Doxycycline to target breast cancer stem cells in early ER+/HER2- disease

NEODOXy: Targeting Cancer Stem Cells With NEOadjuvant DOXYcycline in Patients With Early Estrogen Receptor Positive / Human Epidermal Growth Factor Receptor 2- Negative Breast Cancer. A Prospective, Multicenter, Single Arm, Open Label Phase II Trial

We will test whether giving the antibiotic doxycycline together with standard pre-surgery chemotherapy helps people with early ER+/HER2- breast cancer by targeting cancer stem cells and improving treatment response.

Quick facts

• Phase: PHASE2
• Study type: Interventional
• Enrollment: 50 (estimated)
• Ages: 18 Years and up
• Sex: All
• Sponsor: Swiss Cancer Institute (other)
• Drugs / interventions: chemotherapy, cyclophosphamide
• Locations: 8 sites (Sankt Gallen, Canton of St. Gallen and 7 other locations)
• Trial ID: NCT06452394 on ClinicalTrials.gov

What this trial studies

This Phase 2 interventional study adds doxycycline to standard neoadjuvant chemotherapy (epirubicin/cyclophosphamide followed by weekly paclitaxel) for patients with early ER+/HER2- breast cancer. Patients will have tumor samples taken before and after treatment to measure cancer stem cell markers such as ALDH1 and to determine pathological response at surgery. The approach is based on preclinical data suggesting doxycycline can disrupt mitochondrial function in cancer stem cells and increase their sensitivity to chemotherapy. The study is conducted at Swiss sites and focuses on improving tumor response to preoperative therapy.

Who should consider this trial

Good fit: Ideal candidates are adults with histologically confirmed early-stage ER+ (≥1%)/HER2- invasive breast cancer of at least 2 cm who are planned for neoadjuvant chemotherapy and curative surgery and have nodal status cN0-3.

Not a fit: Patients with HER2-positive or ER-negative disease, metastatic cancer, those not receiving the specified neoadjuvant chemotherapy, or with contraindications to doxycycline (for example pregnancy or severe allergy) are unlikely to benefit from this intervention.

Why it matters

Potential benefit: If successful, this approach could increase the number of patients who have a stronger tumor response to pre-surgery chemotherapy and potentially reduce recurrence by targeting resistant cancer stem cells.

How similar studies have performed: Preclinical studies over the past two decades suggest doxycycline can target cancer stem cells, but clinical evidence in this setting is limited and the approach remains largely untested in randomized clinical trials.

Eligibility criteria

Inclusion Criteria:

* Written informed consent according to Swiss law and current ICH GCP E6 regulations before registration and prior to any trial specific procedures.
* Histologically confirmed ER+/HER2- primary invasive breast cancer, according to ASCO/CAP Guideline1,2, defined as ER expression rate ≥ 1%.
* Patients are candidate for curative surgery and with a tumor size of at least 2 cm and nodal classification cN0-3 according to the 8th edition, January 2017 of the anatomic TNM classification3.
* Patients with multiple synchronous ipsilateral tumors are allowed, as long as all lesions are ER+/HER2-. Only one target lesion will be considered for ALDH1 primary endpoint, and the target lesion has to be the largest lesion.
* Patients are planned for neoadjuvant chemotherapy according to the local standards.
* Patients accept standard curative surgery after neoadjuvant chemotherapy with 4 cycles of epirubicin and cyclophosphamide (EC) followed by 12 doses of weekly paclitaxel (or nab-paclitaxel).
* Diagnostic tumor tissue is available for the mandatory central pathology examinations; or an additional biopsy is planned in case of lack of remaining material from the diagnostic biopsy, provided that the patient has consented to the optional TR-project.
* Patients with a prior malignancy and treated with curative intention are eligible if all treatment of that malignancy was completed at least 2 years before registration in this trial and the patient has no evidence of disease at registration. Less than 2 years is acceptable for adequately treated cervical carcinoma in situ or localized non-melanoma skin cancer.
* Male or female patients age ≥ 18 years.
* ECOG performance status 0-1.
* Adequate bone marrow function:

  * neutrophil count ≥ 1.5 x 10\^9/L,
  * platelet count ≥ 100 x 10\^9/L,
  * hemoglobin ≥ 90 g/L.
* Adequate hepatic function:

  * total bilirubin ≤ 1.5 x ULN (except for patients with Gilbert's disease max. 3.0 x ULN),
  * AST and ALT ≤ 2.5 x ULN.
* Adequate renal function: estimated glomerular filtration rate (eGFR) ≥ 50 mL/min/1.73 m2 (according to CKD-EPI formula).
* No known cardiac dysfunction contraindicating the planned neoadjuvant chemotherapy with 4 cycles of EC followed by 12 doses of weekly paclitaxel.
* Women of childbearing potential must use highly effective, are not pregnant or lactating and agree not to become pregnant during trial treatment and until 12 months after the last dose of investigational drug. A negative pregnancy test before inclusion into the trial is required for all women of childbearing potential.
* Men agree not to donate sperm or to father a child during trial treatment and until 12 months after the last dose of investigational drug.
* Patient is able and willing to swallow trial drug as whole tablet.

Exclusion Criteria:

* Patients with 2 synchronous breast cancers or more of different subtypes (other than ER+/HER2-).
* Metastatic patients.
* Patients having received or planned to undergo neoadjuvant endocrine therapy or other investigational therapies before surgery.
* History of intracranial hypertension (IH).
* Concomitant or recent (within 30 days of registration) treatment with any other experimental drug.
* Concomitant use of drugs contraindicated with doxycycline according to the Swissmedic-approved product information or contraindicated according to the trial protocol.
* Use of dietary supplements, natural therapies, phytotherapy or complementary and integrative medicines (homeopathy, spagyric remedies, etc) without approval of the sponsor.
* Concomitant use of other anti-cancer drugs or radiotherapy.
* Patients having received doxycycline or other antibiotics of the cyclin family within 28 days before registration.
* Known hypersensitivity to cyclin group of substances, including tetracyclines, doxycycline or to any component of the trial drug.
* Any other serious underlying medical, psychiatric, psychological, familial or geographical condition, which in the judgment of the investigator may interfere with the planned staging, treatment and follow-up, affect patient compliance or place the patient at high risk from treatment-related complications.

Where this trial is running

Sankt Gallen, Canton of St. Gallen and 7 other locations

• Kantonsspital St.Gallen — Sankt Gallen, Canton of St. Gallen, Switzerland (RECRUITING)
• Clinique de Genolier — Genolier, Canton of Vaud, Switzerland (RECRUITING)
• Kantonsspital Winterthur — Winterthur, Canton of Zurich, Switzerland (RECRUITING)
• Kantonsspital Graubünden — Chur, Kanton Graubünden, Switzerland (RECRUITING)
• Tumor Zentrum Aarau — Aarau, Switzerland (RECRUITING)
• Réseau du sein Lausanne — Lausanne, Switzerland (RECRUITING)
• Centre Hospitalier Universitaire Vaudois (CHUV) — Lausanne, Switzerland (RECRUITING)
• Tumor- und Brustzentrum Ostschweiz — Sankt Gallen, Switzerland (RECRUITING)

Study contacts

• Study coordinator: Daniela Zoelly, PhD

Conditions: Breast Cancer, early ER+/HER2- breast cancer, NEODOXy, Doxycycline, Human Epidermal Growth Factor Receptor 2 negative, Estrogen Receptor