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

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ClinicalTrials.gov Identifier: NCT02126449
Recruitment Status : Completed
First Posted : April 30, 2014
Last Update Posted : October 24, 2019
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

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 131 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
Actual Study Start Date : February 2014
Actual Primary Completion Date : November 2018
Actual Study Completion Date : November 2018

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 ]

Information from the National Library of Medicine

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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 ClinicalTrials.gov identifier (NCT number): NCT02126449

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Leids Universitair Medisch Centrum
Leiden, Zuid-holland, Netherlands, 2333ZA
Medisch Centrum Alkmaar
Alkmaar, Netherlands
Amsterdam, Netherlands
Alexander Monro hospital
Bilthoven, Netherlands
Amphia Hospital
Breda, Netherlands
Deventer Hospital
Deventer, Netherlands
Ziekenhuis Gelderse Valei
Ede, Netherlands
, Catharina ziekenhuis Hospital
Eindhoven, Netherlands
Kennemer gasthuis
Haarlem, Netherlands
Medisch Centrum Leeuwarden
Leeuwarden, Netherlands
Bronovo Hospital
The Hague, Netherlands
Haga Hospital
The Hague, Netherlands
VieCurie Hospital
Venlo, Netherlands
Lange Land Hospital
Zoetermeer, Netherlands
Zwolle, Netherlands
Sponsors and Collaborators
Leiden University Medical Center
Borstkanker Onderzoek Groep
Pink Ribbon Inc.
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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:
Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
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Responsible Party: J.R. Kroep, MD, PhD, Leiden University Medical Center
ClinicalTrials.gov Identifier: NCT02126449    
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: October 24, 2019
Last Verified: October 2019
Additional relevant MeSH terms:
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Breast Neoplasms
Neoplasms by Site
Breast Diseases
Skin Diseases