Nivolumab with or without ipilimumab in patients with recurrent or metastatic cervical cancer (CheckMate 358): a phase 1-2, open-label, multicohort trial

BACKGROUND

In preliminary findings from the recurrent or metastatic cervical cancer cohort of CheckMate 358, nivolumab showed durable anti-tumour responses, and the combination of nivolumab plus ipilimumab showed promising clinical activity. Here, we report long-term outcomes from this cohort.

METHODS

CheckMate 358 was a phase 1-2, open-label, multicohort trial. The metastatic cervical cancer cohort enrolled patients from 30 hospitals and cancer centres across ten countries. Female patients aged 18 years or older with a histologically confirmed diagnosis of squamous cell carcinoma of the cervix with recurrent or metastatic disease, an Eastern Cooperative Oncology Group performance status of 0 or 1, and up to two previous systemic therapies were enrolled into the nivolumab 240 mg every 2 weeks group, the randomised groups (nivolumab 3 mg/kg every 2 weeks plus ipilimumab 1 mg/kg every 6 weeks [NIVO3 plus IPI1] or nivolumab 1 mg/kg every 3 weeks plus ipilimumab 3 mg/kg every 3 weeks for four cycles then nivolumab 240 mg every 2 weeks [NIVO1 plus IPI3]), or the NIVO1 plus IPI3 expansion group. All doses were given intravenously. Patients were randomly assigned (1:1) to NIVO3 plus IPI1 or NIVO1 plus IPI3 via an interactive voice response system. Treatment continued until disease progression, unacceptable toxicity, or consent withdrawal, or for up to 24 months. The primary endpoint was investigator-assessed objective response rate. Anti-tumour activity and safety were analysed in all treated patients. This study is registered with ClinicalTrials.gov (NCT02488759) and is now completed.

FINDINGS

Between October, 2015, and March, 2020, 193 patients were recruited in the recurrent or metastatic cervical cancer cohort of CheckMate 358, of whom 176 were treated. 19 patients received nivolumab monotherapy, 45 received NIVO3 plus IPI1, and 112 received NIVO1 plus IPI3 (45 in the randomised group and 67 in the expansion group). Median follow-up times were 19·9 months (IQR 8·2-44·8) with nivolumab, 12·6 months (7·8-37·1) with NIVO3 plus IPI1, and 16·7 months (7·2-27·5) with pooled NIVO1 plus IPI3. Objective response rates were 26% (95% CI 9-51; five of 19 patients) with nivolumab, 31% (18-47; 14 of 45 patients) with NIVO3 plus IPI1, 40% (26-56; 18 of 45 patients) with randomised NIVO1 plus IPI3, and 38% (29-48; 43 of 112 patients) with pooled NIVO1 plus IPI3. The most common grade 3-4 treatment-related adverse events were diarrhoea, hepatic cytolysis, hyponatraemia, pneumonitis, and syncope (one [5%] patient each; nivolumab group), diarrhoea, increased gamma-glutamyl transferase, increased lipase, and vomiting (two [4%] patients each; NIVO3 plus IPI1 group), and increased lipase (nine [8%] patients) and anaemia (seven [6%] patients; pooled NIVO1 plus IPI3 group). Serious treatment-related adverse events were reported in three (16%) patients in the nivolumab group, 12 (27%) patients in the NIVO3 plus IPI1 group, and 47 (42%) patients in the pooled NIVO1 plus IPI3 group. There was one treatment-related death due to immune-mediated colitis in the NIVO1 plus IPI3 group.

INTERPRETATION

Nivolumab monotherapy and nivolumab plus ipilimumab combination therapy showed promise in the CheckMate 358 study as potential treatment options for recurrent or metastatic cervical cancer. Future randomised controlled trials of nivolumab plus ipilimumab or other dual immunotherapy regimens are warranted to confirm treatment benefit in this patient population.

FUNDING

Bristol Myers Squibb and Ono Pharmaceutical.

Clinical Translation and Validation of a Predictive Biomarker for Patritumab, an Anti-human Epidermal Growth Factor Receptor 3 (HER3) Monoclonal Antibody, in Patients With Advanced Non-small Cell Lung Cancer

Background

During early clinical development, prospective identification of a predictive biomarker and validation of an assay method may not always be feasible. Dichotomizing a continuous biomarker measure to classify responders also leads to challenges. We present a case study of a prospective–retrospective approach for a continuous biomarker identified after patient enrollment but defined prospectively before the unblinding of data. An analysis of the strengths and weaknesses of this approach and the challenges encountered in its practical application are also provided.

Methods

HERALD (NCT02134015) was a double-blind, phase 2 study in patients with non-small cell lung cancer (NSCLC) randomized to erlotinib with placebo or with high or low doses of patritumab, a monoclonal antibody targeted against human epidermal growth factor receptor 3 (HER3). While the primary objective was to assess safety and progression-free survival (PFS), a secondary objective was to determine a single predictive biomarker hypothesis to identify subjects most likely to benefit from the addition of patritumab. Although not identified as the primary biomarker in the study protocol, on the basis of preclinical results from 2 independent laboratories, expression levels of the HER3 ligand heregulin (HRG) were prospectively declared the predictive biomarker before data unblinding but after subject enrollment. An assay to measure HRG mRNA was developed and validated. Other biomarkers, such as epidermal growth factor receptor (EGFR) mutation status, were also evaluated in an exploratory fashion. The cutoff value for high vs. low HRG mRNA levels was set at the median delta threshold cycle. A maximum likelihood analysis was performed to evaluate the provisional cutoff. The relationship of HRG values to PFS hazard ratios (HRs) was assessed as a measure of internal validation. Additional NSCLC samples were analyzed to characterize HRG mRNA distribution.

Results

The subgroup of patients with high HRG mRNA levels (“HRG-high”) demonstrated clinical benefit from patritumab treatment with HRs of 0.37 (P = 0.0283) and 0.29 (P = 0.0027) in the high- and low-dose patritumab arms, respectively. However, only 102 of the 215 randomized patients (47.4%) had sufficient tumor samples for HRG mRNA measurement. Maximum likelihood analysis showed that the provisional cutoff was within the optimal range. In the placebo arm, the HRG-high subgroup demonstrated worse prognosis compared with HRG-low. A continuous relationship was observed between increased HRG mRNA levels and lower HR. Additional NSCLC samples (N = 300) demonstrated a similar unimodal distribution to that observed in this study, suggesting that the defined cutoff may be applicable to future NSCLC studies.

Conclusions

The prospective–retrospective approach was successful in clinically validating a probable predictive biomarker. Post hoc in vitro studies and statistical analyses permitted further testing of the underlying assumptions. However, limitations of this analysis include the incomplete collection of adequate tumor tissue and a lack of stratification. In a phase 3 study, findings are being confirmed, and the HRG cutoff value is being further refined.

ClinicalTrials.gov Number

NCT02134015.

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High heregulin levels predict benefit from patritumab treatment in patients with NSCLC.

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A prospective–retrospective approach provisionally validated a predictive biomarker.

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Post hoc analyses can be used to test underlying assumptions in biomarker validation.

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The median may be a reasonable initial cutoff for a unimodal continuous biomarker.

A randomized, open-label phase II study of efatutazone in combination with FOLFIRI as second-line therapy for metastatic colorectal cancer (mCRC)

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Background: Efatutazone, a highly-selective peroxisome proliferator-activated receptor gamma (PPARγ) agonist, has shown efficacy and manageable toxicity in phase I trials in solid tumors, including CRC. This study evaluated efatutazone in combination with chemotherapy for second-line mCRC. Methods: Patients (pts) from the United States and Latin America with mCRC progressing after first-line therapy not containing irinotecan were stratified by Eastern Cooperative Oncology Group (ECOG) status (0/1 vs. 2) and randomized 1:1 to efatutazone + FOLFIRI (E+F) or FOLFIRI alone (F). Treatment was administered in 4-week cycles until disease progression (PD), unacceptable toxicity, or consent withdrawal. Efatutazone (0.5 mg) was administered orally, twice daily; FOLFIRI (irinotecan 180 mg/m2, leucovorin 400 mg/m2, 5-fluorouracil 1200 mg/m2/d x 2 days) was administered intravenously once every 2 weeks immediately after efatutazone. The primary end point, progression-free survival (PFS) rate at week 16, was assessed locally according to Response Evaluation Criteria In Solid Tumors (RECIST) v1.0. Results: Characteristics of the 100 randomized pts were generally well balanced between the E+F and F treatment arms: median age, 59.7 vs. 58.3 years; male, 56% vs 56%; and ECOG 0/1, 98% vs. 92%. Across the arms, more pts discontinued due to PD than toxicity: 49% vs. 19%, respectively. While PFS rate at week 16 was 60% vs. 67% for the E+F vs F arms (p = 0.30), overall, PFS was somewhat longer with E+F than with F (hazard ratio [HR], 0.87; 90% [confidence interval [CI], 0.57–1.32) with medians of 4.4 vs. 4.2 months, respectively. The objective response rate also favored E+F over F (20% vs. 14%). Overall survival was not significantly different (HR, 0.95; 90% CI, 0.65–1.38). Fluid retention, which was managed with diuretics, was more frequent with E+F than with F: 86% vs. 12% (grade 3/4: 12% vs. 0%). Hematologic adverse events, including neutropenia (66% vs. 20%; grade 3/4: 44% vs. 12%) and febrile neutropenia (14% vs 0%), were more common with E+F than with F. Conclusions: Efatutazone minimally improved efficacy of FOLFIRI for CRC and increased neutropenia and fluid retention. Clinical trial information: NCT00967616.

Abstract P4-16-09: Phase 1b/2 trial of the HER3 inhibitor patritumab (U3-1287) in combination with trastuzumab plus paclitaxel in newly-diagnosed patients with HER2+ metastatic breast cancer (MBC)

Background: Patritumab is a fully human anti-HER3 monoclonal antibody that has shown potent antitumor activity in vivo. HER3 is a key dimerization partner for other HER family members, and studies suggest that the HER3:HER2 heterodimer is the most potent signaling pair. Therefore, combined inhibition of HER3 and HER2 may synergistically inhibit breast cancer tumor growth. In the CLEOPATRA trial, pertuzumab combined with trastuzumab and docetaxel prolonged progression-free survival compared to trastuzumab and docetaxel alone, demonstrating the benefit of comprehensive blockade of HER2 dimer signaling. Trastuzumab is approved in combination with paclitaxel for first-line treatment of HER2+ MBC. This phase 1b/2 study is investigating patritumab in combination with trastuzumab and paclitaxel in patients (pts) with newly-diagnosed MBC. Results of the phase 1b portion are reported here.

Methods: Eligible pts had HER2+ newly-diagnosed MBC. In the open-label, phase 1b portion of this trial, pts received intravenous (IV) patritumab 18 mg/kg in combination with trastuzumab (8 mg/kg IV loading dose; 6 mg/kg IV maintenance dose) and paclitaxel (175 mg/m2 IV) every 3 weeks (Q3W). In the event that 18 mg/kg was not tolerated based on dose-limiting toxicity (DLT) assessment, sequential cohorts were to receive de-escalating doses of patritumab. Phase 1b study end points included adverse event (AE) incidence, human antihuman antibody (HAHA) formation, pharmacokinetics (PK), and tumor response.

Results: Six pts were enrolled in the phase 1b portion of the trial, with a median age of 61 years (range, 51-78). There were no reported DLTs. Grade ≥3 treatment-related AEs occurred in 3 pts: 1 pt had a serious AE of grade 3 pneumonia; 1 pt had grade 3 worsening of arm pain; 1 pt had grade 3 oral mucositis, prolonged QTc, flu-like syndrome, and increased transaminases. In this limited pt population, most ECG changes were within or slightly above normal limits of the QTc interval. Only 2 pts had increased values close to 50 msec compared with baseline. It should be noted that baseline QTc values for 3 pts (including the pt that experienced grade 3 prolonged QTc) were close to the upper limit of normal. There were no grade 4 AEs, and no other serious AEs. All other treatment-related AEs were grades 1 or 2. All 6 pts tested negative for HAHA formation after drug administration. PK data are consistent with previous studies with patritumab. Two pts had complete response (CR) as their best overall response, 2 pts had partial response (PR), 1 pt had stable disease, and 1 pt was not evaluated for tumor response. All 6 pts have discontinued treatment; 2 due to progressive disease, 3 due to pt decision (2 with CR and 1 with PR), and 1 at the investigator's discretion.

Conclusions: Results to date indicate that the combination of patritumab with trastuzumab and paclitaxel is generally well tolerated, with a promising response rate. As no DLTs were reported, the recommended phase 2 dose is patritumab 18 mg/kg with trastuzumab (8 mg/kg loading; 6 mg/kg maintenance) and paclitaxel 175 mg/m2 Q3W.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-16-09.

A phase 1 study of efatutazone, an oral peroxisome proliferator-activated receptor gamma agonist, administered to patients with advanced malignancies

BACKGROUND

Efatutazone (CS-7017), a novel peroxisome proliferator-activated receptor gamma (PPARγ) agonist, exerts anticancer activity in preclinical models. The authors conducted a phase 1 study to determine the recommended phase 2 dose, safety, tolerability, and pharmacokinetics of efatutazone.

METHODS

Patients with advanced solid malignancies and no curative therapeutic options were enrolled to receive a given dose of efatutazone, administered orally (PO) twice daily for 6 weeks, in a 3 + 3 intercohort dose-escalation trial. After the third patient, patients with diabetes mellitus were excluded. Efatutazone dosing continued until disease progression or unacceptable toxicity, with measurement of efatutazone pharmacokinetics and plasma adiponectin levels.

RESULTS

Thirty-one patients received efatutazone at doses ranging from 0.10 to 1.15 mg PO twice daily. Dose escalation stopped when maximal impact on PPARγ-related biomarkers had been reached before any protocol-defined maximum-tolerated dose level. On the basis of a population pharmacokinetic/pharmacodynamic analysis, the recommended phase 2 dose was 0.5 mg PO twice daily. A majority of patients experienced peripheral edema (53.3%), often requiring diuretics. Three episodes of dose-limiting toxicities, related to fluid retention, were noted in the 0.10-, 0.25-, and 1.15-mg cohorts. Of 31 treated patients, 27 were evaluable for response. A sustained partial response (PR; 690 days on therapy) was observed in a patient with myxoid liposarcoma. Ten additional patients had stable disease (SD) for ≥60 days. Exposures were approximately dose proportional, and adiponectin levels increased after 4 weeks of treatment at all dose levels. Immunohistochemistry of archived specimens demonstrated that PPARγ and retinoid X receptor expression levels were significantly greater in patients with SD for ≥60 days or PR (P = .0079), suggesting a predictive biomarker.

CONCLUSIONS

Efatutazone demonstrates acceptable tolerability with evidence of disease control in patients with advanced malignancies.

Abstract PR6: Phase 1b/2 trial of HER3 inhibitor U3-1287 in combination with erlotinib in advanced NSCLC patients (pts): HERALD study

Background: EGFR is frequently overexpressed in NSCLC, and while many advanced NSCLC tumors initially respond to EGFR tyrosine kinase inhibitors (TKIs), development of therapeutic resistance often follows. HER3 is a key dimerization partner of HER family members, including EGFR, and activates oncogenic signaling pathways. HER3 overexpression occurs in many solid tumors and is associated with poor prognosis in lung cancer pts. Data indicate that HER3 expression may play a role in EGFR TKI resistance, suggesting that simultaneous inhibition of HER3 and EGFR may be beneficial. U3-1287 is a fully human anti-HER3 monoclonal antibody with synergistic anticancer activity in combination with anti-EGFR inhibitors in preclinical models. The phase 1b/2 HERALD trial was initiated to investigate the combination of U3-1287 with erlotinib in the treatment of advanced NSCLC pts after failure of at least 1 prior chemotherapy. Results as of August 12, 2011 are reported here.

Methods: Eligible pts had stage IIIB/IV NSCLC that progressed on ≥1 prior chemotherapy treatments and were EGFR treatment-naive. In the open-label, phase 1b portion, pts received erlotinib 150 mg/day orally and U3-1287 18 mg/kg intravenously every 3 weeks (Q3W). In the event that 18 mg/kg was not tolerated based on DLT assessment, sequential cohorts were to receive de-escalating doses of U3-1287. As no DLTs were reported, the recommended phase 2 dose is 18 mg/kg Q3W for U3-1287 in combination with 150 mg/day erlotinib. The phase 2 portion of the study is a randomized, placebo-controlled, double-blind study assessing the efficacy and safety of U3-1287 combined with erlotinib relative to erlotinib alone. It is a 3-arm study of 150 mg/day erlotinib with U3-1287 high-dose (18 mg/kg Q3W), U3-1287 low-dose (18 mg/kg loading dose followed by 9 mg/kg Q3W), or placebo. Study end points include adverse event (AE) incidence, pharmacokinetics, human antihuman antibody (HAHA) formation, tumor response, and progression-free survival (PFS).

Results: The phase 1b portion of the trial enrolled 7 pts (4 male), with a median age of 68 years (range, 48–78). There were no reported DLTs. Erlotinib-related AEs reported in ≥2 pts were rash (6 pts), diarrhea (4), dry skin (3), decreased appetite (3), stomatitis (3), dehydration, dermatitis acneiform, dysgeusia, mucosal inflammation, nausea, and skin exfoliation (2 each). The only U3-1287–related AE reported in ≥2 pts was decreased appetite (2 pts). AEs grade ≥3 occurred in 2 pts: one grade 3 case each of pain, fatigue, headache, dehydration, diarrhea, and blood creatinine increase; none were related to U3-1287. Three pts had 3 serious AEs: grade 3 pain (unrelated to study treatment), grade 3 dehydration (erlotinib-related), and grade 1 decreased appetite (erlotinib- and U3-1287-related). All seven pts tested negative for HAHA formation after drug administration. As of Aug 12, 3 pts have ended study treatment due to disease progression. Four pts had best responses of stable disease lasting 86, 87, 90, and 117 days. As of Aug 12, in the phase 2 portion, 11 pts (4 male) have been screened; first study treatment was June 21. Pts had a median age of 70 years (range, 49–83). There have been 2 serious AEs in 1 pt, both unrelated to study treatment: grade 2 cardiac disorder requiring hospitalization and death due to multi-organ failure. Treatment-related AEs reported were diarrhea (3 pts), rash (3), cardiac disorder, decreased appetite, nausea, and vomiting (1 each); all were grade 1 or 2.

Conclusions: Results across the phase 1b and 2 portions indicate that U3-1287 in combination with erlotinib is generally well tolerated.

This abstract is also presented as Poster B38.

Abstract A187: A phase 1b/2 trial of U3–1287, a HER3 inhibitor, in combination with erlotinib in patients (pts) with advanced NSCLC

Background: EGFR is frequently overexpressed in NSCLC, particularly in adenocarcinomas. Many advanced NSCLCs initially respond to EGFR tyrosine kinase inhibitors (TKIs) but subsequently develop resistance. HER3 is a key dimerization partner of HER family members, including EGFR, and activates oncogenic signaling pathways. Overexpression of HER3 occurs in many solid tumors and is associated with poor prognosis in lung cancer pts. Data suggest that HER3 expression may play a role in EGFR TKI resistance, suggesting that simultaneous inhibition of HER3 and EGFR may offer therapeutic benefit. U3–1287 is a fully human anti-HER3 monoclonal antibody with synergistic anticancer activity in combination with anti-EGFR inhibitors in preclinical models. A phase 1b/2 trial was initiated to investigate the combination of U3–1287 with the EGFR TKI erlotinib in the treatment of advanced NSCLC pts. We report here the results of the phase 1b portion as of June 13, 2011.

Materials and Methods: To be eligible, pts had to have stage IIIB/IV NSCLC that had progressed on ≥1 prior chemotherapy treatments and were EGFR treatment-naive. In the open-label, phase 1b portion of the study, pts received erlotinib 150 mg/day orally and U3–1287 18 mg/kg intravenously every 3 weeks (Q3W). The U3–1287 dose was selected on the basis of results from the first-in-human phase 1 study (ENA 2010, abstract 234) in which no dose-limiting toxicities (DLTs) were observed up to the maximum administered dose of 20 mg/kg Q2W. In the event that 18 mg/kg was not tolerated based on DLT assessment, sequential cohorts were to receive de-escalating doses of U3–1287. DLTs included any treatment-related grade ≥3 toxicity except for anorexia, grade 3 fatigue persistent ≥7 days, nausea/vomiting in the absence of standard anti-emetic therapy, and lymphopenia. Phase 1b study end points included adverse event (AE) incidence, pharmacokinetics, and tumor response.

Results: Seven pts (4 male) enrolled in the phase 1b portion of the trial, with a median age of 68 years (range, 48–78). Five pts had adenocarcinoma, and 2 pts had squamous carcinoma. Pts had 1, 2, or 3 prior NSCLC therapies (n=4, 2, and 1, respectively). There were no reported DLTs. Erlotinib-related AEs reported in ≥2 pts were rash (6 pts), diarrhea (4), dry skin (3), decreased appetite, dehydration, dermatitis acneiform, dysgeusia, mucosal inflammation, nausea, skin exfoliation, and stomatitis (2 each). No U3–1287-related AEs were reported in >1 pt; those that occurred in 1 pt each were increases in blood creatinine and urea, decreased appetite, diarrhea, dysgeusia, mucosal inflammation, nausea, proteinuria, rash, ventricular extrasystoles, and vomiting. AEs grade ≥3 occurred in 2 pts, and included a grade 3 case each of pain, fatigue, headache, dehydration, diarrhea, and increase in blood creatinine; none were related to U3–1287. One pt had grade 3 diarrhea and a serious AE of grade 3 dehydration requiring hospitalization after the DLT observation period (cycle 1); both AEs were erlotinib-related. All other treatment-related AEs were grades 1 or 2. At the week-6 visit, 4 pts had stable disease, and 3 had progressive disease.

Conclusions: Results to date indicate that the combination of U3–1287 with erlotinib is generally well tolerated. As no DLTs were reported, the recommended phase 2 dose is 18 mg/kg Q3W for U3–1287 in combination with 150 mg/day erlotinib.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr A187.

Phase I trial of weekly tigatuzumab, an agonistic humanized monoclonal antibody targeting death receptor 5 (DR5)

BACKGROUND

TRA-8 is a murine agonist monoclonal antibody to death receptor 5 (DR5), which is able to trigger apoptosis in DR5 positive human tumor cells without the aid of crosslinking. It has demonstrated cytotoxicity in vitro and in vivo antitumor efficacy to a wide range of solid tumors in murine xenograft models. Tigatuzumab is a humanized IgG1 monoclonal antibody derived from TRA-8.

METHODS

A phase I trial of tigatuzumab in patients with relapsed/refractory carcinomas (n = 16) or lymphoma (n = 1) was designed to determine the maximal tolerated dose (MTD), pharmacokinetics, immunogenicity, and safety. Three to six (3-6) patients were enrolled in successive escalating cohorts at doses ranging from 1 to 8 mg/kg weekly.

RESULTS

Seventeen (17) patients enrolled, 9 in the 1-, 2-, and 4-mg/kg dose cohorts (3 in each cohort) and 8 in the 8-mg/kg dose cohort. Tigatuzumab was well tolerated with no DLTs observed, and the MTD was not reached. There were no study-drug-related grade 3 or 4, renal, hepatic, or hematologic toxicities. Plasma half-life was 6-10 days, and no anti-tigatuzumab responses were detected. Seven (7) patients had stable disease, with the duration of response ranging from 81 to 798 days.

CONCLUSIONS

Tigatuzumab is well tolerated, and the MTD was not reached. The high number of patients with stable disease suggests antitumor activity.