Carboplatin, Pemetrexed, and Bevacizumab with or without Atezolizumab for the Treatment of Stage IV Non-squamous Non-small Cell Lung Cancer
- Patients must have histologically or cytologically confirmed stage IV non-squamous non-small cell lung cancer
- Patients must either have tumors that harbor an EGFR mutation in exon 19 or exon 21, or must be never smoker wild-types. Never smoker wild-types are defined as patients with tumors without an ALK or ROS1 rearrangement, and are not harboring any EGFR mutation (this includes exons 19 or 21, exon 20, and any other rare EGFR mutations). Never smoker wild-type patients must have smoked less than 100 cigarettes in a lifetime. Patients with an EGFR mutation in exon 19 or 21 may be included irrespective of their smoking history. If tissue-based testing for EGFR mutation status is not available, blood-based EGFR testing that confirms presence of a mutation in exon 19 or 21 is acceptable, and these patients may be included in the study
- Patients must have measurable disease by computed tomography (CT) or magnetic resonance imaging (MRI), defined as at least one lesion that can be accurately measured in at least one dimension in accordance with Response Evaluation Criteria in Solid Tumors (RECIST) criteria version (v) 1.1
- Patients with tumors that harbor an EGFR exon 19 or exon 21 mutation must have received prior treatments with one or more tyrosine kinase inhibitors (TKIs). A washout period of at least 2 weeks is required to begin treatment in this trial. Patients who are never smoker wild-types must be treatment naive
- All patients must be chemotherapy, vascular endothelial growth factor (VEGF) therapy, and immunotherapy naive, with the exception of prior oral TKIs which are required for EGFR mutated patients. The number of prior oral TKIs and duration of use is neither specified nor limited
- Patients with a history of treated asymptomatic central nervous system (CNS) metastases are eligible, provided they meet all of the following criteria: * Only supratentorial and cerebellar metastases allowed (i.e., no metastases to midbrain, pons, medulla or spinal cord) * No ongoing requirement for corticosteroids as therapy for CNS disease * No stereotactic radiation within 7 days or whole-brain radiation within 14 days prior to randomization * No evidence of interim progression between the completion of CNS-directed therapy and the screening radiographic study
- Patients with new asymptomatic CNS metastases detected at the screening scan must receive radiation therapy and/or surgery for CNS metastases. Following treatment, these patients may then be eligible without the need for an additional brain scan prior to randomization, if all other criteria are met
- Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1
- The use of granulocyte colony-stimulating factor (G-CSF) should follow standard recommendations and physician discretion
- Absolute neutrophil count > 1,500/mcL
- Hemoglobin >= 9.0 mg/ml. If blood transfusion is performed for achieving hemoglobin levels, the levels should stay at >= 9.0 mg/ml for at least a week after transfusion
- Platelets > 100,000/mcL
- Total bilirubin =< 1.5 x institutional upper limit of normal (ULN)
- Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) (serum glutamic oxaloacetic transaminase [SGOT]/serum glutamate pyruvate transaminase [SGPT]) < 3 times institutional normal limits, or up to 5 times institutional normal limits if the patient has liver metastases
- Creatinine =< 1.5 x ULN OR creatinine clearance > 40 Ml/min/1.73 m^2 for patients with creatinine levels above institutional normal as per Cockcroft-Gault formula
- International normalized ratio (INR) or prothrombin time (PT) =< 1.5 x ULN unless subject is receiving anticoagulant therapy as long as PT or partial thromboplastin time (PTT) is within therapeutic range of intended use of anticoagulants
- Activated partial thromboplastin time (aPTT) < 1.5 x ULN unless subject is receiving anticoagulant therapy as long as PT or PTT is within therapeutic range of intended use of anticoagulants
- Thyroid stimulating hormone (TSH) within normal limits. If TSH is not within normal limits at baseline, the subject will still be eligible if total T3 or free T4 are within normal limits
- Patients on full-dose anticoagulation must be on a stable dose (minimum duration 14 days) of oral anticoagulant or low molecular weight heparin (LMWH). If receiving warfarin, the patient must have an INR =< 3.0. For heparin and LMWH there should be no clinically significant active bleeding (with no bleeding within 14 days prior to first dose of protocol therapy) or pathological condition present that carries a high risk of bleeding (for example, tumor involving major vessels or known varices)
- Ability to understand and willingness to sign a written informed consent and Health Insurance Portability and Accountability Act (HIPAA) consent document
- A core biopsy must be available for the study. The biopsy sample must be adequate for analyses. If the sample is not adequate, the patient must agree to provide a fresh biopsy specimen before the start of treatment. Any available archival tissue will also be collected
- Urinary protein must be =< 1+ on dipstick or routine urinalysis (UA; if urine dipstick or routine analysis is >= 2+, a 24 hour urine collection for protein must demonstrate < 1000 mg of protein in 24 hours to allow participation in the protocol)
- Female subjects of child-bearing potential must be willing to use an effective method of contraception for the course of the study through at least 6 months after the last dose of study medication
- Male patients who have women of childbearing potential (WOCBP) partners must agree to use effective method of contraception for the course of the study through 8 months after the last dose of study medication
- Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for the subject
- Patients currently receiving any other investigational agents, immunomodulatory agents, chemotherapy, or TKIs. EGFR mutation-positive patients must have received prior TKI treatment
- The patient has experienced any grade 3-4 gastrointestinal (GI) bleeding within 3 months prior to first dose of protocol therapy
- The patient has a history of deep vein thrombosis (DVT), pulmonary embolism (PE), or any other significant thromboembolism (venous port or catheter thrombosis or superficial venous thrombosis are not considered “significant”) during the 3 months prior to the first dose of protocol therapy
- Subjects with untreated CNS metastases are excluded, even if they are asymptomatic. Patients with treated asymptomatic brain metastases will be allowed if brain imaging obtained within 28 days of trial enrollment reveals stable disease
- Cirrhosis at a level of Child-Pugh B or worse, or cirrhosis of any degree and a history of hepatic encephalopathy, or clinically meaningful ascites resulting from cirrhosis. Clinically meaningful ascites is defined as ascites from cirrhosis requiring diuretics or paracentesis
- The patient has experienced any arterial thromboembolic events, including but not limited to myocardial infarction, transient ischemic attack, cerebrovascular accident, or unstable angina, within 6 months prior to first dose of protocol therapy
- The patient has uncontrolled or poorly-controlled hypertension (> 150 mmHg systolic or > 100 mmHg diastolic for > 4 weeks) despite standard medical management or
- Prior history of hypertensive crisis or hypertensive encephalopathy
- Significant vascular disease (e.g., aortic aneurysm requiring surgical repair or recent peripheral arterial thrombosis) within 6 months prior to randomization
- Evidence of bleeding diathesis or coagulopathy (in the absence of therapeutic anticoagulation)
- History of abdominal or tracheoesophageal fistula or gastrointestinal perforation within 6 months prior to randomization
- Clinical signs of gastrointestinal obstruction or requirement for routine parenteral hydration, parenteral nutrition, or tube feeding
- Evidence of abdominal free air not explained by paracentesis or recent surgical procedure
- Serious, non-healing wound, active ulcer, or untreated bone fracture within 28 days prior to first dose of protocol therapy
- Subjects with a history of smoking greater than a 100 cigarettes in a lifetime, unless their tumor has an EGFR exon 19 or exon 21 mutation
- Patients with active, suspected, or known autoimmune disease that has required systemic treatment in the past one year (i.e., with use of disease modifying agents, corticosteroids or immunosuppressive drugs). Hormone replacement therapy (e.g. thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment
- Patients with a history of hemoptysis (defined as bright red blood or >= 1/2 teaspoons) within 1 month prior to first dose of protocol therapy or with radiographic evidence of major blood vessel invasion or encasement by cancer
- The patient has undergone major surgery within 28 days prior to first dose of study treatment, or minor surgery/ subcutaneous venous access device placement within 7 days prior to first dose of protocol therapy. The patient has elective or planned major surgery to be performed during the course of the clinical trial
- The patient is receiving chronic anti-platelet therapy other than aspirin, including non-steroidal anti-inflammatory drugs (NSAIDs, including ibuprofen, naproxen, and others), dipyridamole or clopidogrel, or similar agents. Once-daily aspirin use (maximum dose 325 mg/day) is permitted. Occasional use of NSAIDs is allowed (for example daily use for less than a week; treating physician discretion is permitted to differentiate between occasional versus [vs] chronic use)
- Patients who have not recovered from adverse events due to agents administered earlier except neuropathy and alopecia. Physician’s discretion is allowed to decide which unresolved adverse events from previous therapy (for NSCLC) prohibit patient participation in this study
- Patients requiring more than 10 mg prednisolone (or its equivalent) per day are excluded
- Patients with any evidence of current interstitial lung disease (ILD) or pneumonitis or a prior history of ILD or pneumonitis requiring oral or IV glucocorticoids * History of radiation pneumonitis in the radiation field (fibrosis) is permitted
- Patients with active tuberculosis infection are excluded
- Patients who have received a live vaccine within 30 days prior to cycle 1 day 1
- Uncontrolled illness including, but not limited to, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia (significant), cirrhosis, or psychiatric illness/ social situations that would limit compliance with the study requirements
- Known history of testing positive for immunodeficiency virus (HIV) or known acquired immunodeficiency syndrome (AIDS)
- Known history of chronic hepatitis B virus infection or chronic hepatitis C virus indicating chronic infection that is not cured
- Subjects with previous malignancies (except non-melanoma skin cancers, and in situ cancers, such as, bladder, gastric, colon, cervical/dysplasia, melanoma, or breast) are excluded unless a complete remission was achieved at least 2 years prior to study registration and no additional therapy is required or anticipated to be required during the study period
- Leptomeningeal disease
- Uncontrolled tumor-related pain * Patients requiring pain medication must be on a stable regimen at study entry * Symptomatic lesions amenable to palliative radiotherapy (e.g., bone metastases or metastases causing nerve impingement) should be treated prior to randomization. Patients should be recovered from the effects of radiation. There is no required minimum recovery period * Asymptomatic metastatic lesions whose further growth would likely cause functional deficits or intractable pain (e.g., epidural metastasis that is not currently associated with spinal cord compression) should be considered for locoregional therapy, if appropriate, prior to randomization
- Uncontrolled pleural effusion, pericardial effusion, or ascites requiring recurrent drainage procedures (once monthly or more frequently) * Patients with indwelling catheters (e.g., PleurX) are allowed
- Calcium (Ca) > 12 mg/dl or corrected serum calcium > ULN * Patients who are receiving denosumab prior to randomization must be willing and eligible to receive a bisphosphonate instead while in the study
- Pregnant or breast feeding
- Known hypersensitivity to Chinese hamster ovary cell products or any of the study drugs
- Prior allogeneic bone marrow transplantation or solid organ transplant
- Clear tumor infiltration into the thoracic great vessels is seen on imaging
- Clear cavitation of pulmonary lesions is seen on imaging
- Subjects with squamous cell carcinoma of the lung
- Subjects with a lung tumor with a known ALK or ROS1 rearrangement or an EGFR mutation other than in exon 19 or exon 21
I. To compare progression free survival (PFS) in patients receiving atezolizumab in addition to a platinum doublet and bevacizumab (Arm A) to those receiving a platinum doublet and bevacizumab without atezolizumab (Arm B), in stage IV non-squamous non-small cell lung cancer (NSCLC) patients who are with tumors that harbor an EGFR mutation in exon 19 or exon 21, or who are never smoker wild-types.
I. To perform a safety analysis in all treated subjects.
II. To compare the overall response rate (ORR) of Arm A to Arm B.
III. To compare the duration of response of Arm A to Arm B.
IV. To compare the time to response of Arm A to Arm B.
V. In the subset of patients with tumors with a known EGFR exon 19 or 21 mutation, to compare PFS and overall survival (OS) of Arm A to Arm B.
CORRELATIVE AND EXPLORATORY OBJECTIVES:
I. Correlative studies will evaluate biomarkers of the signaling network, tumor microenvironment, and study molecular mechanisms of resistance in tissue and blood, and correlate with response to therapy.
II. Characterize potential contributions of metabolites of estrogen to lung cancer.
III. Exploratory studies that characterize T-cell subpopulations will be performed on blood and tissue samples.
OUTLINE: Patients are randomized to 1 of 2 arms.
ARM A: Patients receive carboplatin intravenously (IV) over 30 minutes, pemetrexed disodium IV over 10 minutes, bevacizumab IV over 30 minutes, and atezolizumab IV over 30-60 minutes on day 1. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Beginning in cycle 5, patients receive pemetrexed disodium IV over 10 minutes, bevacizumab IV over 30 minutes, and atezolizumab IV over 30-60 minutes on day 1. Cycles repeat every 21 days in the absence of disease progression or unacceptable toxicity.
ARM B: Patients receive carboplatin IV over 30 minutes, pemetrexed disodium IV over 10 minutes, and bevacizumab IV over 30 minutes on day 1. Treatment repeats every 21 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Beginning in cycle 5, patients receive pemetrexed disodium IV over 10 minutes and bevacizumab IV over 30 minutes on day 1. Cycles repeat every 21 days in the absence of disease progression or unacceptable toxicity.
After completion of study treatment, patients are followed up at 3 weeks, and then at 30 and 100 days.
Trial Phase Phase II
Trial Type Treatment
Fox Chase Cancer Center
Joseph Anthony Treat
- Primary ID TH-138
- Secondary IDs NCI-2019-06174
- Clinicaltrials.gov ID NCT03786692