Efficacy, safety, and biomarker analyses of bintrafusp alfa, a bifunctional fusion protein targeting TGF-β and PD-L1, in patients with advanced non-small cell lung cancer

BACKGROUND

Bintrafusp alfa, a first-in-class bifunctional fusion protein targeting transforming growth factor-β (TGF-β) and programmed cell death ligand 1, has demonstrated encouraging efficacy as second-line treatment in patients with non-small cell lung cancer (NSCLC) in a dose expansion cohort of the phase 1, open-label clinical trial (NCT02517398). Here, we report the safety, efficacy, and biomarker analysis of bintrafusp alfa in a second expansion cohort of the same trial (biomarker cohort).

METHODS

Patients with stage IIIb/IV NSCLC who were either immune checkpoint inhibitor (ICI)-naïve (n=18) or ICI-experienced (n=23) were enrolled. The primary endpoint was the best overall response. Paired biopsies (n=9/41) and peripheral blood (n=14/41) pretreatment and on-treatment were studied to determine the immunological effects of treatment and for associations with clinical activity.

RESULTS

Per independent review committee assessment, objective responses were observed in the ICI-naïve group (overall response rate, 27.8%). No new or unexpected safety signals were identified. Circulating TGF-β levels were reduced (>97%; p<0.001) 2 weeks after initiation of treatment with bintrafusp alfa and remained reduced up to 12 weeks. Increases in lymphocytes and tumor-associated macrophages (TAMs) were observed in on-treatment biospies, with an increase in the M2 (tumor trophic TAMs)/M1 (inflammatory TAMs) ratio associated with poor outcomes. Specific peripheral immune analytes at baseline and early changes after treatment were associated with clinical response.

CONCLUSIONS

Bintrafusp alfa was observed to have modest clinical activity and manageable safety, and was associated with notable immunologic changes involving modulation of the tumor immune microenvironment in patients with advanced NSCLC.

Fostamatinib for the treatment of warm antibody autoimmune hemolytic anemia: Phase 2, multicenter, open-label study

Patients with relapsed warm antibody autoimmune hemolytic anemia (wAIHA) have limited treatment options. Fostamatinib is a potent, orally administered spleen tyrosine kinase inhibitor approved in the United States and Europe for the treatment of adults with chronic immune thrombocytopenia (ITP). This phase 2 study evaluated the response to fostamatinib, administered at 150 mg BID orally with or without food in adults with wAIHA and active hemolysis with hemoglobin (Hgb) <10 g/dL who had failed at least one prior treatment. Hemoglobin levels and safety assessments were performed at visits every 2 weeks. The primary endpoint was Hgb >10 g/dL with an increase of ≥2 g/dL from baseline by week 24 without rescue therapy or red blood cell transfusion. Eleven of 24 (46%) patients achieved the primary endpoint. Increases in median Hgb were detected at week 2 and sustained over time. Median lactate dehydrogenase levels and reticulocyte counts generally declined over time with little change in median haptoglobin levels. The most common adverse events (AEs) were diarrhea (42%), fatigue (42%), hypertension (27%), dizziness (27%), and insomnia (23%). AEs were manageable and consistent with the fostamatinib safety database of over 3900 patients across multiple diseases (rheumatoid arthritis, B-cell lymphoma, COVID-19, and ITP). No new safety signals were detected. Fostamatinib may be a promising therapeutic option for wAIHA. A randomized, double-blind, phase 3 study is nearing completion.

Eflapegrastim, a Long-Acting Granulocyte-Colony Stimulating Factor for the Management of Chemotherapy-Induced Neutropenia: Results of a Phase III Trial

Background

Eflapegrastim, a novel, long‐acting recombinant human granulocyte‐colony stimulating factor (rhG‐CSF), consists of a rhG‐CSF analog conjugated to a human IgG4 Fc fragment via a short polyethylene glycol linker. Preclinical and phase I and II pharmacodynamic and pharmacokinetic data showed increased potency for neutrophil counts for eflapegrastim versus pegfilgrastim. This open‐label phase III trial compared the efficacy and safety of eflapegrastim with pegfilgrastim for reducing the risk of chemotherapy‐induced neutropenia.

Materials and Methods

Patients with early‐stage breast cancer were randomized 1:1 to fixed‐dose eflapegrastim 13.2 mg (3.6 mg G‐CSF) or standard pegfilgrastim (6 mg G‐CSF) following standard docetaxel plus cyclophosphamide chemotherapy for 4 cycles. The primary objective was to demonstrate the noninferiority of eflapegrastim compared with pegfilgrastim in mean duration of severe neutropenia (DSN; grade 4) in cycle 1.

Results

Eligible patients were randomized 1:1 to study arms (eflapegrastim, n = 196; pegfilgrastim, n = 210). The incidence of cycle 1 severe neutropenia was 16% (n = 31) for eflapegrastim versus 24% (n = 51) for pegfilgrastim, reducing the relative risk by 35% (p = .034). The difference in mean cycle 1 DSN (−0.148 day) met the primary endpoint of noninferiority (p < .0001) and also showed statistical superiority for eflapegrastim (p = .013). Noninferiority was maintained for the duration of treatment (all cycles, p < .0001), and secondary efficacy endpoints and safety results were also comparable for study arms.

Conclusion

These results demonstrate noninferiority and comparable safety for eflapegrastim at a lower G‐CSF dose versus pegfilgrastim. The potential for increased potency of eflapegrastim to deliver improved clinical benefit warrants further clinical study in patients at higher risk for CIN.

Implications for Practice

Chemotherapy‐induced neutropenia (CIN) remains a significant clinical dilemma for oncology patients who are striving to complete their prescribed chemotherapy regimen. In a randomized, phase III trial comparing eflapegrastim to pegfilgrastim in the prevention of CIN, the efficacy of eflapegrastim was noninferior to pegfilgrastim and had comparable safety. Nevertheless, the risk of CIN remains a great concern for patients undergoing chemotherapy, as the condition frequently results in chemotherapy delays, dose reductions, and treatment discontinuations.

Myelosuppression, particularly neutropenia, has presented a major challenge in cancer treatment since the introduction of cytotoxic chemotherapy. This article reports the results of a phase III trial that compared the efficacy and safety of eflapegrastim with pegfilgrastim for reducing the risk of chemotherapy‐induced neutropenia.

Association of a Lay Health Worker Intervention With Symptom Burden, Survival, Health Care Use, and Total Costs Among Medicare Enrollees With Cancer

IMPORTANCE

Undertreated patient symptoms require approaches that improve symptom burden.

OBJECTIVE

To determine the association of a lay health worker-led symptom screening and referral intervention with symptom burden, survival, health care use, and total costs among Medicare Advantage enrollees with a new diagnosis of solid or hematologic malignant neoplasms.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study conducted at 9 community oncology practices from November 1, 2016, to October 31, 2018, compared newly diagnosed Medicare Advantage enrollees with solid or hematologic malignant neoplasms with patients diagnosed and treated 1 year prior. Analysis was conducted from August 1, 2019, to January 11, 2020.

INTERVENTIONS

Usual care augmented by a lay health worker trained to screen symptoms and refer patients to palliative care and behavioral medicine.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in symptoms using the Edmonton Symptom Assessment Scale and the 9-item Patient Health Questionnaire at baseline and 6 and 12 months after enrollment. Secondary outcomes were between-group comparison of survival, 12-month health care use, and costs.

RESULTS

Among 425 patients in the intervention group and 407 patients in the control group, the mean (SD) age was 78.8 (8.3) years, 345 (41.5%) were female, and 407 (48.9%) were non-Hispanic white. Patients in the intervention group experienced a lower symptom burden as measured by the Edmonton Symptom Assessment Scale score over time compared with patients in the control group (mean [SD] difference, -1.9 [14.2]; 95% CI, -3.77 to -0.19; P = .01 for the intervention group and 2.32 [17.7]; 95% CI, 0.47 to 4.19; P = .02 for the control group). Similar findings were noted in 9-item Patient Health Questionnaire depression scores (mean [SD] difference, -0.63 [3.99]; 95% CI, -1.23 to -0.028; P = .04 for the intervention group and 1.67 [5.49]; 95% CI, 0.95 to 2.37; P = .01 for the control group). Patients in the intervention group compared with patients in the control group had fewer mean (SD) inpatient visits (0.54 [0.77]; 95% CI, 0.47-0.61 vs 0.72 [1.12]; 95% CI, 0.61-0.83; P = .04) and emergency department visits (0.43 [0.76]; 95% CI, 0.36-0.50 vs 0.57 [1.00]; 95% CI, 0.48-0.67; P = .002) per 1000 patients per year and lower total costs (median, $17 869 [interquartile range, $6865-$32 540] vs median, $18 473 [interquartile range, $6415-$37 910]; P = .02). A total of 180 patients in the intervention group and 189 patients in the control group died within 12 months. Among those who died, patients in the intervention group had greater hospice use (125 of 180 [69.4%] vs 79 of 189 [41.8%]; odds ratio, 3.16; 95% CI, 2.13-4.69; P < .001), fewer mean (SD) emergency department and hospital visits (emergency department: 0.10 [0.30]; 95% CI, 0.06-0.14 vs 0.30 [0.46]; 95% CI, 0.24-0.38; P = .001; hospital: 0.27 [0.44]; 95% CI, 0.21-0.34 vs 0.43 [0.82]; 95% CI, 0.32-0.55; P = .02), and lower costs (median, $3602 [interquartile range, $1076-$9436] vs median, $12 726 [interquartile range, $5259-$22 170]; P = .002), but there was no significant difference in inpatient deaths (18 of 180 [10.0%] vs 30 of 189 [15.9%]; P = .14).

CONCLUSIONS AND RELEVANCE

This study suggests that a lay health worker-led intervention may be one way to improve burdensome and costly care.

Abstract P2-14-12: Eflapegrastim, a novel long-acting granulocyte-colony stimulating factor: Integrated safety results in patients with early-stage breast cancer treated with TC chemotherapy

Background: Eflapegrastim (E) represents the first myeloid growth factor innovation in more than 15 years. A novel, long-acting recombinant human granulocyte-colony stimulating factor (rhG-CSF), E consists of a rhG-CSF analog conjugated to a human IgG4 Fc fragment via a polyethylene glycol linker. Preclinical and Phase I and II pharmacodynamic and pharmacokinetic data showed increased potency for E versus pegfilgrastim (P). Two independent randomized Phase III trials comparing fixed dose E and P (E 3.6 mg G-CSF and P 6.0 mg G-CSF) for the management of chemotherapy-induced neutropenia (CIN) have recently been completed. Both trials met the primary endpoint of non-inferiority for E vs P in Cycle 1 duration of severe neutropenia (P&lt;.001). Here we provide an integrated summary of the safety of E administered at a fixed dose in a pre-filled syringe.

Patients and Methods: Patients with early-stage breast cancer (ESBC) who were candidates for adjuvant or neoadjuvant chemotherapy were randomized 1:1 in two open-label Phase III trials to E 13.2 mg (3.6 mg G-CSF) or standard P (6 mg G-CSF) administered on Day 2 following TC (docetaxel/cyclophosphamide) chemotherapy on Day 1 of each of 4 cycles. Blood for CBC and serum chemistry was collected in every cycle. Safety assessments began with the first dose of TC and continued for one year after the last dose of study drug. AEs and laboratory values were graded according to NCI CTCAE version 4.03. Immunogenicity was assessed from blood samples collected on Day 1 of each cycle, at the end-of-treatment visit, and at 6- and 12-month follow-up visits.

Results: A total of 660 patients who received at least one dose of eflapegrastim (n=334) or pegfilgrastim (n=326) were included in this integrated safety analysis. The two treatment groups were well balanced for demographics and baseline disease characteristics. The mean age was 59y, ~40% were aged &gt;65y, ~54% weighed &gt;75kg, and ~80% were treated in the adjuvant setting. Median relative dose intensity for T and C was &gt;99% for both groups. A similar percentage of patients in both treatment groups discontinued treatment due to AEs (4% E vs 6% P), with 2% in each group discontinuing due to AEs related to E or P. Serious AEs were similar in both groups (15% each). Incidence of AEs irrespective of causality were also similar between groups (74% E vs. 72% P). No notable differences between groups were observed in the types of study-drug-related AEs. The majority of study-drug-related AEs occurred with an incidence ≤10% for both E and P. As expected with myeloid growth factors, study-drug-related AEs occurring in &gt;10% in either group were bone pain (E vs P: 33% vs 34%), arthralgia (15% vs 10%), back pain (14% vs 9%), myalgia (14% vs 9%), and headache (11% vs 8%). Incidence of febrile neutropenia and neutropenic complications were similar and less than 5% in each treatment group. No leukocytosis, splenic rupture, or anaphylaxis was reported in any patient receiving E or P. The overall incidence of immunogenicity was similar in both groups and there was no demonstrable impact on clinical safety or efficacy.

Conclusions: Two large, randomized Phase III trials (Total n=660) of E vs P administered once-per-cycle showed E at a lower G-CSF dose to be safe and effective for the prophylaxis of CIN in patients with ESBC receiving TC chemotherapy. E is a novel long-acting rhG-CSF with increased potency and similar toxicity to P and may provide an attractive alternative for growth factor support of patients at high risk for CIN-related complications.

Citation Format: Lee S Schwartzberg, Gajanan Bhat, Julio Peguero, Richy Agajanian, Jayaram Bharadwaj, Alvaro Restrepo, Osama Hlalah, Inderjit Mehmi, Shanta Chawla, Francois Lebel, Patrick W Cobb. Eflapegrastim, a novel long-acting granulocyte-colony stimulating factor: Integrated safety results in patients with early-stage breast cancer treated with TC chemotherapy [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-14-12.

Lay Health Worker-Led Cancer Symptom Screening Intervention and the Effect on Patient-Reported Satisfaction, Health Status, Health Care Use, and Total Costs: Results From a Tri-Part Collaboration

PURPOSE

Poor patient experiences and increasing costs from undertreated symptoms require approaches that improve patient-reported outcomes and lower expenditures. We developed and evaluated the effect of a lay health worker (LHW)-led symptom screening intervention on satisfaction, self-reported overall and mental health, health care use, total costs, and survival.

METHODS

From November 1, 2015, to September 30, 2016, we enrolled in this study all newly diagnosed Medicare Advantage enrollees with stage 3 or 4 solid tumors or hematologic malignancies who were receiving care in a community oncology practice. We evaluated symptom changes from baseline to 12 months for the intervention group. We compared with a control group (a historical cohort of Medicare Advantage enrollees diagnosed with cancer from November 1, 2014, to October 31, 2015) changes in satisfaction and overall and mental health with validated assessments at diagnosis and 5 months postdiagnosis, 12-month health care use, total costs, and survival.

RESULTS

Among 186 patients in the intervention group and 102 in the control group, most were female and non-Hispanic white or Hispanic, and the mean age was 79 years. There were no survival differences between the groups. Relative to the control group, the intervention group experienced improvements in satisfaction with care (difference-in-difference: 1.35; 95% CI, 1.08 to 1.63), overall health (odds ratio, 2.23; 95% CI, 1.49 to 3.32), and mental or emotional health (odds ratio, 2.22; 95% CI, 1.46 to 3.38) over time; fewer hospitalizations (mean ± standard deviation: 0.72 ± 0.96 v 1.02 ± 1.44; P = .03) and emergency department visits per 1,000 members per year (0.61 ± 0.98 v 0.92 ± 1.53; P = .03), and lower median (interquartile range) total health care costs ($21,266 [$8,102-$47,900] v $31,946 [$15,754-$57,369]; P = .02).

CONCLUSION

An LHW-led symptom screening intervention could be one solution to improve value-based cancer care.

Pomalidomide plus low-dose dexamethasone in relapsed refractory multiple myeloma after lenalidomide treatment failure

Patients with relapsed/refractory multiple myeloma (RRMM) for whom the benefits of lenalidomide have been exhausted in early treatment lines need effective therapies. In cohort A of the phase 2 MM‐014 trial, we examined the safety and efficacy of pomalidomide plus low‐dose dexamethasone immediately after lenalidomide‐based treatment failure in patients with RRMM and two prior lines of therapy. Pomalidomide 4 mg was given on days 1 to 21 of 28‐day cycles. Dexamethasone 40 mg (20 mg for patients aged >75 years) was given on days 1, 8, 15 and 22 of 28‐day cycles. The primary endpoint was overall response rate (ORR), and secondary endpoints included progression‐free survival (PFS), overall survival (OS) and safety. The intention‐to‐treat population comprised 56 patients; all received prior lenalidomide (87·5% lenalidomide refractory) and 39 (69·6%) received prior bortezomib. ORR was 32·1% (28·2% in the prior‐bortezomib subgroup). Median PFS was 12·2 months (7·9 months in the prior‐bortezomib subgroup). Median OS was 41·7 months (38·6 months in the prior‐bortezomib subgroup). The most common grade 3/4 treatment‐emergent adverse events were anaemia (25·0%), pneumonia (14·3%) and fatigue (14·3%). These findings support earlier sequencing of pomalidomide‐based therapy in lenalidomide‐pretreated patients with RRMM, including those who have become refractory to lenalidomide.

Trial registration: http://www.ClinicalTrials.gov identifier NCT01946477.

Enhancing community capacity to deliver value-based cancer care at the end-of-life

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Background: To improve value-based cancer care, we designed an intervention using lay health workers (LHWs) who we trained to assess patient's symptoms. LHWs referred patients to palliative care and/or behavioral health in response to positive assessments. We implemented the intervention in collaboration with a community oncology group and a Medicare Advantage payer for patients with all stages of cancer. At ASCO 2019 we demonstrated the associated reductions in patient-reported symptoms, acute care use, and total costs of care. This study evaluates the effect of the intervention on end-of-life cancer care, specifically healthcare use in the last month of life and total costs of care from diagnosis until death. Methods: We enrolled all newly diagnosed health plan beneficiaries with solid and hematologic malignancies from 11/2016 through 9/2018 and compared outcomes to all patients diagnosed with cancer in the year prior to the intervention (control arm). For all patients who died within 12-months follow-up, we compared risk of death using Cox Models and generalized linear regression to compare healthcare use in the last month of life, and total costs of care from diagnosis until death. All models were adjusted for age, stage, comorbidities, diagnosis, and length of follow-up. Results: 180 patients in the intervention and 156 in the control died during the study. In both groups, the mean age was 80 years; 49% were non-Hispanic White, 40% Hispanic, 5% Asian/Pacific Islander, and 4% black. There were no differences in survival (HR 0.96, p = 0.6). Intervention patients as compared to the control had lower mean inpatient admissions (0.3 +/- 0.04 versus 0.5 +/- 0.07, p = 0.02) and emergency department visits per thousand members per year (0.11 +/- 0.02 versus 0.49 +/- 0.06, p < 0.001) in the last month of life, greater proportion of patients with hospice use (69% versus 48%, p < 0.001), lower proportion of patients with acute care facility deaths (37.5% versus 62.5%, p = 0.02) and lower median total healthcare costs from diagnosis until death ($24,902 versus $33,145, p = 0.02). Conclusions: An LHW intervention significantly improved the value of end-of-life cancer care and may be a solution to improve burdensome and costly care for patients.

Enhancing community capacity to improve cancer care delivery and the effect on patient-reported outcomes, healthcare utilization and total costs of care

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Background: To curb rising expenditures and improve patient-reported outcomes (PROs), we designed an intervention with patient, caregiver, provider, and payer input. The intervention is based on prior work using a lay health worker (LHW) to assess advanced cancer patients' symptoms. In this study, we trained the LHW to refer patients to palliative care and/or behavioral health services in response to positive assessments and expanded the intervention to all cancer stages. We implemented the intervention with a health plan and a community oncology group serving elderly racially/ethnically diverse patients to test the effect on symptoms, healthcare use, and total costs. Methods: We enrolled all newly diagnosed health plan beneficiaries with solid and hematologic malignancies from 10/2016 to 11/2017 and compared outcomes to all cancer patients diagnosed in the year prior to the intervention (control arm). Our primary outcome was change in patient-reported symptoms using the Edmonton Symptom Assessment Scale and Personal Health Questionnaire-9 at baseline, 6 and 12 months post-enrollment. Secondarily, we compared 12 month healthcare use and costs. All generalized linear regression models were adjusted for age, stage, comorbidities, diagnosis, and follow-up. Results: 425 patients were in the intervention; 407 in the control. In both groups, mean age was 79 years; 48% were non-Hispanic White, 43% Hispanic, 3% Black, 6% Asian/Pacific Islander; 60% had advanced stages; 28% had breast, 28% had gastrointestinal, and 10% had thoracic cancers. Intervention patients had significantly decreased symptom burden over time as compared with the control (Mean Difference: intervention (-0.77 +/- 0.28 p = 0.01) vs. control: (0.45 +/- 0.25 p = 0.06)); difference in difference: (-0.68 +/- 0.25 p = 0.007)). Depression scores also significantly decreased over time among intervention patients as compared with the control (Mean Difference: intervention (-1.10 +/- 0.38 p = 0.04)) vs control: (1.21 +/- 0.34 p = 0.01); (difference in difference: -2.03 +/- 0.3 p < 0.001)). As compared to the control arm, intervention patients had lower inpatient admissions (0.7 vs. 0.5 p = 0.01) and emergency department visits per thousand patients per year (0.6 vs. 0.42 p = 0.02), and lower median total healthcare costs ($32,270 versus $25,512 p = 0.01). Conclusions: An LHW intervention significantly improved patient-reported outcomes and the value of cancer care delivery and may be a solution to improve burdensome and costly care for patients.

An open-label, dose-ranging study of Rolontis, a novel long-acting myeloid growth factor, in breast cancer

This randomized, open‐label, active‐controlled study investigated the safety and efficacy of three doses of Rolontis (eflapegrastim), a novel, long‐acting myeloid growth factor, versus pegfilgrastim in breast cancer patients being treated with docetaxel and cyclophosphamide (TC). The primary efficacy endpoint was duration of severe neutropenia (DSN) during the first cycle of treatment. Patients who were candidates for adjuvant/neoadjuvant TC chemotherapy were eligible for participation. TC was administered on Day 1, followed by 45, 135, or 270 μg/kg Rolontis or 6 mg pegfilgrastim on Day 2. Complete blood counts were monitored daily when the absolute neutrophil count (ANC) fell to <1.5 × 10⁹/L. Up to four cycles of TC were investigated. The difference in DSN (time from ANC <0.5 × 10⁹/L to ANC recovery ≥2.0 × 10⁹/L) between the Rolontis and pegfilgrastim groups was −0.28 days (confidence interval [CI]: −0.56, −0.06) at 270 μg/kg, 0.14 days (CI: −0.28, 0.64) at 135 μg/kg, and 0.72 days (CI: 0.19, 1.27) at 45 μg/kg. Noninferiority to pegfilgrastim was demonstrated at 135 μg/kg (P = 0.002) and 270 μg/kg (P < .001), with superiority demonstrated at 270 μg/kg (0.03 days; P = 0.023). The most common treatment‐related adverse events (AEs) were bone pain, myalgia, arthralgia, back pain, and elevated white blood cell counts, with similar incidences across groups. All doses of Rolontis were well tolerated, and no new or significant treatment‐related toxicities were observed. In Cycle 1, Rolontis demonstrated noninferiority at the 135 μg/kg dose and statistical superiority in DSN at the 270 μg/kg dose when compared to pegfilgrastim.

Pomalidomide (POM) + low-dose dexamethasone (LoDEX) after lenalidomide (LEN)-based second-line (2L) treatment (Tx) in patients (Pts) with relapsed/refractory multiple myeloma (RRMM): Analysis of progression-free survival (PFS) by level of disease control

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Background: Recent trials of triple therapy in 2L and third-line (3L) Tx excluded pts refractory to LEN. This is not reflective of standard of care in first line and 2L where LEN is given until progressive disease (PD). MM-014 enrolled pts with RRMM and 2L LEN-based Tx failure. Here we report results only from cohort A of pts receiving POM + LoDEX. Cohort B will investigate POM + LoDEX + daratumumab. Methods: Adult pts with MM, 2 prior Tx lines, and PD after ≥ 2 cycles of 2L LEN-based Tx received POM + LoDEX. The primary endpoint was overall response rate (ORR). Other endpoints included time to response (TTR), PFS, second primary malignancies (SPMs), and biomarkers. Results: Of 51 pts in cohort A, 39 (76.5%) discontinued Tx. Most pts (88.2%) were refractory to their last LEN Tx, (median Tx duration 24.6 mos) and 72.5% had prior bortezomib. At a median follow-up of 13.6 mos, ORR was 29.4% (2.0% complete response, 9.8% very good partial response, and 17.6% partial response [PR]) and median TTR was 1.9 mos; 66% of pts had ongoing response at 1 yr. Minimal response [MR] was reached in 15.7%. Median PFS was 13.8 mos. Pts with ≥ MR had similar Tx durations as those achieving ≥ PR. Additional results in Table. Post-Tx T-cell populations were significantly higher vs baseline (CD3+, 72.6% vs 67.8%; CD3+/CD8+, 36.9% vs 32.1%). Relative changes from baseline were significantly greater in pts with response vs pts with no response (CD3+, 10.4 vs −0.8; CD3+/CD4+, 4.2 vs −3.5). Conclusions: This update confirms the safety and efficacy of POM + LoDEX following 2L LEN-based Tx failure in pts with RRMM. Hematologic adverse event (AE) rates improved and median PFS was longer with 3L use than previously reported with POM + LoDEX use in later Tx lines. In addition, achieving disease control of ≥ MR led to similar PFS rates as reaching ≥ PR. Clinical trial information: NCT01946477. [Table: see text]

APF530 versus ondansetron, each in a guideline-recommended three-drug regimen, for the prevention of chemotherapy-induced nausea and vomiting due to anthracycline plus cyclophosphamide-based highly emetogenic chemotherapy regimens: a post hoc subgroup analysis of the Phase III randomized MAGIC trial

BACKGROUND

APF530, a novel extended-release granisetron injection, was superior to ondansetron in a guideline-recommended three-drug regimen in preventing delayed-phase chemotherapy-induced nausea and vomiting (CINV) among patients receiving highly emetogenic chemotherapy (HEC) in the double-blind Phase III Modified Absorption of Granisetron In the prevention of CINV (MAGIC) trial.

PATIENTS AND METHODS

This MAGIC post hoc analysis evaluated CINV prevention efficacy and safety of APF530 versus ondansetron, each with fosaprepitant and dexamethasone, in patient subgroup receiving an anthracycline plus cyclophosphamide (AC) regimen. Patients were randomized 1:1 to APF530 500 mg subcutaneously (granisetron 10 mg) or ondansetron 0.15 mg/kg intravenously (IV) (≤16 mg); stratification was by planned cisplatin ≥50 mg/m² (yes/no). Patients were to receive fosaprepitant 150 mg IV and dexamethasone 12 mg IV on day 1, then dexamethasone 8 mg orally once daily on day 2 and twice daily on days 3 and 4. Patients were mostly younger females (APF530 arm, mean age 54.1 years, female, 99.3%; ondansetron arm, 53.8 years, female 98.3%). The primary end point was delayed-phase (>24-120 hours) complete response (CR).

RESULTS

APF530 versus ondansetron regimens achieved numerically better CINV control in delayed and overall (0-120 hours) phases for CR, complete control, total response, rescue medication use, and proportion with no nausea. APF530 trends are consistent with the overall population, although not statistically superior given the underpowered AC subgroup analysis. The APF530 regimen in this population was generally well tolerated, with safety comparable to that of the overall population.

CONCLUSION

APF530 plus fosaprepitant and dexamethasone effectively prevented CINV among patients receiving AC-based HEC, a large subgroup in whom CINV control has traditionally been challenging.

Abstract P5-11-09: Sustained efficacy of eflapegrastim in breast cancer patients in a phase 2, open-label, dose-ranging study

Background: Eflapegrastim is a distinct biologic that uses the innovative proprietary long-acting protein/peptide discovery technology (LAPSCOVERY™) and consists of a novel, modified recombinant human G-CSF conjugated to the Fc fragment of IgG4 via a polyethylene glycol linker. A Phase 2 study of 3 doses of eflapegrastim vs pegfilgrastim was conducted in breast cancer patients receiving docetaxel + cyclophosphamide (TC) chemotherapy.

Methods: This was an open-label, global, multicenter, dose-ranging study designed to compare the safety and efficacy of eflapegrastim relative to a fixed dose of pegfilgrastim as a concurrent active control. The study included 4 treatment arms: 3 dose levels of eflapegrastim (45 μg/kg, 135 μg/kg, and 270 μg/kg) vs pegfilgrastim (6 mg). The primary objective of the study was the Duration of Severe Neutropenia (DSN) during Cycle 1. The results for the primary objective, along with demographics and safety, were described in a previous presentation (SABCS 2015 P1-10-05). The secondary endpoints included DSN in Cycles 2-4, absolute neutrophil count (ANC) in Cycles 1-4, the overall incidences of febrile neutropenia (FN) and hospitalization rates.

Results: A total of 147 evaluable patients were enrolled. Patient and tumor characteristics were comparable across all 4 treatment arms. Median age was 59.0 years (range 32 to 77 years); most patients were &lt;65 years (68%), Female (98%), and White (95%). The DSN for the 135 µg/kg and 270 µg/kg was non-inferior to pegfilgrastim during all cycles and the DSN for patients treated with 45 µg/kg was non-inferior during Cycles 2 and 3 (Table 1). The ANC was dose proportional across all 4 cycles. The incidence of FN and hospitalization rates was low in all arms and there were no significant differences between the Eflapegrastim and Pegfilgrastim Arms (Table 2).

Table 1. Duration of Severe Neutropenia in Cycles 2 to 4 of TC Chemotherapy by Treatment ArmDSN (Days)Eflapegrastim 45 μg/kg (N=39)Eflapegrastim 135 μg/kg (N=36)Eflapegrastim 270 μg/kg (N=36)Pegfilgrastim 6 mg (N=36)Cycle 2Difference with pegfilgrastim0.380.04-0.05NANon-Inferiority p-value0.001&lt;0.001&lt;0.001NACycle 3Difference with pegfilgrastim0.310.020.01NANon-Inferiority p-value0.002&lt;0.001&lt;0.001NACycle 4Difference with pegfilgrastim0.940.07-0.02NANon-Inferiority p-value0.781&lt;0.001&lt;0.001NADSN = Duration of Severe Neutropenia; NA = Not Applicable

Table 2. Incidence of Febrile Neutropenia and Hospitalizations Eflapegrastim 45 μg/kg (N=39)Eflapegrastim 135 μg/kg (N=36)Eflapegrastim 270 μg/kg (N=36)Pegfilgrastim 6 mg (N=36)Febrile NeutropeniaIncidence (%)3 (7.7%)1 (2.8%)1 (2.8%)2 (5.6%)Difference with Pegfilgrastim2.1 %-2.8%-2.8%NAp-value1.0001.0001.000NAHospitalizationsIncidence (%)3 (7.7%)3 (8.3%)1 (2.8%)5 (13.9%)Difference with Pegfilgrastim-6.2%-5.6%-11.1%NAp-value0.4690.7100.199NA

Conclusions: In breast cancer patients treated with TC, the non-inferiority of DSN of 135 µg/kg and 270 µg/kg eflapegrastim, compared to pegfilgrastim in Cycle 1, was sustained through Cycles 2-4 and the ANC profiles were comparable in Cycles 1-4. In addition, the overall incidence of FN and hospitalizations was comparable between the eflapegrastim arms and the pegfilgrastim arm.

Citation Format: Vacirca JL, Agajanian R, Papai Z, Horvath Z, Makharadze R, Ibrahim EN, Choi MR, Song T, Tedesco KL, McGregor K, Schwartzberg LS. Sustained efficacy of eflapegrastim in breast cancer patients in a phase 2, open-label, dose-ranging study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-11-09.

Abstract OT1-01-11: Randomized phase 3 study of a novel, long-acting G-CSF (eflapegrastim) versus pegfilgrastim in the management of chemotherapy-induced neutropenia in early-stage breast cancer patients receiving docetaxel and cyclophosphamide (TC) (ADVANCE study)

Background: Eflapegrastim is a distinct biologic that uses an innovative, proprietary long-acting protein/peptide discovery technology (LAPSCOVERY™). Eflapegrastim consists of a novel, modified recombinant human G-CSF conjugated to the Fc fragment of IgG4 via a polyethylene glycol linker to produce a new, longer-acting G-CSF with a potentially unique distribution to areas rich in Fc receptors including its site of action in the bone marrow. A successful dose-finding Phase 2 trial including a pegfilgrastim control arm established the dose for a Phase 3 non-inferiority trial.

Trial Design: This is a randomized, open-label, active-controlled, multinational, multicenter, Phase 3 study comparing the efficacy and safety of eflapegrastim to pegfilgrastim. Patients (n=580) will be randomized in a 1:1 ratio to receive either eflapegrastim (equivalent to 3.6 mg G-CSF) or pegfilgrastim (equivalent to 6.0 mg G-CSF) once per chemotherapy cycle (up to 4 cycles), approximately 24 hours after chemotherapy. The primary endpoint is to compare the efficacy of a single dose of eflapegrastim with pegfilgrastim in patients with ESBC receiving TC, as measured by the Duration of Severe Neutropenia (DSN) in Cycle 1. Key secondary objectives include Time to Absolute Neutrophil Count (ANC) Recovery in Cycle 1; Depth of ANC Nadir in Cycle 1; incidence of Febrile Neutropenia. Safety and pharmacokinetics will also be assessed.

Eligibility Criteria: This study is enrolling histologically confirmed ESBC patients who are: eligible to receive adjuvant or neoadjuvant TC chemotherapy; at least 18 years of age, with adequate hematologic, renal and hepatic function. Patients will be excluded if they have: active concurrent malignancy or life-threatening disease; a known sensitivity or previous reaction to E. coli derived products or any of the products to be administered during study participation; concurrent adjuvant cancer therapy; locally recurrent/metastatic or contralateral breast cancer; previous exposure to filgrastim, pegfilgrastim, or other G-CSF products in clinical development prior to the administration of study drug; bone marrow or hematopoietic stem cell transplant or radiation therapy prior to enrollment, or are pregnant or breast-feeding.

Statistical Methods: The goal of this study is to demonstrate non-inferiority. For the Primary Efficacy Analysis, the mean DSN in Cycle 1 will be compared between the eflapegrastim and pegfilgrastim treatment arms. A 2-sided 95% confidence interval (CI) of the difference between the mean DSN of the eflapegrastim arm and the mean DSN of the pegfilgrastim arm will be calculated using bootstrap resampling with treatment as the only stratification factor. For the Secondary Efficacy Analyses, the results will each be summarized by treatment arm and cycle. The two-sided 95% CI for the difference between the treatment arms will be calculated.

Target Accrual: Approximately 580 patients. Enrollment began January 2016.

Contact Information: Spectrum Pharmaceuticals. advance@sppirx.com.

Citation Format: Schwartzberg LS, Bharadwaj J, Peguero JA, Vacirca JL, Ibrahim EN, Bhat G, Choi MR, McGregor K, Agajanian R. Randomized phase 3 study of a novel, long-acting G-CSF (eflapegrastim) versus pegfilgrastim in the management of chemotherapy-induced neutropenia in early-stage breast cancer patients receiving docetaxel and cyclophosphamide (TC) (ADVANCE study) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT1-01-11.

Abstract P5-11-08: Immunogenicity of eflapegrastim in a phase 2 open-label dose-ranging study of eflapegrastim in breast cancer patients receiving TC regimen

Background: Eflapegrastim (SPI-2012/HM10460A) is a novel, long-acting recombinant human granulocyte colony-stimulating factor (rhG-CSF). Eflapegrastim consists of an rhG-CSF conjugated to a recombinant E. coli derived Fc fragment of IgG4 via a polyethylene glycol linker. Eflapegrastim is in clinical development for the treatment of chemotherapy induced neutropenia in cancer patients.

Methods: Immunogenicity of eflapegrastim was investigated in an open label, dose-ranging Phase 2 study in breast cancer patients receiving docetaxel + cyclophosphamide (TC) chemotherapy. The study consisted of 4 arms. Patients in Arms 1 through 3 received subcutaneous doses of 45, 135, or 270 µg/kg eflapegrastim and Arm 4 received 6 mg pegfilgrastim (Neulasta®) on Day 2 of each 21-day chemotherapy cycle. Blood samples for immunogenicity analysis were collected before the start of each chemotherapy cycle (Day 1) and at the End-of-Study Visit. Samples were tested in a screening assay for Anti-Drug Antibodies (ADA) to eflapegrastim by a validated enzyme linked immunosorption assay (ELISA). Positive samples from the screening assay were further tested in a confirmatory assay for antibodies binding to eflapegrastim or G-CSF. Samples found positive in the confirmatory assay were further tested in a validated cell based neutralizing antibody assay.

Results: Serum samples from 143 patients in the study were tested for ADA to eflapegrastim and G-CSF. Preexisting antibodies binding to eflapegrastim or G-CSF were detected in 9 out of 143 (6.3%) patients. One out of the 27 patients (3.7%) in the Pegfilgrastim Arm who was negative prior to dosing was positive for ADA in the G-CSF confirmatory assay. Two out of 100 patients (2.0%) treated with eflapegrastim, who were negative prior to dosing, demonstrated treatment-induced formation of ADA in the G-CSF confirmatory assay. However, the responses in these patients were transient (ie, not consistently positive at all the sampling times) and the assay response values were low and only slightly above the plate-specific cut points. None of the patients tested were positive for G-CSF neutralizing antibodies. A formal assessment of the impact of serum ADA on the PK of eflapegrastim was not performed since PK was examined in only a limited number of patients and all of those patients were negative for ADA both at study initiation and post-dose.

Conclusion: No neutralizing antibodies against eflapegrastim or G-CSF were detected in patients administered eflapegrastim in this study.

Citation Format: Vacirca JL, Papai Z, Agajanian R, Horvath Z, Makharadze R, Ibrahim E, Koli P, Reddy G, Tedesco KL, McGregor K, Schwartzberg LS. Immunogenicity of eflapegrastim in a phase 2 open-label dose-ranging study of eflapegrastim in breast cancer patients receiving TC regimen [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-11-08.

APF530 (granisetron injection extended-release) in a three-drug regimen for delayed CINV in highly emetogenic chemotherapy

Aim: APF530, extended-release granisetron, provides sustained release for ≥5 days for acute- and delayed-phase chemotherapy-induced nausea and vomiting (CINV). We compared efficacy and safety of APF530 versus ondansetron for delayed CINV after highly emetogenic chemotherapy (HEC), following a guideline-recommended three-drug regimen. Methods: HEC patients received APF530 500 mg subcutaneously or ondansetron 0.15 mg/kg intravenously, with dexamethasone and fosaprepitant. Primary end point was delayed-phase complete response (no emesis or rescue medication). Results: A higher percentage of APF530 versus ondansetron patients had delayed-phase complete response (p = 0.014). APF530 was generally well tolerated; treatment-emergent adverse event incidence was similar across arms, mostly mild-to-moderate injection-site reactions. Conclusion: APF530 versus the standard three-drug regimen provided superior control of delayed-phase CINV following HEC. ClinicalTrials.gov : NCT02106494.

Achieving the triple aim in cancer care through a tri-part research collaboration

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Background: Curbing rising cancer care costs require models that safely lower expenditures and improve experience and outcomes. We developed a care delivery model integrating lay health workers to address early goals of care and symptoms (JOP 2015). We then created a research-collaboration with a health plan (which paid for care and processed claims), a contracted oncology group (which implemented the model), and a university research center (which designed the intervention and conducted the evaluation) to test effects on patient satisfaction, utilization, and costs. Methods: All patients newly diagnosed with cancer, referred to the contracted oncology group, and who were beneficiaries of the health plan from 11/17/13 through 9/30/15 were enrolled. We analyzed descriptive statistics and pre-intervention and 5-month post-intervention surveys to assess satisfaction with care and decision-making. Results: There were a total of 412 patients with cancer enrolled over the study period. The mean age of enrollees was 76 years; 53% were women. The mean risk adjustment score was 2.5 (www.CMS.gov). Gastrointestinal malignancies were the highest proportion of cancer diagnoses (26%) followed by breast (23%) and genitourinary cancers (13%). Thirty-one percent of patients were diagnosed with stage IV disease; 22% with stage I; 18% with stages II and III; and 10% with unknown stage. Twenty-two percent of patients died during the study period. In comparison to pre-intervention surveys, there were statistically significant improvements in overall mental and emotional health (p < 0.05) and improvements in satisfaction with care and decision-making (p < 0.05). Conclusions: Research collaborations can help to rapidly implement and test novel strategies of care delivery. These collaborations are needed to align stakeholder priorities to improve cancer care and reduce healthcare spending. Our collaboration demonstrates the feasibility of an all-stakeholder approach to designing and implementing innovative high-value cancer care delivery strategies. Our early findings demonstrate improvements in patient emotional and mental health and satisfaction with care and decision-making.

Abstract OT3-02-13: Randomized phase 3 study of a novel, long-acting G-CSF (SPI-2012) versus pegfilgrastim in the management of chemotherapy-induced neutropenia in early-stage breast cancer patients receiving docetaxel and cyclophosphamide (TC) (ADVANCE study)

Background: SPI-2012 is a distinct biologic that uses the innovative, proprietary long-acting protein/peptide discovery technology (LAPSCOVERY™) to enhance the activity of G-CSF. SPI-2012 consists of a novel, modified recombinant human G-CSF conjugated to the Fc fragment of IgG4 via a polyethylene glycol linker to produce a new, more potent, longer-acting G-CSF with a potentially unique distribution to areas rich in Fc receptors. The primary endpoint of this Phase 3 study is to compare the efficacy of a single dose of SPI-2012 with pegfilgrastim in patients with early-stage breast cancer (ESBC) receiving TC chemotherapy, as measured by the Duration of Severe Neutropenia (DSN) in Cycle 1. Key secondary objectives include the comparison of SPI-2012 with pegfilgrastim during Cycle 1 in: Time to Absolute Neutrophil Count (ANC) Recovery; Depth of ANC Nadir and Incidence of Febrile Neutropenia. Safety and pharmacokinetics will also be assessed.

Trial Design: This is a randomized, open-label, active-controlled, multicenter study comparing the efficacy and safety of SPI-2012 to pegfilgrastim. Patients (n=506) will be randomized in a 1:1 ratio to receive either SPI-2012 (equivalent to 3.6 mg G-CSF) or pegfilgrastim (equivalent to 6.0 mg G-CSF) once per chemotherapy cycle (up to 4 cycles), approximately 24 hrs after chemotherapy.

Eligibility Criteria: This study will enroll histologically confirmed ESBC patients who are eligible to receive adjuvant or neoadjuvant TC chemotherapy and at least 18 years of age, with adequate hematologic, renal and hepatic function. Patients will be excluded if they have active concurrent malignancy or life-threatening disease; a known sensitivity or previous reaction to E. coli derived products or any of the products to be administered during study participation; concurrent adjuvant cancer therapy; locally recurrent/metastatic or contralateral breast cancer; previous exposure to filgrastim, pegfilgrastim, or other G-CSF products in clinical development prior to the administration of study drug; bone marrow or hematopoietic stem cell transplant or radiation therapy prior to enrollment or are pregnant or breast-feeding.

Statistical Methods: The goal of the study is to demonstrate non-inferiority of SPI-2012 to pegfilgrastim. For the Primary Efficacy Analysis, the mean DSN in Cycle 1 will be compared between the SPI-2012 and pegfilgrastim treatment arms. A 2-sided 95% confidence interval (CI) of the difference between the mean DSN of the SPI-2012 arm and the mean DSN of the pegfilgrastim arm will be calculated using bootstrap resampling with treatment as the only stratification factor. For the Secondary Efficacy Analyses, the results will each be summarized by treatment arm and Cycle. The two-sided 95% CI for the difference between the treatment arms will be calculated.

Target Accrual: Approximately 506 pts.

Citation Format: Schwartzberg L, Vacirca JL, Hager SJ, Adoo CS, Ibrahim EN, Bhat G, Choi MR, Allen LF, Tedesco KL, Agajanian R. Randomized phase 3 study of a novel, long-acting G-CSF (SPI-2012) versus pegfilgrastim in the management of chemotherapy-induced neutropenia in early-stage breast cancer patients receiving docetaxel and cyclophosphamide (TC) (ADVANCE study). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT3-02-13.

Abstract P1-10-07: Phase 3 comparison of APF530 versus ondansetron, each in a guideline-recommended 3-drug regimen for prevention of chemotherapy-induced nausea and vomiting due to anthracycline + cyclophosphamide (AC)–based highly emetogenic chemotherapy (HEC) regimens: A post hoc subgroup analysis of the MAGIC trial

Background:Managing delayed chemotherapy-induced nausea and vomiting (CINV) associated with HEC is an unmet need. AC-based HEC is often administered to breast cancer patients (pts), a mostly female, high-CINV-risk population. APF530, an extended-release formulation of granisetron, demonstrated superior complete response (CR; no emesis [vomiting, retching] + no rescue medication use) in delayed-phase (&gt;24-120 h) CINV with HEC (ASCO criteria) vs ondansetron (Ond) (65% vs 57%, P=0.014), each combined with a neurokinin-1 antagonist and dexamethasone (Dex) (NCT02106494). This post hoc analysis evaluated efficacy and safety of APF530 in pts receiving AC-based therapy.

Methods: In this randomized, double-blind, multicenter trial, pts scheduled to receive single-day HEC were stratified by cisplatin ≥50 mg/m2 yes/no and randomized 1:1 to APF530 500 mg SC (granisetron 10 mg) or Ond 0.15 mg/kg IV. Pts received concomitant Dex 12 mg IV and fosaprepitant 150 mg IV on day 1 and oral Dex on days 2-4. The primary end point was CR in the delayed phase. Secondary and other end points included CR in acute (0-24 h) and overall (0-120 h) phases, and complete control (CC; CR and no more than mild nausea) and total response (TR; CR and no nausea) in acute, delayed, and overall phases. Rates were compared using 95% confidence intervals (CIs) for treatment differences; post hoc analysis was not powered to detect treatment differences in the AC subgroup. Safety assessments included adverse events (AEs), injection-site reactions (ISRs), laboratory parameters, and vital signs.

Results: A total of 589/902 pts (65%) in the modified intent-to-treat population received AC-based HEC (APF530 291, Ond 298). Baseline demographics were balanced between treatment arms. The majority of pts in the AC subgroup were female (APF530 99%, Ond 98%). Delayed-phase CR was higher with APF530 vs Ond, approaching statistical significance (APF530 64%, Ond 56%; P=0.062) in the AC subgroup, similar to the benefit seen in the larger study. No appreciable benefit of APF530 vs Ond was observed in the acute phase, and trends favorable to APF530 were observed in the overall phase (Table). APF530 was well tolerated. Most AEs were ISRs, generally mild or moderate, and resolved by end of study.

Phase, n (%)APF530OndansetronTreatment DifferenceN=291N=298(95% CI), %Complete responseDelayed185 (64)167 (56)8 (-0.4, 15.4)Overall163 (56)153 (51)5 (-3.4, 12.7)Acute205 (70)204 (69)1 (-5.4, 9.4)Complete controlDelayed171 (59)156 (52)7 (-1.6, 14.4)Overall149 (51)143 (48)3 (-4.9, 11.3 )Acute193 (66)191 (64)2 (-5.5, 9.9)Total responseDelayed119 (41)107 (36)5 (-2.9, 12.8)Overall100 (34)94 (32)2 (-4.8, 10.4)Acute164 (56)173 (58)-2 (-9.7, 6.3)

Conclusions: APF530 demonstrated an apparent clinical benefit in delayed-phase CR in pts receiving AC-based HEC, concordant with the statistically significant benefit seen in the overall study population. Prevention of CINV in this patient population continues to be a treatment challenge and further investigation is needed.

Citation Format: Schnadig I, Agajanian R, Dakhil S, Taylor C, Wilks S, Cooper W, Mosier M, Payne Y, Klepper M, Vacirca J. Phase 3 comparison of APF530 versus ondansetron, each in a guideline-recommended 3-drug regimen for prevention of chemotherapy-induced nausea and vomiting due to anthracycline + cyclophosphamide (AC)–based highly emetogenic chemotherapy (HEC) regimens: A post hoc subgroup analysis of the MAGIC trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-07.

Abstract P1-10-05: Randomized phase 2, open-label, dose-ranging study of a novel, long-acting G-CSF (SPI-2012) or pegfilgrastim for the management of neutropenia in patients with breast cancer (BC) treated with (Neo) adjuvant chemotherapy with docetaxel + cyclophosphamide (TC)

Background: SPI-2012 is a distinct biologic that uses the innovative proprietary long-acting protein/peptide discovery technology (LAPSCOVERY™) to enhance the activity of G-CSF. SPI-2012 consists of a novel, modified recombinant human G-CSF conjugated to the Fc fragment of IgG4 via a polyethylene glycol linker to produce a new, more potent, longer-acting G-CSF with a potentially unique distribution to areas rich in Fc receptors. To assess the effect of SPI-2012 in supporting patients with breast cancer receiving myelosuppressive chemotherapy with TC, we conducted a randomized Phase 2 study of 3 SPI-2012 doses versus pegfilgrastim.

Methods: This was an open-label, global, multicenter, dose-ranging study designed to compare the safety and efficacy of SPI-2012 relative to a fixed, standard dose of pegfilgrastim as a concurrent active control. The study included 4 treatment arms: 3 dose levels of SPI-2012 (45 μg/kg, 135 μg/kg, and 270 μg/kg) vs pegfilgrastim (6 mg,). The primary objective of the study was the Duration of Severe Neutropenia (DSN) during Cycle 1 in patients with BC who received adjuvant or neoadjuvant TC chemotherapy.

Results: A total of 147 evaluable patients were enrolled. Patient and tumor characteristics were comparable across all 4 treatment arms. Mean age was 58.2 years (range 32 to 77 years); most patients were &lt;65 years (68%), female (98%) and white (95%). The study met its primary endpoint with DSN in patients treated in the 135 µg/kg and 270 µg/kg SPI-2012 treatment arms in Cycle 1 showing non-inferiority to the DSN in patients treated with pegfilgrastim (p=0.002 and p&lt;0.001, respectively). In addition, superiority was demonstrated in patients treated with 270 µg/kg SPI-2012 compared to pegfilgrastim (p=0.023). Non-inferiority in DSN was also observed in Cycles 2 to 4 in both the 135 µg/kg and 270 µg/kg SPI-2012 treatment arms compared to pegfilgrastim.

Duration of Severe Neutropenia in Cycle 1 of TC chemotherapy by Treatment Arm  45 μg/kg SPI-2012 (N=39) 135 μg/kg SPI-2012 (N=36) 270 μg/kg SPI-2012 (N=36)Pegfilgrastim (N=36)DSN Mean (SD)(days)1.03 (1.5)0.44 (1.3)0.03 (0.2)0.31 (0.8)Difference with pegfilgrastim0.720.14-0.28NANon-inferiority p-value0.2960.002&lt;0.001NASuperiority p-value0.0060.5280.023NASD=Standard Deviation; NA=Not Applicable

The common treatment-emergent adverse events observed in ≥20% of patients were similar across all 4 study arms with similar or lower incidence in the SPI-2012 treatment arms, and included fatigue, nausea, alopecia, diarrhea, and bone pain.

Conclusions: All doses of SPI-2012 administered in this Phase 2 study were well tolerated, and no new or significant dose-related toxicities were observed. Most reported adverse events were mild and similar to those previously reported in clinical trials with filgrastim and pegfilgrastim in patients receiving myelosuppressive chemotherapy. In Cycle 1, the 135 µg/kg dose of SPI-2012 was non-inferior compared to pegfilgrastim, and the 270 µg/kg dose was superior in terms of DSN. Additional efficacy and safety data for SPI-2012 will be collected in planned Phase 3 clinical trials.

Citation Format: Vacirca JL, Chan A, Mezei K, Adoo CS, Papai Z, McGregor K, Okera M, Horvath Z, Landherr L, Hanslik J, Hager SJ, Ibrahim EN, Ghazal H, Rostom M, Bhat G, Choi MR, Allen LF, Tedesco KL, Agajanian R, Lang I. Randomized phase 2, open-label, dose-ranging study of a novel, long-acting G-CSF (SPI-2012) or pegfilgrastim for the management of neutropenia in patients with breast cancer (BC) treated with (Neo) adjuvant chemotherapy with docetaxel + cyclophosphamide (TC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-05.

Phase III study of APF530 versus ondansetron with a neurokinin 1 antagonist + corticosteroid in preventing highly emetogenic chemotherapy-induced nausea and vomiting: MAGIC trial

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Background: Managing chemotherapy-induced nausea and vomiting (CINV) associated with delayed ( > 24-120 h) highly emetogenic chemotherapy (HEC) is an unmet need. APF530, extended-release granisetron, provides sustained release over ≥ 5 days to prevent acute (0-24 h) and delayed CINV. This trial compared the efficacy and safety of APF530 in preventing CINV after HEC in a 3-drug regimen vs a standard 3-drug regimen with ondansetron (Ond). Methods: In this double-blind, multicenter study (NCT02106494), patients (pts) receiving single-day HEC (2011 ASCO guidelines) were randomized 1:1 to APF530 500 mg SC (10 mg granisetron) or Ond 0.15 mg/kg IV and stratified by cisplatin ( ≥ 50 mg/m2, yes/no). Pts were scheduled to receive concomitant dexamethasone (Dex) 12 mg IV + fosaprepitant (Fos) 150 mg IV on day 1 + PO Dex on days 2-4. The primary end point was delayed-phase complete response (CR) (no emesis, no rescue medication). Secondary end points included CR in acute and overall phases and complete control (CC; CR and no more than mild nausea) in acute, delayed, and overall phases. Treatment (tx) comparisons used chi-square test controlling for cisplatin. Adverse events (AEs) and injection-site reactions (ISRs) were assessed. Results: Modified intent-to-treat analysis included 902 pts (APF530, n = 450; Ond, n = 452) with baseline demographics balanced between tx groups. A significantly higher % of APF530 (65%) vs Ond (57%) pts had delayed-phase CR (P= .014). A significantly higher % of APF530 (61%) vs Ond (53%) pts had delayed-phase CC (P= .022, Table). CR and CC rates in acute and overall phases were numerically higher with APF530 vs Ond, but not statistically significant. APF530 was well tolerated. Most common AEs were ISRs, mostly mild or moderate. Conclusions: APF530 with Fos+Dex led to statistically higher CR and CC rates in delayed-phase CINV with HEC vs a standard 3-drug regimen of Ond with Fos+Dex. Clinical trial information: NCT02106494. [Table: see text]

Tasquinimod and survival in men with metastatic castration-resistant prostate cancer: Results of long-term follow-up of a randomized phase II placebo-controlled trial

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Background: Tasquinimod (T) is an oral quinoline-3-carboxamide derivative that binds S100A9 protein and has preclinical anti-angiogenic and anti-tumor activity. Between 12/07-6/09, 201 (134 T, 67 Placebo (P)) men with metastatic CRPC were randomized and received treatment once-daily at an initial dose of 0.25 mg/day escalated to 1.0 mg/day over 4 weeks. Placebo patients could cross over to T after 6 months or at disease progression. The primary endpoint of improved PCWG2 criteria-defined progression at 6 months was met (69 vs. 37% of patients (T/P) were progression free) with PFS of 7.6 vs. 3.3 months for pts on T vs. P1 with acceptable toxicity. This abstract provides the first analysis on symptomatic progression, overall survival (OS) as well as a multivariate analysis for PFS and OS. Methods: Survival data were collected between June 2011 and January 2012 with a median time to censoring of 32 months. Survival data was also evaluated in an exploratory multivariate model of known prognostic factors in CRPC. Results: An imbalance of several baseline prognostic criteria favored placebo (e.g. baseline PSA of 29 vs. 19 (T/P)) (JCO 2011;20:4022). Time to symptomatic progression was longer in T treated patients (p=0.039, HR=0.42). Record of death (97 events) or survival >13 months was documented in 182 patients. Median time to death was 34.2 vs. 30.2 months (T/P). Median time to death in the PCWG2 bone-metastatic subgroup (N=92/44) was 34.2 vs. 25.6 months. A multivariate analysis of known prognostic factors including PSA, LDH, PSA kinetics, and hemoglobin demonstrated an adjusted HR for PFS of 0.54 (95% CI 0.37,0.81) and OS of 0.72 (95% CI 0.46,1.12) in the total population and 0.63 (95% CI 0.37,1.07, n=136) in the bone-metastatic group. Conclusions: OS observed after tasquinimod treatment is longer than previously reported in this patient population. The current exploratory data indicates that the prolongation in PFS observed with tasquinimod treatment may lead to a survival advantage in men with metastatic CRPC. A phase III placebo-controlled study (NCT01234311) is ongoing in men with bone-metastatic CRPC powered to detect an OS improvement.