Neratinib +/- Fulvestrant in HER2+, ER+ Metastatic Breast Cancer

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 approved Neratinib as a treatment for
breast cancer. Fulvestrant has been FDA approved for treatment of metastatic hormone receptor
positive breast cancer.

The purpose of this research study is to determine how well neratinib, by itself or together
with Fulvestrant, works in treating breast cancer that has spread to other parts of the body.
Neratinib is a recently discovered oral drug that may stop breast cancer cells from growing
abnormally by inhibiting (or blocking) members of a family of proteins that include Human
Epidermal Growth Factor Receptor 2 (HER2).

Neratinib has been used in other research studies and information from those other research
studies suggests that neratinib may help to shrink or stabilize HER2-positive breast cancer
in this research study.

Inclusion Criteria:

- Participants must have histologically or cytologically confirmed inoperable locally
advanced or metastatic ER+ breast cancer. To fulfill the requirement for ER+ disease,
a breast cancer must express, by immunohistochemistry (IHC), ER in ≥10% of cells, on
the most recent biopsy. Central confirmation of ER status is not required.

- Participants must have documented HER2+ disease by overexpression and/or gene
amplification on the most recent biopsy, per current ASCO-CAP (American Society of
Clinical Oncology - College of American Pathologists) 2013 guidelines. Central
confirmation of HER2 status is not required.

- Participants must have received prior therapy with the following agents in any
combination, and in setting (i.e., neoadjuvant, adjuvant, metastatic, etc.). These
therapies do not need to be the most recent line of therapy.

- Trastuzumab

- Pertuzumab

- Ado-trastuzumab emtansine (T-DM1)

- Participants must agree to undergo a research biopsy of a reasonably accessible
metastatic lesion (chest wall, skin, subcutaneous tissue, lymph nodes, skin, breast,
bones, lung, and liver metastases). If a reasonably accessible metastatic lesion is
not available, the patient may go on study provided that archived tissue is available.
However, if a reasonably accessible site is available for biopsy, the patient must
agree to biopsy. Any patients not undergoing biopsy must be approved for study
enrollment by the Overall Principal Investigator at DFCI. Biopsies may be done with
local anesthesia or intravenous conscious sedation, according to institutional
guidelines. If a biopsy requires general anesthesia, then it is only allowed if
acquisition of tissue is clinically indicated, and excess tissue may be collected for
research purposes. Patients without sites available for biopsy must have available
tissue [archived formalin-fixed paraffin embedded blocks (FFPB), blocks from which
slides can be created, or fresh frozen tissue from original diagnosis or metastatic
setting] for correlative studies. Tissue needs to be located and available at the time
of registration See Section 9.3 for more details.

- Women ≥ 18 years of age. Men are not eligible.

- Eastern Cooperative Oncology Group (ECOG) performance status 0-2 (see Appendix A).

- Participants must have normal organ and marrow function as described below:

- Absolute neutrophil count ≥1,000/uL

- Platelets ≥75,000/uL

- Hemoglobin ≥8g/dL

- Total bilirubin ≤ 1.5 X institutional upper limit of normal (ULN); in case of
known Gilbert's syndrome, <2 x ULN is allowed

- AST(SGOT)/ALT(SGPT) ≤3X institutional ULN without liver metastases, or ≤5X
institutional ULN with liver metastases

- Creatinine clearance ≥ 50 mL/min

- Left ventricular ejection fraction ≥50%, as determined by RVG (MUGA) or
echocardiogram (ECHO) within 60 days prior to initiation of protocol therapy

- Participants may have received any number of prior therapies as long as they have
adequate performance status and meet all other eligibility criteria.

- Women of childbearing potential (including premenopausal women and women less than 12
months after menopause) must have a negative β-human chorionic gonadotropin (hCG)
urine pregnancy test within 4 weeks of registration.

- The effects of neratinib and fulvestrant on the developing human fetus are unknown.
For this reason and because SERD agents are known to be teratogenic, women of
child-bearing potential must agree to be abstinent, or to use a highly effective
double barrier method of contraception (e.g, a combination of male condom with an
intravaginal device such as the cervical cap, diaphragm, or vaginal sponge with
spermicide) or a non-hormonal method, while enrolled in the study, until at least 28
days after the last dose of neratinib or 1 year after the last dose of fulvestrant.
Should a woman become pregnant or suspect she is pregnant while she is participating
in this study, she should inform her treating physician immediately. If a woman is of
childbearing potential, she must agree to use adequate contraception prior to the
study, for the duration of study participation, and for one year after completion of
the study drug.

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

Exclusion Criteria:

- Participants who have a history of allergic reactions attributed to compounds of
similar chemical or biologic composition to neratinib or fulvestrant.

- Participants who have known hypersensitivity to any component of loperamide or
budesonide.

- Participants who have received previous therapy with neratinib or fulvestrant.

- Participants who have received anti-cancer therapy (including chemotherapy, biological
therapy, investigational agents, hormonal therapy, or other anti-cancer therapy) or
radiotherapy within ≤14 days prior to the planned initiation of investigational
products, or those who have not recovered to grade ≤1from adverse events due to their
most recent therapy (excepting alopecia).

- Participants who have had any major surgery ≤28 days prior to the planned initiation
of study therapy, or those who have not recovered from adverse events due to
agents/surgery administered more than 4 weeks earlier.

- Participants who are receiving any other investigational agents.

- Participants with symptomatic or progressive brain metastases, or requiring steroids
to control symptoms of brain metastases.

- Participant has active, uncontrolled cardiac disease, including cardiomyopathy,
congestive heart failure (New York Heart Association functional classification of ≥2),
unstable angina, myocardial infarction within 12 months of enrollment, or ventricular
arrhythmia.

- Participant has a QTc interval >470 ms or known history of QTc prolongation or Torsade
de Pointes.

- Participant has an active infection or unexplained fever >38.5°C (101.3°F).

- Participant has had another malignancy within the past 5 years with the exception of
a) adequately treated basal cell carcinoma, squamous cell skin cancer, or thyroid
cancer; b) carcinoma in situ of the breast, cervix or vulva; or c) cancer considered
cured by surgical resection or unlikely to impact survival during the duration of the
study, such as localized transitional cell carcinoma of the bladder, or benign tumors
of the adrenal or pancreas.

- Participant has significant chronic gastrointestinal disorder with diarrhea as a major
symptom (e.g., Crohn's disease, malabsorption, or Grade ≥2 (NCI CTCAE v.4.0) diarrhea
of any etiology at screening).

- Participant has known active infection with hepatitis B or hepatitis C virus.
Hepatitis B and C serology testing is not required, unless active infection is
suspected.

- Participant is unable or unwilling to swallow tablets.

- Participant has evidence of significant medical illness, abnormal laboratory finding,
or psychiatric illness/social situations that would, in the Investigator's judgment,
limit compliance with study requirements.

- Pregnant women are excluded from this study because fulvestrant is a SERD agent with
the potential for teratogenic or abortifacient effects. Because there is an unknown
but potential risk for adverse events in nursing infants secondary to treatment of the
mother with neratinib and/or fulvestrant, breastfeeding should be discontinued if the
mother is treated with neratinib and/or fulvestrant.