertriglyceridemia >= grade 2 (4)
 hyperglycemia (fasting) >= grade 2

 -  Patients with congestive heart failure, congenital long QT syndrome; bradyarrhythmias,
 drugs known to prolong the QT interval unless the principal investigator and/or
 attending physician deems the risk for QT prolongation to be low

 -  The following foods/supplements are prohibited at least 7 days prior to initiation of
 and during study treatment: (1) St. John's wort or hyperforin (potent CYP3A4 enzyme
 inducer) (2) grapefruit juice (potent cytochrome P450 CYP3A4 enzyme inhibitor)

 -  ATEZOLIZUMAB-RELATED EXCLUSION CRITERIA:

 -  Prior treatment with anti-PD-1, or anti-PD-L1 therapeutic antibody or pathway
 targeting agents: (a) patients who have received prior treatment with anti·CTLA-4 may
 be enrolled, provided the following requirements are met: (i) minimum of 12 weeks from
 the first dose of anti-CTLA-4 and > 6 weeks from the last dose; (ii) no history of
 severe immune-related adverse effects from anti-CTLA 4 (National Cancer Institute
 [NCI] Common Terminology for Cancer Adverse Effects CTCAE] grade 3 and 4)

 -  Treatment with systemic immunostimulatory agents (including but not limited to
 interferon [IFN]-a or interleukin [IL]-2) within 6 weeks or five half-lives of the
 drug (whichever is shorter) prior to study treatment

 -  Treatment with investigational agent within 4 weeks prior to study treatment (or
 within five half lives of the investigational product, whichever is longer)

 -  Treatment with systemic immunosuppressive medications (including but not limited to
 prednisone, cyclophosphamide, azathioprine, methotrexate, thalidomide, and anti-tumor
 necrosis factor [anti-TNF] agents) within 2 weeks prior to study treatment; a.
 patients who have received acute, low dose, systemic immunosuppressant medications
 (e.g., a one-time dose of dexamethasone for nausea) may be enrolled; b. the use of
 inhaled corticosteroids and mineralocorticoids (e.g., fludrocortisone) for patients
 with orthostatic hypotension or adrenocortical insufficiency is allowed

 -  History of severe allergic, anaphylactic, or other hypersensitivity reactions to
 chimeric or humanized antibodies or fusion proteins

 -  Patients with prior solid organ transplantation on anti-immunosuppressant