Cabozantinib +/- Trastuzumab In Breast Cancer Patients w/ Brain Metastases

This research study is a Phase II clinical trial. Phase II clinical trials test the safety
and effectiveness of an investigational intervention to learn whether the intervention works
in treating a specific disease. "Investigational" means that the intervention is being
studied.

The FDA (the U.S. Food and Drug Administration) has not approved cabozantinib for your
specific disease but it has been approved for other uses.

Few treatments exist for brain metastases from breast cancer. Radiation and surgery are
generally included as a possible standard of care treatments for this diagnosis.

In this research study, the investigator are looking at how well cabozantinib works in
treating breast cancer that has spread to the brain. Cabozantinib has been used in some phase
I studies and information from those other research studies suggests that cabozantinib may
help to shrink or stabilize the participant's breast cancer. In addition, information from
these studies has shown that cabozantinib may pass through the blood brain barrier (a
protective layer that prevents most large molecules and cells found in the blood from
entering the brain tissue) and may be an effective treatment for brain metastases.

If the participant has HER2-positive breast cancer, they will receive trastuzumab in addition
to cabozantinib. Trastuzumab is an FDA approved drug for the treatment of HER2-positive
metastatic breast cancer. However, the combination of cabozantinib and trastuzumab has not
yet been tested. Trastuzumab may help to shrink or stabilize breast cancer in combination
with cabozantinib. If the participant's breast cancer is HER2-negative, they will not receive
trastuzumab as part of this clinical trial.

The names of the study interventions involved in this study are:

- Cabozantinib (XL184)

- Trastuzumab (herceptin) (participants with HER2-positive disease only)

Inclusion Criteria:

- Patients must have histologically or cytologically confirmed invasive breast cancer,
with stage IV disease.

- New or progressive CNS lesions, as assessed by the patient's treating physician.

- For patients who have received prior cranial radiation, no increase in corticosteroid
dose in the week prior to the baseline brain MRI

- Discontinued prior therapy (with the exception of trastuzumab for patients with HER2+
breast cancer)

- Recovery to baseline or ≤ Grade 1 CTCAE v.4.0 from toxicities related to any prior
treatments, unless AE(s) are clinically nonsignificant and/or stable on supportive
therapy;

- The subject has an ECOG performance status of 0 or 1

- Patients must have normal organ and marrow function and laboratory values as follows
within 4 days before the first dose of cabozantinib

- Sexually active subjects (men and women) must agree to use medically accepted barrier
methods of contraception (e.g., male or female condom) during the course of the study
and for 4 months after the last dose of study drug(s)

- Subjects of childbearing potential must not be pregnant at screening.

- Patients on bisphosphonates may continue receiving bisphosphonate therapy during
study. Patients wanting to initiate bisphosphonate therapy may do so.

- The subject has had an assessment of all known disease sites eg, by computerized
tomography (CT) scan, magnetic resonance imaging (MRI), bone scan as appropriate,
within 28 days before the first dose of cabozantinib

Exclusion Criteria:

- The subject has received cabozantinib or another c-Met inhibitor (please note ARQ 197
is not considered a MET inhibitor for purposes of this study given data to suggest it
inhibits tubulin)

- The subject has uncontrolled, significant intercurrent or recent illness

- Leptomeningeal disease as the only site of CNS involvement

- Known contraindication to MRI with gadolinium contrast, such as cardiac pacemaker,
shrapnel, or ocular foreign body

- More than 2 seizures over the last 4 weeks prior to study entry

- Grade 1 or higher CNS hemorrhage on baseline brain MRI, or history of grade 2 or
higher CNS hemorrhage within 12 months

- The subject has tumor in contact with, invading or encasing any major blood vessels

- The subject has evidence of tumor invading the GI tract (esophagus, stomach, small or
large bowel, rectum or anus), or any evidence of endotracheal or endobronchial tumor
within 28 days before the first dose of cabozantinib

- The subject requires concomitant treatment, in therapeutic doses, with anticoagulants.
Low dose aspirin (≤ 81 mg/day), low-dose warfarin ( ≤1 mg/day), and prophylactic LMWH
are permitted.

- The subject has prothrombin time (PT)/INR or partial thromboplastin time (PTT) test
≥1.3 × the laboratory ULN within 7 days before the first dose of cabozantinib.

- Inability to swallow intact tablets

- Diagnosis of another malignancy within 2 years before the first dose of cabozantinib,
except for superficial skin cancers, or localized, low grade tumors deemed cured and
not treated with systemic therapy

- Subjects with clinically relevant ongoing complications from prior radiation therapy
are not eligible

- The subject is known to be positive for the human immunodeficiency virus (HIV)

- Subjects with clinically relevant ongoing complications from prior surgery are not
eligible

- QTcF > 500 msec on average of screening EKGs performed within 28 days of first dose of
cabozantinib. Three EKGs must be performed at screening. If the average of these three
consecutive results for QTcF is > 500 msec, the subject is ineligible.

- Active infection requiring IV antibiotics at Day 1 of cycle 1

- No prior lapatinib within 7 days prior to initiation of protocol treatment

- Previously identified allergy or hypersensitivity to components of the cabozantinib
formulations

- The subject requires chronic concomitant treatment with strong CYP3A4 inducers