Ipatasertib with Aromatase Inhibitor, Fulvestrant, and/or Palbociclib in Treating Patients with Hormone Receptor Positive, HER2 Negative Locally Advanced or Metastatic Breast Cancer

Inclusion Criteria

• Biopsy proven HR+/HER2 negative breast cancer; HR+ defined as >= 1% positivity for estrogen receptor (ER), and/or progesterone receptor (PR) (>= 1%), as per local assessment. HER2 as per standard College of American Pathologists (CAP) guidelines (local assessment)
• Postmenopausal women with locally advanced or metastatic breast cancer (BC). Patients must be postmenopausal women as defined by one of the following: * Women > 60 years OR * Women =< 60 years, and any one of following: ** Luteinizing hormone (LH) and follicle stimulating hormone (FSH) level in the postmenopausal range according to institutional standards ** Surgery and procedures (s/p) post bilateral surgical oophorectomy ** Premenopausal/perimenopausal women on gonadotropin-releasing hormone agonist (to be continued during study) and estradiol level in the postmenopausal range according to institutional standards
• Disease progression on at least one prior therapy for metastatic disease, including endocrine therapy with/without CDK 4/6 inhibitor (palbociclib or ribociclib or abemaciclib). Disease recurrence during or within 12 months of completion/discontinuation of (neo)adjuvant endocrine therapy (with/without CDK 4/6 inhibitor) will count as one prior therapy for this definition. No upper limit on number of prior lines of endocrine therapy. 0-2 prior lines of chemotherapy for metastatic disease allowed. (Note: 0-2 prior line criteria refers to chemotherapy discontinued due to disease progression. Chemotherapy discontinued before one cycle of treatment or due to adverse effects would not count towards this definition for 0-2 prior line criteria)
• Eastern Cooperative Oncology Group (ECOG) performance status 0 – 2
• Evaluable or measurable disease: at least one lesion that can be accurately measured in at least one dimension >= 20 mm with conventional imaging techniques or >= 10 mm with spiral computed tomography (CT) or magnetic resonance imaging (MRI). Bone lesions in the absence of measurable disease as defined above is also acceptable
• Discontinuation of prior breast cancer therapies
• Prior mTOR inhibitor and/or PI3K inhibitor allowed (all arms)
• Prior aromatase inhibitor is allowed (all arms)
• Patients who have a history of a second malignancy are eligible, provided the malignancy has been adequately treated, there is no ongoing treatment for the second malignancy, and overall principal investigator (PI) approval is obtained
• Absolute neutrophil count (ANC) >= 1000/mm^3
• Hemoglobin >= 9 g/dl
• Platelets >= 100,000/mm^3
• Total bilirubin < 1.5 mg/dL
• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) < 3 X institutional upper limit of normal (ULN) (or 5 X Institutional ULN in presence of hepatic metastases [mets])
• Calculated creatinine clearance >= 30 mL/min
• Fasting blood glucose < 140 mg/dL
• Hemoglobin A1c < 7
• Signed informed consent and agree to comply with study procedures
• Patient is a good candidate for the study, as per treating investigator
• Confirmation of adequate archival tissue (20 unstained slides cut at 5 um or 1 block) or pre-treatment biopsy required before study entry. If adequate tissue is not available, principal investigator (PI) approval is required prior to study entry

Exclusion Criteria

• Participants with progressive central nervous system (CNS) metastatic disease. Patients with stable CNS metastasis would be eligible, provided mets radiologically decreasing/stable for at least one month, and patient is not actively taking steroids
• Participants who have had anti-cancer therapy, including endocrine therapy or targeted therapy or antibody-based therapy or immunotherapy or chemotherapy or radiotherapy, within 2 weeks prior to entering the study or those who have not recovered from clinically significant adverse events (grade 2 or higher). Asymptomatic lab abnormality (grade 2 or higher) could be allowed after discussion and approval by PI
• Prior use of AKT inhibitor (any setting)
• Treatment with strong CYP3A inhibitors or strong CYP3A inducers within 14 days or 5 drug-elimination half-lives, whichever is longer, prior to initiation of study treatment. Because the lists of these agents are constantly changing, it is important to regularly consult a frequently-updated list; medical reference texts such as the Physicians’ Desk Reference may also provide this information. As part of the enrollment/informed consent procedures, the patient will be counseled on the risk of interactions with other agents, and what to do if new medications need to be prescribed or if the patient is considering a new over-the-counter medicine or herbal product
• Uncontrolled inter-current illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements. Patient has impairment of gastrointestinal (GI) function or GI disease that may significantly alter the absorption of the study drugs (e.g., inflammatory bowel disease, ulcerative diseases, uncontrolled nausea, vomiting, diarrhea, malabsorption syndrome, or small bowel resection)
• Clinically significant, uncontrolled heart disease and/or cardiac repolarization abnormality including any of the following: * History of angina pectoris, symptomatic pericarditis, coronary artery bypass graft (CABG) or myocardial infarction within 6 months prior to study entry * Known (documented) cardiomyopathy, i.e. known left ventricular ejection fraction (LVEF) < 50% (echocardiogram [ECHO] or multigated acquisition scan [MUGA] not needed specifically for this trial) * History of cardiac failure, significant/symptomatic bradycardia, long QT syndrome, family history of idiopathic sudden death or congenital long QT syndrome or any of the following: * Known risk to prolong the QT interval or induce Torsade’s de Pointes * Uncorrected hypomagnesemia or hypokalemia of grade 3 or higher * Systolic blood pressure (SBP) > 160 mmHg or < 90 mmHg * Bradycardia (heart rate < 50 at rest), by electrocardiography (ECG) (based on a mean of 3 ECGs) or pulse * On screening, Fridericia's correction formula (QTcF) > 470 screening ECG (based on a mean of 3 ECGs)
• History of clinically significant, uncontrolled gastrointestinal (GI) toxicity that lead to discontinuation of a previous oral cancer therapy regimen
• Uncontrolled pleural effusion, pericardial effusion, or ascites, as judged by the investigator
• Human immunodeficiency virus (HIV)-positive participants on combination antiretroviral therapy are ineligible. These participants are at increased risk of lethal infections when treated with marrow-suppressive therapy. Appropriate studies will be undertaken in participants receiving combination antiretroviral therapy when indicated
• History of type I or type II diabetes mellitus requiring insulin. Patients who are on a stable dose of oral diabetes medication >= 2 weeks prior to initiation of study treatment are eligible for enrollment. Patients must meet the laboratory eligibility criteria for fasting blood glucose and hemoglobin A1c as outlined in the inclusion criteria
• Pregnant women are excluded from this study because the safety of study medications is not established in pregnant women
• Women of child-bearing potential, defined as all women physiologically capable of becoming pregnant, unless they are using highly effective methods of contraception throughout the study and for 8 weeks after study drug discontinuation. In the case of bilateral oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment is she considered not of child bearing potential. Highly effective contraception methods include: * Total abstinence when this is in line with the preferred and usual lifestyle of the patient. Periodic abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable methods of contraception * Female sterilization (have had surgical bilateral oophorectomy with or without hysterectomy), total hysterectomy, or tubal ligation at least six weeks before taking study treatment. In case of oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment * Use of oral, injected or implanted hormonal methods of contraception or placement of an intrauterine device (IUD) or intrauterine system (IUS), or other forms of hormonal contraception that have comparable efficacy (failure rate < 1%), for example hormone vaginal ring or transdermal hormone contraception * In case of use of oral contraception, women should have been stable on the same pill for a minimum of 3 months before taking study treatment ** Note: While oral contraceptives are allowed, they should be used in conjunction with a barrier method of contraception due to unknown effect of drug-drug interaction
• For Arm C only: history of (h/o) of intolerable toxicity to CDK 4/6 inhibitor resulting in treatment discontinuation due to toxicity
• Any other disease, metabolic dysfunction, physical examination finding, or clinical laboratory finding that, in the investigator's opinion, gives reasonable suspicion of a disease or condition that contraindicates the use of an investigational drug or that may affect the interpretation of the results or render the patient at high risk from treatment complications
• Patient has any condition that would preclude enrollment, as per investigator judgement