Botensilimab and Balstilimab before Standard Chemotherapy for the Treatment of Mismatch Repair Proficient Rectal Cancer
This phase II trial tests how well botensilimab and balstilimab before standard chemotherapy work in treating patients with mismatch repair proficient (MMRp) rectal cancer. Botensilimab is a type of drug called a CTLA-4 inhibitor and balstilimab is a type of drug called a programmed cell death protein 1 (PD-1) inhibitor. The CTLA-4 protein and PD-1 act as a “brake” on the immune system. Blocking these proteins is like releasing the brakes, so the immune system can target tumor cells and destroy them. Standard chemotherapy works in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Rectal cancer that is MMRp means that cells are working normally to repair any mistakes made during the cell division process. Giving botensilimab and balstilimab before standard chemotherapy may kill more tumor cells in patients with MMRp rectal cancer.
Inclusion Criteria
- Willing and able to provide written informed consent for trial. * If participant is unable to provide written informed consent, the legally authorized representative (LAR) of the person who is being asked to participate in this research study may give consent on the participant’s behalf.
- Be ≥ 18 years of age on the date of signing informed consent.
- Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1.
- Histologically confirmed rectal adenocarcinoma.
- Adenocarcinoma with distal margin of 15 cm or less from the anal verge on endoscopy, staged with endorectal ultrasound (ERUS) or magnetic resonance imaging (MRI) as cT3/cT4 N0 or cT(any) cN1/2.
- No evidence of distant metastases.
- Radiologically measurable or clinically evaluable disease.
- Tumor specimen that demonstrates intact mismatch repair enzymes by immunohistochemistry or microsatellite stability as demonstrated by next-generation sequencing (NGS) or polymerase chain reaction (PCR).
- Negative pregnancy test done within 14 days prior to beginning treatment, for women of childbearing potential only. Subjects of childbearing potential must be willing to use an adequate method of contraception. Appropriate methods of birth control include abstinence, oral contraceptives, implantable hormonal contraceptives, or double barrier method (diaphragm plus condom). Contraception is required for the course of the study starting with the first dose of study medication through 150 days after the last dose of study medication. Note: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for the subject.
- Nonchildbearing potential is defined as follows (by other than medical reasons): * ≥ 45 years of age and has not had menses for >1 year. * Patients who have been amenorrhoeic for < 2 years without history of a hysterectomy and oophorectomy must have a follicle stimulating hormone value in the postmenopausal range upon screening evaluation. * Post-hysterectomy, post-bilateral oophorectomy, or post-tubal ligation. Documented hysterectomy or oophorectomy must be confirmed with medical records of the actual procedure or confirmed by an ultrasound. Tubal ligation must be confirmed with medical records of the actual procedure, otherwise the patient must be willing to use 2 adequate barrier methods throughout the study.
- Absolute neutrophil count (ANC) ≥ 1,500 /mm^3 (within 14 days of treatment initiation).
- Platelets ≥ 100,000 / mcL (within 14 days of treatment initiation).
- Hemoglobin ≥ 8.0 g/dL (within 14 days of treatment initiation).
- Serum creatinine OR measured or calculated creatinine clearance (glomerular filtration rate [GFR] can also be used in place of creatinine or creatinine clearance [CrCl]) ≤ 1.5 × upper limit of normal (ULN) OR ≥ 60 mL/min for subject with creatinine levels > 1.5 × institutional ULN (within 14 days of treatment initiation). * Creatinine clearance should be calculated per institutional standard.
- Serum total bilirubin. Total bilirubin ≤ 1.5 × upper limit of normal (ULN), except for subjects with known Gilbert’s disease who may enroll if the conjugated bilirubin is >= 1.5 x ULN (within 14 days of treatment initiation).
- Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT]) and alanine aminotransferase (ALT) (serum glutamic pyruvic transaminase [SGPT]) ≤ 2.5 × ULN (within 14 days of treatment initiation).
- International normalized ratio (INR) or prothrombin time (PT) or activated partial thromboplastin time (aPTT). For patients not taking warfarin: INR ≤ 1.5 or PT ≤ 1.5 x ULN; and either partial thromboplastin time (PTT) or aPTT ≤ 1.5 x ULN. Patients on warfarin may be included on a stable dose with a therapeutic INR < 3.5 (within 14 days of treatment initiation).
Exclusion Criteria
- Recurrent rectal cancer.
- Prior pelvic radiation therapy, chemotherapy, or surgery for rectal cancer.
- Tumor is causing symptomatic bowel obstruction (patients who have a temporary diverting ostomy are eligible).
- Other invasive malignancy ≤ 2 years prior to registration. Exceptions are nonmelanoma skin cancer that has undergone potentially curative therapy and in situ cervical carcinoma.
- Active infection requiring systemic therapy.
- Other anticancer or experimental therapy. No other experimental therapies (including chemotherapy, radiation, hormonal treatment, antibody therapy, immunotherapy, gene therapy, vaccine therapy, angiogenesis inhibitors, matrix metalloprotease inhibitors, thalidomide, anti-VEGF/Flk-1 monoclonal antibody or other experimental drugs) of any kind are permitted while the patient is receiving study treatment.
- Known history of interstitial lung diseases/pneumonitis.
- Known history of human immunodeficiency virus (HIV) (HIV 1/2 antibodies).
- Known active hepatitis B (e.g., hepatitis B surface antigen [HbsAg] reactive) or hepatitis C (e.g., hepatitis C virus ribonucleic acid [HCV RNA] [qualitative] is detected).
- Live vaccination within 28 days prior to receiving the first dose of immunotherapy. The use of inactivated seasonal influenza vaccines (e.g., Fluzone®) will be permitted on study without restriction.
- Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine or booster < 7 days before cycle 1 day 1 (C1D1). For vaccines requiring more than 1 dose, the full series should be completed prior to C1D1, when feasible. Booster shot not required but also must be administered > 7 days from C1D1 or > 7 days from future cycle on study.
- Clinically significant (i.e., active) cardiovascular disease: cerebral vascular accident/stroke or myocardial infarction within 180 days of enrollment, unstable angina, congestive heart failure (New York Heart Association class ≥ III), or serious uncontrolled cardiac arrhythmia requiring medication. * QTcF (QT interval corrected using Fridericia’s formula) of ≥ 450 ms.
- Known active tuberculosis.
- Receiving systemic corticosteroid therapy 1 week prior to the first dose of study drug or receiving any other form of systemic immunosuppressive medication. * Corticosteroid use as a premedication for IV contrast allergies/reactions is allowed. Subjects who are receiving daily corticosteroid replacement therapy are also an exception to this rule. Daily prednisone at doses of ≤ 7.5 mg or equivalent hydrocortisone dose are examples of permitted replacement therapy. Use of inhaled or topical corticosteroids is permitted.
- Has ongoing or recent (within 5 years) evidence of significant autoimmune disease or any other condition that required treatment with systemic immunosuppressive treatments. The following are not exclusionary: vitiligo, childhood asthma that has resolved, endocrinopathies (such as hypothyroidism or type 1 diabetes) that require only hormone replacement.
- Prior allogeneic tissue/solid organ transplant, except for corneal transplants.
Additional locations may be listed on ClinicalTrials.gov for NCT06843434.
Locations matching your search criteria
United States
New Jersey
Basking Ridge
Middletown
Montvale
New York
Commack
New York
Uniondale
West Harrison
PRIMARY OBJECTIVE:
I. To determine the best overall response rate (ORR) of combination botensilimab and balstilimab alone in patients with MMRp/microsatellite stable (MSS) locally advanced (stage II or III) rectal adenocarcinoma.
SECONDARY OBJECTIVES:
I. To determine the clinical complete response (cCR) of combination botensilimab and balstilimab alone or in combination with standard capecitabine and oxaliplatin (CAPEOX)/leucovorin, fluorouracil, and oxaliplatin (FOLFOX) in patients with MMRp/MSS locally advanced (stage II or III) rectal adenocarcinoma.
II. To determine the safety and tolerability of patients treated with botensilimab and balstilimab combination therapy.
III. To determine 3 year disease-free survival (DSF).
CORRELATIVE OBJECTIVE:
I. To investigate the relationship between candidate efficacy/resistance biomarkers and antitumor activity of balstilimab and botensilimab using pre-treatment (baseline), on-treatment, and post-treatment tumor biopsies and plasma collection, including circulating tumor deoxyribonucleic acid (ctDNA).
OUTLINE:
NEOADJUVANT TREATMENT: Patients receive botensilimab intravenously (IV) over 30 minutes on day 1 of cycle 1 and balstilimab IV over 30 minutes on days 1 and 15 of each cycle. Cycles repeat every 28 days for up to 6 cycles in the absence of disease progression or unacceptable toxicity.
ADJUVANT TREATMENT: Patients then receive standard of care chemotherapy with 1 of 2 regimens at the discretion of the treating physician.
REGIMEN 1 CAPEOX: Patients receive capecitabine orally (PO) twice daily (BID) on days 1 - 14 of each cycle and oxaliplatin IV over 130 minutes on day 1 of each cycle. Cycles repeat every 21 days for 12 weeks in the absence of disease progression or unacceptable toxicity.
REGIMEN 2 FOLFOX: Patients receive fluorouracil IV on days 1 - 2 of each cycle, oxaliplatin IV on day 1 of each cycle, and leucovorin on study. Cycles repeat every 14 days for 12 weeks in the absence of disease progression or unacceptable toxicity.
CHEMORADIATION: Patients not achieving a cCR receive standard of care chemotherapy with either CAPEOX or FOLFOX (dosing per institutional guidelines.) for 12 weeks in the absence of disease progression or unacceptable toxicity. Patients who achieve cCR continue onto non-operative management. Patients who do not achieve cCR receive capecitabine PO BID 5 days per week or fluorouracil IV continuously 5 days per week at the discretion of the treating physician and undergo concurrent radiation therapy (RT) for 27 to 30 fractions over 27 to 30 consecutive weekdays. Treatment continues for approximately 5.5 weeks in the absence of disease progression or unacceptable toxicity.
SURGERY: Patients not achieving a cCR after chemoradiation undergo standard of care surgical tumor resection on study.
Additionally, patients undergo endoscopy, biopsy, blood sample collection, computed tomography (CT) and magnetic resonance imaging (MRI) throughout the study.
After completion of study treatment, patients are followed up at 2 - 8 weeks and then every 4 - 6 months for 3 to 5 years.
Trial PhasePhase II
Trial Typetreatment
Lead OrganizationMemorial Sloan Kettering Cancer Center
Principal InvestigatorAndrea Cercek
- Primary ID24-389
- Secondary IDsNCI-2025-01601
- ClinicalTrials.gov IDNCT06843434