DIetary REstriction as an Adjunct to Neoadjuvant ChemoTherapy for HER2 Negative Breast Cancer (DIRECT)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Know the risks and potential benefits of clinical studies and talk to your health care provider before participating. Read our disclaimer for details. Identifier: NCT02126449
Recruitment Status : Recruiting
First Posted : April 30, 2014
Last Update Posted : January 3, 2018
Borstkanker Onderzoek Groep
Pink Ribbon Inc.
Information provided by (Responsible Party):
J.R. Kroep, Leiden University Medical Center

Brief Summary:
Preclinical studies provide strong support for the concept that fasting evokes resistance to multiple forms of stress. Fasting reduces plasma levels of growth factors and modulates intracellular nutrient sensing systems, thereby diverting energy from growth to maintenance. Accordingly, the currently available preclinical evidence suggests that short-term fasting protects normal cells against the perils of chemotherapy. In contrast, cancer cells are not protected, as a result of their self-sufficiency in growth signals. This phenomenon is termed Differential Stress Resistance (DSR). DSR reduces the severity of toxic side-effects of chemotherapy and interestingly, it simultaneously renders cancer cells more vulnerable to chemotherapeutics. Importantly, extensive preclinical evidence and preliminary clinical data indicate that a specifically designed very low calorie, low amino acid substitution diet ("Fasting Mimicking Diet, FMD") has effects on cancer therapy that are very similar to those of fasting. This study aims to evaluate the impact of the FMD on tolerance to and efficacy of neoadjuvant chemotherapy in women with stage II or III breast cancer.

Condition or disease Intervention/treatment Phase
Fasting Mimicking Diet Breast Cancer Neoadjuvant Chemotherapy Pathological Complete Response Other: Fasting mimicking diet Phase 2 Phase 3

Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 250 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: DIetary REstriction as an Adjunct to Neoadjuvant ChemoTherapy for HER2 Negative Breast Cancer
Study Start Date : February 2014
Estimated Primary Completion Date : December 2018
Estimated Study Completion Date : December 2019

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Breast Cancer

Arm Intervention/treatment
Experimental: Fasting mimicking diet
Short term fasting using Fasting mimicking diet around neoadjuvant chemotherapy (AC>T)
Other: Fasting mimicking diet
No Intervention: regular diet
Standard neoadjuvant chemotherapy (AC>T)

Primary Outcome Measures :
  1. The percentage of patients with grade III/IV toxicity according to the National Cancer Institute Common Terminology Criteria for Adverse Events version (NCI CTCAE) v4.03. [ Time Frame: 2 years ]
    Phase II

  2. The percentage of pCR. [ Time Frame: 4 years ]
    Phase III

Secondary Outcome Measures :
  1. Clinical response measured by MRI (RECIST1.1) after 4 cycles chemotherapy. [ Time Frame: 4 years ]
  2. Grade I/II side effects of chemotherapy according to NCI CTCAE v4.03. [ Time Frame: 4 years ]
  3. Metabolic (Glucose, insulin, insulin-like growth factor-I (IGF-I), insulin-like growth factor binding protein 3 (IGF-BP3), free thyroxin (FT4), triiodothyronine (T3) and thyroid-stimulating hormone (TSH)) and inflammatory response (CRP) to chemotherapy. [ Time Frame: 4 years ]
  4. DNA damage, apoptosis, immunology and nutrient sensing system activity in the tumor. [ Time Frame: 5 years ]
  5. Patient's quality of life (using EORTC QLQ-C30 and EORTC QLQ-BR23 questionnaires), burden of therapy noted by a visual analogue scale (VAS) (Distress Thermometer) and differences of Illness Perceptions (B-IPQ). [ Time Frame: 4 years ]
  6. Long term efficacy of treatment (DFS, OS). [ Time Frame: 4years ]
  7. Hormone receptor percentage, Ki67 and immunologic tumor profile and tumor/stroma ratio as predictive biomarker [ Time Frame: 4 years ]
  8. SNPs used as biomarker to predict treatment outcome. [ Time Frame: 5 years ]

Other Outcome Measures:
  1. Protein profiles and cytokines used as biomarker to predict treatment outcome [ Time Frame: 4 years ]
  2. Quantification of chemotherapy-induced DNA damage in leukocytes (with γ-H2AX modification and comet assay). [ Time Frame: 3years ]
  3. Quantification of nutrient sensing system gene expression (with western blot). [ Time Frame: 3 years ]

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Ages Eligible for Study:   18 Years to 70 Years   (Adult, Older Adult)
Sexes Eligible for Study:   Female
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Female patients with stage II or III (cT1cN+ or ≥T2 any cN, cM0) breast cancer receiving neoadjuvant AC-T
  • Measurable disease (breast and/or lymph nodes)
  • HER2 negative core biopsy Age ≥18 years
  • WHO performance status 0-2
  • Adequate bone marrow function : white blood cells (WBCs) ≥3.0 x 109/l, neutrophils ≥1.5 x 109/l, platelets ≥100 x 109/l
  • Adequate liver function: bilirubin ≤1.5 x upper limit of normal (UNL) range, ALAT and/or ASAT ≤2.5 x UNL, Alkaline Phosphatase ≤5 x UNL
  • Adequate renal function: the calculated creatinine clearance should be ≥50 mL/min
  • Patients must be accessible for treatment and follow-up
  • Written informed consent according to the local Ethics Committee requirements
  • Willing to fill in quality of life questionnaires
  • Able to read and write in Dutch

Exclusion Criteria:

  • History of breast cancer (invasive or non-invasive)
  • Previous malignancy within 5 years, with exception of a history of a previous basal cell carcinoma of the skin or pre-invasive carcinoma of the cervix.
  • Serious other diseases such as recent myocardial infarction, clinical signs of cardiac failure or clinically significant arrhythmias
  • Diabetes Mellitus
  • Body mass index (BMI) < 19 kg/m2
  • Pregnancy or lactating
  • Significant food allergies which would make the subject unable to consume the food provided (ex: nuts or soy)
  • Any metabolic disorders that may affect gluconeogenesis or adaptation to short fasting periods.
  • Medical or psychological condition which in the opinion of the investigator would not permit the patient to complete the study or sign meaningful informed consent

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT02126449

Contact: Judith R Kroep, MD, PhD +31715263464
Contact: Stefanie de Groot, MD +31715263464

Leids Universitair Medisch Centrum Recruiting
Leiden, Zuid-holland, Netherlands, 2333ZA
Contact: Judith R Kroep, MD, PhD    +31715263464   
Contact: Stefanie de Groot, MD    +31715263464   
Principal Investigator: J R Kroep, MD, PhD         
Principal Investigator: H Pijl, MD PhD         
Principal Investigator: J JM van der Hoeven, Md PhD Ir         
Medisch Centrum Alkmaar Recruiting
Alkmaar, Netherlands
Contact: M P Hendriks, MD PhD         
OLVG Not yet recruiting
Amsterdam, Netherlands
Contact: J M Meerum Terwogt, MD PhD         
Alexander Monro hospital Not yet recruiting
Bilthoven, Netherlands
Contact: E. Goker , MD         
Amphia Hospital Recruiting
Breda, Netherlands
Contact: J B Heijns, MD PhD         
Deventer Hospital Recruiting
Deventer, Netherlands
Contact: A LT Imholz, MD, PhD         
Contact: L W Kessels, MD, PhD         
Ziekenhuis Gelderse Valei Recruiting
Ede, Netherlands
Contact: A Baars, MD, PhD         
, Catharina ziekenhuis Hospital Recruiting
Eindhoven, Netherlands
Contact: B EPJ Vriens, MD         
Kennemer gasthuis Not yet recruiting
Haarlem, Netherlands
Contact: G.J. Klerk, MD         
Medisch Centrum Leeuwarden Recruiting
Leeuwarden, Netherlands
Contact: H de Graaf, MD PhD         
Bronovo Hospital Recruiting
The Hague, Netherlands
Contact: N I Weijl, MD PhD         
Haga Hospital Recruiting
The Hague, Netherlands
Contact: J Portielje, MD PhD         
VieCurie Hospital Recruiting
Venlo, Netherlands
Contact: Y van de Wouw, Md PhD         
Lange Land Hospital Recruiting
Zoetermeer, Netherlands
Contact: A JM Pas, MD         
Isala Recruiting
Zwolle, Netherlands
Contact: A H Honkoop, MD PhD         
Sponsors and Collaborators
Leiden University Medical Center
Borstkanker Onderzoek Groep
Pink Ribbon Inc.
Principal Investigator: Judith R Kroep, MD, PhD Leiden University Medical Center
Principal Investigator: Hanno Pijl, MD PhD Leiden University Medical Center
Principal Investigator: Koos JM van der Hoeven, MD PhD Ir Leiden University Medical Center

Additional Information:
Responsible Party: J.R. Kroep, MD, PhD, Leiden University Medical Center Identifier: NCT02126449     History of Changes
Other Study ID Numbers: NL44684.058.13
BOOG2013-04 ( Other Identifier: BOOG )
p13.135 ( Other Identifier: CME LUMC )
First Posted: April 30, 2014    Key Record Dates
Last Update Posted: January 3, 2018
Last Verified: December 2017

Additional relevant MeSH terms:
Breast Neoplasms
Neoplasms by Site
Breast Diseases
Skin Diseases