Cabozantinib and Pembrolizumab as First Line Therapy in Treating Patients with Cisplatin-Ineligible Metastatic, Locally Advanced, or Unresectable Urothelial Cancer
This phase II trial studies the side effects and best dose of cabozantinib when given together with pembrolizumab and how well it works as first line therapy in treating patients with cisplatin-ineligible urothelial cancer that has spread to nearby tissue or lymph nodes or has spread to other places in the body (locally advanced) or cannot be removed by surgery (unresectable). Cabozantinib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Immunotherapy with monoclonal antibodies, such as pembrolizumab, may help the body’s immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Giving cabozantinib and pembrolizumab may work better in treating patients with cisplatin-ineligible metastatic, locally advanced or unresectable urothelial cancer.
- PRE-SCREENING ELIGIBILITY: Clinically, subject is a candidate for urothelial diagnostic procedure (fresh soft-tissue biopsy or transurethral resection of bladder tumor [TURBT])
- PRE-SCREENING ELIGIBILITY: Subject meets standard of care eligibility criteria for consideration of treatment with immunotherapy using a checkpoint inhibitor following surgical resection
- Histologically proven transitional cell or urothelial carcinoma
- Metastatic (any N+ or M1) or locally advanced, unresectable (T4bN0) disease
- Measurable disease is required as determined by Response Evaluation Criteria in Solid Tumors (RECIST) version (v)1.1
- Performance status Eastern Cooperative Oncology Group (ECOG) 0 - 2
- Cisplatin-ineligibility based on >= 1 of the following: * Estimated creatinine clearance between >= 30 and < 60 ml/min (Cockcroft-Gault formula) * ECOG performance status (PS) > 1 * Hearing loss * Baseline neuropathy > grade 1 * Patient refusal
- Absolute neutrophil count (ANC) >= 1.5 x 10^9/L (without granulocyte colony-stimulation factor support within 2 weeks of screening)
- Platelet count >= 100 x 10^9/L (without platelet transfusion within 2 weeks of screening)
- Hemoglobin >= 9 g/dL (may have been transfused)
- White blood cell count (WBC) >= 2.5 x 10^9/L
- Total bilirubin level =< 1.5 x the upper limit of normal (ULN) (=< 3 x ULN for subjects with Gilbert’s disease)
- Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels =< 2.5 x ULN or AST and ALT levels =< 3 x ULN for subjects with documented metastatic disease. Patient with a history of unconjugated hyperbilirubinemia with otherwise acceptable liver enzyme levels (as per above criteria) may have higher bilirubin levels
- Urine protein/creatinine ratio (UPCR) =< 2 mg/mg (=< 113.2 mg/mmol)
- Serum creatinine =< 2.0 x ULN or calculated creatinine clearance >= 30 mL/min (>= 0.5 mL/sec) using the Cockcroft-Gault equation
- Serum albumin >= 2.8 g/dl
- Alkaline phosphatase (ALP) =< 3 x upper limit of normal (ULN). ALP =< 5 x ULN with documented bone metastases
- Negative serum or urine pregnancy test at screening for women of childbearing potential
- Highly effective contraception for both male and female subjects throughout the study and for at least 120 days after last pembrolizumab treatment administration if the risk of conception exists
- Must have recovered from adverse effects of any prior surgery, radiotherapy or other antineoplastic therapy to grade =< 2. If not recovered to grade =< 2, these must be deemed to be irreversible adverse events related to prior surgery and /or radiation therapy (such as incontinence or sexual dysfunction) per investigator clinical judgment
- Recovery to baseline or =< grade 2 Common Terminology Criteria for Adverse Events (CTCAE) v5 from toxicities related to any prior treatments, unless adverse event (AE)(s) are clinically nonsignificant and/or stable on supportive therapy. Alopecia, sensory neuropathy grade =< 2, or other grade =< 2 not constituting a safety risk based on investigator’s judgment are acceptable.
- Last dose of any radiation therapy > 2 weeks before first dose of study treatment
- Able to provide informed consent and willing to sign an approved consent form that conforms to federal and institutional guidelines
- No prior chemotherapy for metastatic urothelial carcinoma, and prior chemotherapy for localized urothelial carcinoma must have been greater than 6 months before registration
- Variant histologies other than urothelial carcinoma will not be allowed. Patients with a component of variant histologies will be allowed to enroll, if urothelial carcinoma is the predominant histology. Patients with any component of small cell will be excluded
- Has received prior treatment with cabozantinib
- Receipt of any type of small molecule kinase inhibitor (including investigational kinase inhibitor) within 2 weeks before first dose of study treatment
- Receipt of any type of cytotoxic, biologic, or other systemic anticancer therapy (including investigational) within 4 weeks before first dose of study treatment
- Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent or other checkpoint inhibitors in the adjuvant setting
- Radiation therapy for bone metastasis =< 2 weeks, any other radiation therapy within 4 weeks before first dose of study treatment. Systemic treatment with radionuclides within 6 weeks before the first dose of study treatment. Subjects with clinically relevant ongoing complications from prior radiation therapy are not eligible
- Has known active central nervous system (CNS) metastases and/or carcinomatous meningitis. Subjects with previously treated brain metastases may participate provided they are stable (without evidence of progression by imaging for at least 4 weeks prior to the first dose of trial treatment and any neurologic symptoms have returned to baseline), have no evidence of new or enlarging brain metastases, and are not using steroids for at least 7 days prior to trial treatment. This exception does not include carcinomatous meningitis which is excluded regardless of clinical stability
- Concomitant anticoagulation with oral anticoagulants (e.g., warfarin, direct thrombin and Factor Xa inhibitors) or platelet inhibitors (e.g., clopidogrel) Allowed anticoagulants are the following: * Low-dose aspirin for cardioprotection (per local applicable guidelines) * Low-dose low molecular weight heparins (LMWH) * Anticoagulation with therapeutic doses of LMWH is allowed in subjects without known brain metastases, and who have had no clinically significant hemorrhagic complications from the anticoagulation regimen or the tumor
- The subject has prothrombin time (PT)/INR or partial thromboplastin time (PTT) test >= 1.3 x ULN within 14 days before the first dose of study treatment
- Cardiovascular disorders: * Ongoing congestive heart failure exacerbation or New York Heart Association class 4, unstable angina pectoris, serious cardiac arrhythmias * Uncontrolled hypertension defined as sustained blood pressure (BP) > 150 mm Hg systolic or > 100 mm Hg diastolic despite optimal antihypertensive treatment. Uncontrolled hypertension needs to be determined based on persistently high blood pressure readings over more than 24 hours and should NOT be based on the blood pressure readings from one clinic visit. Blood pressure readings done at home or by primary care providers are acceptable. If a blood pressure reading on the day of screening is high, but there are documented acceptable (=< 150 mm Hg systolic and =< 100 mm Hg diastolic) blood pressure readings prior to or after the screening visit (with or without the use of anti-hypertensive medications), patient will not be considered to have uncontrolled hypertension * Stroke (including transient ischemic attack [TIA]), myocardial infarction (MI), or other ischemic event, or thromboembolic event (eg, deep venous thrombosis, pulmonary embolism) within 6 months before first dose * Class 3 congestive heart failure
- Gastrointestinal (GI) disorders including those associated with a high risk of perforation or fistula formation: * The subject has evidence of tumor invading the GI tract, active peptic ulcer disease, inflammatory bowel disease (e.g., Crohn’s disease), diverticulitis, cholecystitis, symptomatic cholangitis or appendicitis, acute pancreatitis, acute obstruction of the pancreatic duct or common bile duct, or gastric outlet obstruction * Abdominal fistula, GI perforation, bowel obstruction, or intraabdominal abscess within 6 months before first dose ** Note: Complete healing of an intra-abdominal abscess must be confirmed before first dose
- Clinically significant hematuria, hematemesis, or hemoptysis of > 0.5 teaspoon (2.5 ml) of red blood, or other history of significant bleeding (e.g., pulmonary hemorrhage) within 12 weeks before first dose
- Cavitating pulmonary lesion(s) or known endotracheal or endobronchial disease manifestation
- Lesions invading or encasing any major blood vessels
- Other clinically significant disorders that would preclude safe study participation: * Serious non-healing wound/ulcer/bone fracture * Uncompensated/symptomatic hypothyroidism * Moderate to severe hepatic impairment (Child-Pugh B or C).
- Other severe acute or chronic medical conditions including immune colitis, inflammatory bowel disease, immune pneumonitis, pulmonary fibrosis or psychiatric conditions including recent (within the past year) or active suicidal ideation or behavior; or laboratory abnormalities that may increase the risk associated with study participation or study treatment administration or may interfere with the interpretation of study results and, in the judgment of the investigator, would make the patient inappropriate for entry into this study
- Major surgery (e.g., GI surgery, removal or biopsy of brain metastasis) within 8 weeks before first dose of study treatment; complete wound healing from major surgery must have occurred 1 month before first dose and from minor surgery (e.g., simple excision, tooth extraction) at least 10 days before first dose; subjects with clinically relevant ongoing complications from prior surgery are not eligible
- Corrected QT interval calculated by the Fridericia formula (QTcF) > 500 ms per electrocardiogram (ECG) within 28 days before first dose of study treatment * Note: If a single ECG shows a QTcF with an absolute value > 500 ms, two additional ECGs at intervals of approximately 3 minutes must be performed after the initial ECG, and the average of these three consecutive results for QTcF will be used to determine eligibility
- Diagnosis of another malignancy within 2 years before first dose of study treatment, with the exception of those determined by the treating investigator to have a negligible risk of metastasis or death (such as adequately treated carcinoma in situ of the cervix, basal or squamous cell skin cancer, ductal carcinoma in situ treated surgically with curative intent, localized prostate cancer treated with curative intent and/or no intent for further treatment, or incidental prostate cancer)
- Current use of immunosuppressive medication, EXCEPT for the following: a. intranasal, inhaled, topical steroids, or local steroid injection (e.g., intra-articular injection); b. Systemic corticosteroids at physiologic doses =< 10 mg/day of prednisone or equivalent; c. Steroids as premedication for hypersensitivity reactions (e.g., CT scan premedication)
- Has active autoimmune disease currently requiring systemic treatment with high dose corticosteroids (dose more than physiologic replacement doses equivalent to prednisone 10 mg daily) or disease modifying immunosuppresive agents). Replacement therapy (e.g. thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, intranasal, inhaled, topical steroids, or local steroid injection) is not considered an exclusion
- Active autoimmune disease that might deteriorate significantly when receiving an immunostimulatory agent per treating physician’s clinical judgment. Subjects with diabetes type I, vitiligo, psoriasis, or hypo- or hyperthyroid diseases not requiring immunosuppressive treatment are eligible
- Prior organ transplantation including allogenic stem-cell transplantation
- Has known history of (non-infectious) pneumonitis that required steroids or has current pneumonitis
- Has an active infection currently requiring systemic (intravenous) antibiotic therapy
- Has a known history of active TB (Bacillus tuberculosis)
- Has known active hepatitis B (e.g., HBsAg reactive) or hepatitis C (e.g., HCV ribonucleic acid [RNA] [qualitative] is detected)
- Has a known history of human immunodeficiency virus (HIV) (HIV 1/2 antibodies)
- Active and inactive vaccinations within 4 weeks of the first dose of pembrolizumab and while on trial is prohibited
- Known prior severe hypersensitivity to investigational products or any component in its formulations, including known severe hypersensitivity reactions to monoclonal antibodies (National cancer institute [NCI] CTCAE v 5.0 grade >= 3)
- Is pregnant or breastfeeding, or expecting to conceive or father children within the projected duration of the trial, starting with the pre-screening or screening visit through 120 days after the last dose of trial treatment
- Subjects taking prohibited medications. A washout period of prohibited medications for a period of at least two weeks or as clinically indicated should occur prior to the start of treatment
- Inability to swallow tablets or evidence of impaired intestinal absorption
Locations & Contacts
Salt Lake City
Contact: Neeraj Agarwal
Trial Objectives and Outline
I. To evaluate measurable disease overall response rate (ORR).
I. To evaluate progression-free survival (PFS) at 6 months (PFS6).
II. To evaluate overall survival (OS).
III. To evaluate toxicities associate with the combination treatment.
I. To evaluate molecular markers for pharmacodynamic pathways associated with response.
II. To evaluate ORR and PFS6 using immune specific disease assessment criteria.
Patients receives cabozantinib orally (PO) daily on days 1-21 and pembrolizumab intravenously (IV) over 30 minutes on day 1. Cycles repeat every 21 days in the absence of disease progression or unacceptable toxicity. Treatment may continue beyond initial radiographic or clinical disease progression as long as the patient is deriving clinical benefit per physician discretion.
After completion of study treatment, patients are followed up to 6 months.
Trial Phase & Type
Huntsman Cancer Institute / University of Utah
Secondary IDs NCI-2018-02081
Clinicaltrials.gov ID NCT03534804