Copanlisib, Letrozole, and Palbociclib in Treating Patients With Hormone Receptor Positive HER2 Negative Stage I-IV Breast Cancer

Inclusion Criteria:

Post-menopausal (if female) defined as: 1) prior bilateral oophorectomy, 2) age 60 or over, or 3) < 60 years and amenorrheic for at least 12 months with follicle-stimulating hormone (FSH) and estradiol in the postmenopausal range per institutional parameters); use of luteinizing hormone-releasing hormone (LHRH) agonists to induce chemical ovarian ablation will not be allowed for this study
Tumor is hormone receptor (HR)+ (estrogen receptor and/or progesterone receptor positive with at least 10% expression of either receptor by local immunohistochemical staining) and HER2 negative based on local assessment
FOR PHASE Ib PORTION OF THE STUDY:
Locally advanced/non-operable or metastatic breast cancer that has not been previously treated in the metastatic setting with systemic therapy (i.e. first line treatment)
Measurable disease per RECIST 1.1
FOR PHASE II PORTION OF THE STUDY:
Clinical stage I (breast tumor >= 1.0 cm in diameter), stage II or stage III breast cancer (according to the American Joint Committee on Cancer [AJCC] Staging Manual, 7th Edition, 2010); multifocal disease is allowed if confined to 1 breast, as long as one tumor is at least 1 cm and meets all of the other inclusion criteria
Breast cancer suitable for mandatory baseline core biopsy
No prior systemic therapy or radiotherapy for currently-diagnosed invasive or noninvasive breast cancer
FOR ALL PHASES (Ib AND II):
Absolute neutrophil count (ANC) >= 1.5 x 10^9/L
Platelets > 100 x 10^9/L

Hemoglobin >= 8 g/dL (phase Ib) or >= 10 g/dL (for phase II portion)

For phase Ib portion only: patients may receive erythrocyte transfusions to achieve this hemoglobin level at the discretion of the investigator; however, initial study drug treatment must not begin earlier than the day of the erythrocyte transfusion
Bilirubin =< 1.5 times the upper limit of normal (ULN)
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) =< 3.0 times ULN
Subjects with Gilbert's syndrome, confirmed by genotyping or Invader UGTIA1 molecular assay prior to study entry, must have total bilirubin < 3.0 times ULN
Serum creatinine =< 1.5 times ULN
Lipase =< 1.5 x ULN
International normalized ratio (INR) and partial thromboplastin time (PTT) < 1.5 x ULN
Left ventricular ejection fraction (LVEF) >= 50%
Eastern Cooperative Oncology Group (ECOG) performance status 0-1

Exclusion Criteria:

FOR PHASE Ib ONLY:
Early stage (curable) breast cancer
FOR PHASE II ONLY:
Metastatic breast cancer (local spread to axillary or internal mammary lymph nodes is permitted)
Prior systemic therapy for invasive or non-invasive (DCIS) breast cancer
Prior radiotherapy to the ipsilateral chest wall or breast for any malignancy
Bilateral invasive breast cancer
FOR ALL PHASES (Ib AND II): Inflammatory breast cancer
FOR ALL PHASES (Ib AND II): Concurrent therapy with any other non-protocol anti-cancer therapy
FOR ALL PHASES (Ib AND II): History of any other malignancy within the past 5 years, with the exception of non-melanoma skin cancer or carcinoma-in-situ of the cervix
FOR ALL PHASES (Ib AND II): Concurrent diagnosis of pheochromocytoma
FOR ALL PHASES (Ib AND II): Current therapy with raloxifene, tamoxifen, aromatase inhibitor, or other selective estrogen receptor modulator (SERM), either for osteoporosis or prevention of breast cancer; subjects must have discontinued therapies for at least 28 days prior to first baseline biopsy
FOR ALL PHASES (Ib AND II): Concurrent treatment with postmenopausal hormone replacement therapy; prior treatment must be stopped for at least 28 days prior to first baseline biopsy
FOR ALL PHASES (Ib AND II): Type I diabetes or patients on insulin therapy are not allowed; uncontrolled type II diabetes not allowed (glycosylated hemoglobin [HbA1c] > 7.5)
FOR ALL PHASES (Ib AND II): Proteinuria of >= Common Terminology Criteria for Adverse Events (CTCAE) grade 3 as estimated by urine protein : creatinine ratio > 3.5 on a random urine sample
FOR ALL PHASES (Ib AND II): Uncontrolled arterial hypertension despite optimal medical management
FOR ALL PHASES (Ib AND II): Hepatitis B (HBV) or hepatitis C (HCV); all patients must be screened for HBV and HCV up to 28 days prior to study drug start using the routine hepatitis virus laboratorial panel
FOR ALL PHASES (Ib AND II): Known history of human immunodeficiency virus (HIV) infection
FOR ALL PHASES (Ib AND II): Uncontrolled infection; active, clinically serious infections (> CTCAE grade 2)

FOR ALL PHASES (Ib AND II): History of significant cardiac disease:

Congestive heart failure > New York Heart Association (NYHA) class 2
Unstable angina (angina symptoms at rest), new-onset angina (begun within the last 3 months)
Myocardial infarction less than 6 months before start of test drug
Anti-arrhythmic therapy (beta blockers or digoxin are permitted)
FOR ALL PHASES (Ib AND II): Arterial or venous thrombotic or embolic events such as cerebrovascular accident (including transient ischemic attacks), deep vein thrombosis or pulmonary embolism within 3 months before the start of study medication
FOR ALL PHASES (Ib AND II): Participants receiving anticoagulation therapy are not allowed
FOR ALL PHASES (Ib AND II): Patients with evidence or history of bleeding diathesis; any hemorrhage or bleeding event >= CTCAE grade 3 within 4 weeks of start of study medication
FOR ALL PHASES (Ib AND II): Blood or platelet transfusion within 7 days prior to treatment start
FOR ALL PHASES (Ib AND II): Non-healing wound or ulcer
FOR ALL PHASES (Ib AND II): History of, or current autoimmune disease
FOR ALL PHASES (Ib AND II): Major surgical procedure or significant traumatic injury (as judged by the investigator) within 28 days before start of study medication, open biopsy within 7 days before start of study medication
FOR ALL PHASES (Ib AND II): Patients with seizure disorder requiring medication
FOR ALL PHASES (Ib AND II): Known hypersensitivity to any of the study drugs, study drug classes, or excipients in the formulation
FOR ALL PHASES (Ib AND II): Systemic continuous corticosteroid therapy at a daily dose higher than 15 mg prednisone or equivalent is not allowed; patients may be using topical or inhaled corticosteroids; previous corticosteroid therapy must be stopped or reduced to the allowed dose at least 7 days prior to the first study drug administration; if a patient is on chronic corticosteroid therapy, corticosteroids should be de-escalated to the maximum allowed dose after the patient has signed the consent document
FOR ALL PHASES (Ib AND II): History of having received an allogeneic bone marrow or organ transplant
FOR ALL PHASES (Ib AND II): Chronic oxygen therapy