NC318 Alone or in Combination with Pembrolizumab for the Treatment of Locally Advanced or Metastatic Non-small Cell Lung Cancer

Inclusion Criteria

• Age >= 18 years
• Histologically or cytologically documented, locally advanced or metastatic (i.e., stage IIIB not eligible for definitive chemoradiotherapy, stage IV, or recurrent) NSCLC (per the American Joint Committee/American Joint Committee on Cancer [AJCC] staging system)
• Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 1
• Measurable disease, as defined by RECIST v1.1. Previously irradiated lesions can be counted as target lesions if clearly progressing after radiation
• Arm 1a, 1b, and 1c: Prior PD-1 axis inhibitor therapy (anti-PD-1 or anti-PD-L1, e.g. nivolumab, pembrolizumab, atezolizumab, durvalumab, avelumab) either alone or in combination with other systemic agents, with documented progressive disease
• Arms 2 and 2a: PD-L1 expression of less than 50 percent (PD-1 axis inhibitor therapy naïve)
• Patients with NSCLC known to harbor an ALK rearrangement, ROS1 rearrangement, EGFR mutation or BRAF mutation known to be sensitive to Food and Drug Administration (FDA) approved tyrosine kinase inhibitors (TKIs), are only eligible after experiencing disease progression (during or after treatment) or intolerance to respective TKI: * Patients with TKI treated EGFR mutant NSCLC harboring the secondary EGFR T790M tumor must have received prior osimertinib * Patients with crizotinib treated ALK rearranged NSCLC must have received a next generation ALK inhibitor (e.g. ceritinib, alectinib, brigatinib or lorlatinib)
• At least one tumor amenable to incisional, excisional, core or forceps (transbronchial) biopsy. Patients must be willing to undergo a tumor biopsy before starting trial therapy and at the time of disease progression
• For female patients of childbearing potential and male patients with partners of childbearing potential, agreement (by patient and/or partner) to use a highly effective form(s) of contraception (i.e., one that results in a low failure rate [< 1% per year] when used consistently and correctly) and to continue its use for 6 months after the last dose of trial therapy. Highly effective contraception is one with a failure rate of < 0.1%. Birth control pills on their own do not achieve that rate * Women of childbearing potential must have a negative pregnancy test (serum or urine) within 72 hours of the start of study drug administration * Women who have recently given birth must no longer be breastfeeding
• Neutrophils >= 1000 cells/uL (without granulocyte colony-stimulating factor support within 2 weeks prior to initiation of trial therapy) (obtained within 14 days prior to the first study treatment)
• Platelets >= 75,000/uL (transfusion to achieve this level is not permitted within 2 weeks of the first study drug administration) (obtained within 14 days prior to the first study treatment)
• Hemoglobin >= 8.0 g/dL (obtained within 14 days prior to the first study treatment)
• Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) =< 3 x institutional upper limit of normal (ULN) with the following exceptions: Patients with documented liver metastases: AST and/or ALT =< 5 x ULN (obtained within 14 days prior to the first study treatment)
• Serum bilirubin =< 1.5 x ULN (Patients with known Gilbert disease who have serum bilirubin level =< 3 x ULN may be enrolled) (obtained within 14 days prior to the first study treatment)
• Serum creatinine =< 1.5 x ULN or creatinine clearance >= 50 mL/min (obtained within 14 days prior to the first study treatment)

Exclusion Criteria

• Has an active autoimmune disease requiring systemic treatment within the past 3 months or a documented history of clinically severe autoimmune disease, or a syndrome that requires systemic steroids or immunosuppressive agents. Subjects with vitiligo or resolved childhood asthma/atopy would be an exception to this rule. Subjects who require intermittent use of inhaled steroids or local steroid injections would not be excluded from the study. Subjects with hypothyroidism stable on hormone replacement, or psoriasis not requiring systemic therapy (within the past 3 years) will not be excluded from the study
• Interstitial lung disease that is symptomatic or may interfere with the detection or management of suspected drug-related pulmonary toxicity
• History of non-infectious pneumonitis requiring steroids or current pneumonitis
• Subjects must not have a history of life-threatening toxicity related to prior anti-PD-1 axis therapy: * Subjects with history of anti-PD-1 axis therapy toxicities that are unlikely to recur with standard countermeasures (e.g., hormone replacement after adrenal crisis) are eligible
• Symptomatic or untreated central nervous system (CNS) metastases. Patients with a history of treated asymptomatic CNS metastases are eligible, provided they meet all of the following criteria: * No evidence of interim progression between the completion of CNS-directed therapy and the start of trial therapy * No ongoing requirement for dexamethasone as therapy for CNS disease; anticonvulsants at a stable dose are allowed * Completed stereotactic radiosurgery at least 1 week prior to initiation of trial therapy or whole-brain radiation at least 2 weeks prior to initiation of trial therapy
• History of leptomeningeal carcinomatosis
• Prior palliative radiotherapy outside the CNS within 2 weeks of the first dose of study drug
• Treatment with systemic immunosuppressive medications (including but not limited to, dexamethasone at doses > 2 mg daily (or equivalent dose of other corticosteroids), cyclophosphamide, tacrolimus, sirolimus, azathioprine, methotrexate, thalidomide, and antitumor necrosis factor [anti-TNF] agents) within 2 weeks prior to initiating trial therapy (Inhaled or topically applied steroids, and acute and chronic standard-dose nonsteroidal antiinflammatory drugs (NSAIDs) are permitted. Replacement steroids are also permitted). Prophylactic corticosteroids prior to imaging with intravenous contrast are allowed per institutional guidelines, without need for delay of 2 weeks
• Subjects must not have received vaccines containing live virus for prevention of infectious diseases within 12 weeks prior to the first dose of study drug * The use of inactivated seasonal influenza vaccines (e.g., Fluzone [registered trademark]) will be permitted on study without restriction
• Any approved systemic anti-cancer therapy, within 3 weeks prior to initiation of study treatment; the following exception is allowed: * TKIs approved for treatment of NSCLC discontinued > 7 days prior to initiation of trial therapy. The baseline scan must be obtained after discontinuation of prior TKIs
• Treatment with any other investigational agent or participation in another clinical trial with therapeutic intent within 21 days prior to enrollment; the following exceptions are allowed: * Unapproved/experimental TKIs discontinued 14 days prior to cycle 1, day 1
• Known infection with human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV). Patients with prior exposure to hepatitis, but no evidence of active or chronic infection, may be eligible * Subjects with positive hepatitis C antibody and negative quantitative hepatitis C by polymerase chain reaction are eligible
• Active systemic infection requiring systemic antibiotic treatment within 72 hours prior to first dose of study treatment
• Uncontrolled intercurrent illness including, but not limited to, symptomatic congestive heart failure, unstable angina pectoris, or psychiatric illness/social situations that would limit compliance with study requirements
• Major surgery or traumatic injury within 4 weeks of starting study drug
• Women who are pregnant or lactating
• Any underlying medical condition that in the Principal Investigator’s opinion will make the administration of study drug hazardous to the patient or would obscure the interpretation of adverse events
• Grade 4 amylase or lipase elevation
• Arms 2 and 2a: No prior PD-1 axis inhibitor therapy