Safety and efficacy of the tumor-selective adenovirus enadenotucirev, in combination with nivolumab, in patients with advanced/metastatic epithelial cancer: a phase I clinical trial (SPICE)

BACKGROUND

Novel combination therapies to overcome anti-PD-1 resistance are required. Enadenotucirev, a tumor-selective blood stable adenoviral vector, has demonstrated a manageable safety profile and ability to increase tumor immune-cell infiltration in phase I studies in solid tumors.

METHODS

We conducted a phase I multicenter study of intravenous enadenotucirev plus nivolumab in patients with advanced/metastatic epithelial cancer not responding to standard therapy. Co-primary objectives were safety/tolerability and maximum tolerated dose and/or maximum feasible dose (MTD/MFD) of enadenotucirev plus nivolumab. Additional endpoints included response rate, cytokine responses, and anti-tumor immune responses.

RESULTS

Overall, 51 heavily pre-treated patients were treated, 45/51 (88%) of whom had colorectal cancer (35/35 patients with information available were microsatellite instability-low/microsatellite stable) and 6/51 (12%) had squamous cell carcinoma of the head and neck. The MTD/MFD of enadenotucirev plus nivolumab was not reached, with the highest dose level tested (1×10¹² vp day 1; 6×10¹² vp days 3 and 5) shown to be tolerable. Overall, 31/51 (61%) patients experienced a grade 3-4 treatment-emergent adverse event (TEAE), most frequently anemia (12%), infusion-related reaction (8%), hyponatremia (6%), and large intestinal obstruction (6%). Seven (14%) patients experienced serious TEAEs related to enadenotucirev; the only serious TEAE related to enadenotucirev occurring in >1 patient was infusion-related reaction (n=2). Among the 47 patients included in efficacy analyses, median progression-free survival was 1.6 months, objective response rate was 2% (one partial response for 10 months), and 45% of patients achieved stable disease. Median overall survival was 16.0 months; 69% of patients were alive at 12 months. Persistent increases in Th1 and related cytokines (IFNγ, IL-12p70, IL-17A) were seen from ~day 15 in two patients, one of whom had a partial response. Among the 14 patients with matching pre-tumor and post-tumor biopsies, 12 had an increase in intra-tumoral CD8⁺ T-cell infiltration and 7 had increased markers of CD8 T-cell cytolytic activity.

CONCLUSIONS

Intravenously dosed enadenotucirev plus nivolumab demonstrated manageable tolerability, an encouraging overall survival and induced immune cell infiltration and activation in patients with advanced/metastatic epithelial cancer. Studies of next-generation variants of enadenotucirev (T-SIGn vectors) designed to further re-program the tumor microenvironment by expressing immune-enhancer transgenes are ongoing.

TRIAL REGISTRATION NUMBER

NCT02636036.

A tumor-selective adenoviral vector platform induces transient antiphospholipid antibodies, without increased risk of thrombosis, in phase 1 clinical studies

Tumor-selective viruses are a novel therapeutic approach for treating cancer. Tumor-Specific Immuno Gene Therapy (T-SIGn) vectors are tumor-selective adenoviral vectors designed to express immunomodulatory transgenes. Prolonged activated partial thromboplastin time (aPTT), associated with the presence of antiphospholipid antibodies (aPL), has been observed in patients with viral infections, and following administration of adenovirus-based medicines. aPL may be detected as lupus anticoagulant (LA), anti-cardiolipin (aCL) and/or anti-beta 2 glycoprotein antibodies (aβ2GPI). No subtype alone is definitive for development of clinical sequalae, however, patients who are 'triple positive' have a greater thrombotic risk. Additionally, isolated aCL and aβ2GPI IgM do not appear to add value in thrombotic association to aPL positivity, rather IgG subtypes must also be present to confer an increased risk. Here we report induction of prolonged aPTT and aPL in patients from eight Phase 1 studies who were treated with adenoviral vectors (n = 204). Prolonged aPTT (≥ Grade 2) was observed in 42% of patients, with a peak at 2-3 weeks post-treatment and resolution within ~ 2 months. Among patients with aPTT prolongation, LA, but not aCL IgG nor aβ2GPI IgG, was observed. The transience of the prolongation and discordance between positive LA and negative aCL/aβ2GPI IgG assays is not typical of a prothrombotic state. Among the patients with prolonged aPTT there was no evidence of an increased rate of thrombosis. These findings elucidate the relationship between viral exposure and aPL in the context of clinical trials. They suggest a framework in which hematologic changes can be monitored in patients receiving similar treatments.Clinical trial registration:NCT02028442, NCT02636036, NCT02028117, NCT03852511, NCT04053283, NCT05165433, NCT04830592, NCT05043714.

Abstract CT213: A multicenter phase 1a/b study of NG-350A, a tumor-selective anti-CD40-antibody expressing adenoviral vector, and pembrolizumab in patients with metastatic or advanced epithelial tumors (FORTIFY)

Background: The efficacy of immune checkpoint inhibitors is often limited by immunosuppressive tumor microenvironments (TME) and novel combination therapies are required to overcome resistance. NG-350A is a novel T-SIGn (Tumor-Specific Immuno Gene) adenoviral vector that expresses a fully human agonistic IgG anti-CD40 antibody to promote innate and adaptive immune responses. Additionally, NG-350A selectively replicates in tumor cells, allowing IV dosing to be coupled with local transgene expression in the TME, thereby targeting all tumor lesions while limiting systemic exposure. Through these immunostimulatory effects the vector is designed to re-program ‘cold’ TMEs to allow functional anti-cancer immune responses. Data from an ongoing study with IV NG-350A monotherapy have shown promising tolerability, as well as prominent and sustained elevations in inflammatory cytokines (IL-2, IFNγ, IL-17A, IL-2 and IFNα2) consistent with the mechanism of action of anti-CD40 in stimulating TME re-programming [Naing 2021]. Based on these promising initial data, we designed a study to further assess the safety, tolerability and preliminary efficacy of NG-350A + pembrolizumab.

Methods: FORTIFY (NCT05165433) is an open-label, dose-escalating, phase 1a/b study of NG-350A + pembrolizumab. Eligible patients have advanced/metastatic epithelial tumors that have progressed after ≥1 line of systemic therapy and are incurable by local therapy. Patients eligible for phase 1a must have experienced failure of prior PD-1/PD-L1 inhibition as part of any prior line of therapy; patients eligible for phase 1b must have primary resistance to PD-1/PD-L1 inhibition. During phase 1a, up to 30 patients will receive escalating doses of IV NG-350A (Bayesian Optimal Interval design) to a maximum of 1 × 1012 viral particles (vp) on Day 1 and 1 × 1013 vp on Days 3 and 5 (1 cycle). Patients will receive a fixed-dose of pembrolizumab (200 mg IV) on Day 15 and then every 3 weeks thereafter for up to 35 cycles. Phase 1b will further investigate the efficacy/safety of the selected regimen in up to 3 tumor-specific cohorts using a Simon 2-stage design. Co-primary objectives are to characterize the safety and tolerability of NG-350A + pembrolizumab and to identify a recommended dose. Preliminary efficacy and immunogenicity are secondary endpoints. Pharmacodynamic outcomes will be assessed using tumor tissues and blood. Analyses of tumor tissue (serial biopsies at baseline and Day 15 of cycles 1-3 [cycles 1-2 only in Phase 1b]) will explore virus replication, transgene expression and immune/inflammatory responses. Analyses of serial blood samples will explore cytokine production and changes in peripheral immune cell subsets. Recruitment is expected to begin in Q1 2022.

Citation Format: Tom Lillie, Mark O'Hara, Christian Ottensmeier, Eileen Parkes, Lee Rosen, David Krige, Marya Chaney, Jo Carter, Vladimir Evilevitch, Matthew Thomas, Aung Naing. A multicenter phase 1a/b study of NG-350A, a tumor-selective anti-CD40-antibody expressing adenoviral vector, and pembrolizumab in patients with metastatic or advanced epithelial tumors (FORTIFY) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT213.

Abstract CT214: A multicenter phase 1a/b study of NG-641, a tumor-selective transgene-expressing adenoviral vector, and nivolumab in patients with metastatic or advanced epithelial tumors (NEBULA)

Background: T-SIGn (Tumor-Specific Immuno Gene Therapy) vectors are transgene-expressing variants of the blood-stable adenovirus enadenotucirev. Through a novel multimodal combination of immunostimulatory effects the vectors are designed to re-program ‘cold’ tumor microenvironments (TME) to allow functional anti-cancer immune responses. T-SIGn vectors selectively replicate in tumor cells, allowing IV delivery to be coupled with local transgene expression in the TME, thereby targeting all tumor lesions while limiting systemic exposure. NG-641 is a T-SIGn vector that expresses a fibroblast activation protein-directed bi-specific T-cell activator antibody to target cancer-associated fibroblasts (CAFs) and an immune-enhancer module (CXCL9/CXCL10/IFNα2) to recruit and activate immune cells. In an ongoing study (NCT04053283), NG-641 monotherapy has been successfully dose-escalated to 1 × 1012 viral particles (vp) on Day 1 and 3 × 1012 vp on Days 3 and 5; initial results from this study have shown a manageable tolerability profile and elevations in serum cytokines indicative of T-cell activation. Based on these promising initial data with NG-641 monotherapy, we designed a new study to assess NG-641 + nivolumab.

Methods: NEBULA (NCT05043714) is an open-label, dose-escalating, phase 1a/b study of NG-641 + nivolumab. Eligible patients (pts) have advanced/metastatic epithelial tumors that have progressed after ≥1 line of systemic therapy and are incurable by local therapy. Pts eligible for phase 1a must have received prior PD-1/PD-L1 inhibition as part of any line of therapy; pts eligible for phase 1b must have primary resistance to PD-1/PD-L1 inhibition. During phase 1a, up to 30 pts will receive escalating doses of IV NG-641 (Bayesian Optimal Interval design) to a maximum dose of 1 × 1012 viral particles (vp) on Day 1 and 1 × 1013 vp on Days 3 and 5 (1 cycle). Pts will receive a fixed-dose of nivolumab (480 mg IV) on Day 15 and then every 4 weeks thereafter for up to 8 cycles. Phase 1b will further investigate the selected dose regimen in up to 3 tumor-specific cohorts (Cohorts A, B and C) using a Simon 2-stage design. Co-primary objectives are to characterize the safety and tolerability of NG-641 + nivolumab and to identify a recommended dose. Preliminary efficacy and immunogenicity are secondary endpoints. Pharmacodynamic outcomes will be assessed using tumor tissues and blood. Analyses of tumor tissue (serial biopsies at baseline and Day 15 of cycles 1-3 [cycles 1-2 only in Phase 1b]) will explore virus replication, transgene expression, immune/inflammatory responses and effects on CAFs by immunohistochemistry and gene expression analysis. Analyses of serial blood samples will explore cytokine production and changes in peripheral immune cell subsets. Enrollment to the first dose-escalation cohort is ongoing.

Citation Format: Tom Lillie, Eileen Parkes, Christian Ottensmeier, David Krige, Behnaz Ravanfar, Vladimir Evilevitch, Matthew Thomas, Lee Rosen. A multicenter phase 1a/b study of NG-641, a tumor-selective transgene-expressing adenoviral vector, and nivolumab in patients with metastatic or advanced epithelial tumors (NEBULA) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT214.

342 Combining enadenotucirev and nivolumab increased tumour immune cell infiltration/activation in patients with microsatellite-stable/instability-low metastatic colorectal cancer in a phase 1 study

Background

Microsatellite-stable (MSS) and instability-low (MSI-L) metastatic colorectal cancer (mCRC) are typically characterised as ”immune-excluded/desert” tumour microenvironments lacking T-cell infiltration. Anti-PD-1 monotherapy has little clinical benefit in MSS/MSI-L mCRC1 and knowledge of the effects of PD-1 inhibition on T-cell activation/infiltration in this population is limited. Novel combination therapies to overcome anti-PD-1 resistance are required. SPICE is a multicentre, open-label, phase 1 study of the tumour-selective chimeric Ad11/Ad3 group B oncolytic adenovirus enadenotucirev plus nivolumab in patients with metastatic/advanced epithelial tumours refractory to standard therapy. Preliminary data from patients with MSS/MSI-L mCRC demonstrated a median overall survival of 14 months, manageable tolerability and intratumoural T-cell infiltration.2 Here we characterise the immunological effects of tumour re-engineering with enadenotucirev in combination with nivolumab in patients with MSS/MSI-L mCRC.

Methods

Patients received increasing doses and/or cycles of intravenous enadenotucirev followed by up to 8 cycles of nivolumab as previously described.2 Wherever possible, pre- and post-treatment (~5 weeks post-first enadenotucirev) biopsies were collected; samples were analysed using immunohistochemistry and automated image analysis. Peripheral blood mononuclear cell immunophenotyping (multiparameter flow cytometry) and serum cytokines were assessed at multiple times.

Results

43 patients with mCRC were treated (86% MSS/MSI-L; 14% unknown). Among the 13 patients (12/13 MSS/MSI-L; 1/13 unknown) with matched biopsies, 11 had increased intratumoural and stromal CD8+ T-cell infiltration in post-treatment biopsies (median [Q1-Q3] fold changes 6.5× [1.5–25.4] and 1.9× [1.5–3.9], respectively; figure 1). CD4+ T-cell density increased in 10/13 patients and 8/13 patients had increased proportions of PD-L1+ immune cells. Increases in CD8 T-cell proliferation (Ki67; 7/9 patients) and cytolytic activity (Granzyme B; 7/13 patients) markers were seen. 4/13 patients converted from a ”desert” to an ”inflamed” immune phenotype (pathologist scored CD8/pan-cytokeratin staining). Immunophenotyping showed trends towards increased T-cell activation (CD38+ and HLA-DR+ CD8+ T cell populations) post-treatment (9/10 patients), including in one patient who had only received enadenotucirev prior to sampling. Persistent increases in inflammatory cytokines (IFNγ, IL-12p70, IL-17a) were seen in two patients from ~Day 15, including one who achieved a sustained objective response.

Abstract 342 Figure 1

Tumour immune cell infiltration following treatment with enadenotucirev plus nivolumab

Conclusions

These data show that intravenous enadenotucirev plus nivolumab can induce immune infiltration/activation within MSS/MSI-L mCRC. These encouraging findings suggest that immune activation can be achieved even in ”immune-excluded/desert” tumours. SPICE has been closed following completion of dose-escalation. Efforts are now focused on the development of next-generation variants of enadenotucirev designed to further re-programme the tumour microenvironment by expressing immune-enhancer transgenes (T-SIGn vectors); these studies are ongoing (NCT04830592, NCT04053283, NCT03852511).

Acknowledgements

This study was funded by PsiOxus Therapeutics Limited and Bristol Myers Squibb. Medical writing support: Lola Parfitt, MRes, of PsiOxus Therapeutics Limited.

Trial Registration

EudraCT number

2017-001231-39NCT number: NCT02636036

References

Kawazoe A, Kuboki Y, Shinozaki E, et al. Multicenter phase I/II trial of napabucasin and pembrolizumab in patients with metastatic colorectal cancer (EPOC1503/SCOOP trial). Clin Cancer Res 2020;26:5887–5894.

Fakih M, Wang D, Harb W, et al. SPICE: a phase I multicenter study of enadenotucirev in combination with nivolumab in tumors of epithelial origin: an analysis of the metastatic colorectal cancer patients in the dose escalation phase. Ann Oncol 2019:30(suppl_5):v252.

Ethics Approval

The study was approved by the WCG Institutional Review Board (study approval number 20152656), UCLA Institutional Review Board (study approval number IRB#15-002010), Vanderbilt Institutional Review Board (study approval number IRB #171453) and Henry Ford Institutional Review Board (study approval number IRB #10349).

437 A multicentre phase 1b study of NG-641, a novel transgene-armed and tumour-selective adenoviral vector, and pembrolizumab as neoadjuvant treatment for squamous cell carcinoma of the head and neck

Background

Despite multimodal management strategies, outcomes for patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) remain poor. Immune checkpoint inhibitors have demonstrated promise as a neoadjuvant strategy to reduce relapse rates1 ; however, the immunosuppressive SCCHN tumour microenvironment (TME) has limited the efficacy of immunotherapy to date. This ‘cold’ TME is characterised by an absence of T-cell activation/inflammation2 and high levels of stromal fibroblast activating protein (FAP),3 indicative of immunosuppressive cancer-associated fibroblasts (CAFs). Novel approaches to ameliorate this immunosuppressive TME are required to realise the full benefit of immunotherapy in SCCHN.NG-641 is a next-generation blood-stable and transgene-armed Tumour-Specific Immuno Gene Therapy (T-SIGn) adenoviral vector that selectively replicates in epithelial tumour cells. NG-641 encodes four immunostimulatory transgenes: a FAP-directed bi-specific T-cell activator antibody to target CAFs, interferon alpha 2 to promote innate and adaptive immune responses, and C-X-C motif chemokine ligands 9 and 10 to induce T cell infiltration.4 Together, these transgenes are designed to locally re-programme the immunosuppressive TME and promote functional anti-cancer immune responses while minimising systemic immune-related toxicities. This mechanism of action is particularly suited to SCCHN and should complement anti–PD-1 inhibitors. We, therefore, designed a study to assess neoadjuvant treatment with NG-641 and pembrolizumab in locally advanced SCCHN.

Methods

The mode-of-action transgene (MOAT) study is a multicentre, open-label, dose-escalating, phase 1b study of NG-641 as monotherapy or with pembrolizumab. Patients are eligible if they have newly diagnosed or recurrent locally advanced SCCHN and have definitive surgery planned within 8 weeks of screening. In Part A, patients will receive three doses of intravenous NG-641 monotherapy prior to surgery (figure 1). Once NG-641 transgene expression is confirmed in excised tumour tissues, Part A will close and NG-641 dose-escalation can continue in Part B. Patients will then also receive a single dose of pembrolizumab given ~5 days after NG-641 to minimize toxicity and take advantage of the mechanism of NG-641 prior to PD-1 blockade. The primary objective is to characterise the safety and tolerability of NG-641 ± pembrolizumab in SCCHN; secondary objectives are to identify a recommended dose of NG-641 plus pembrolizumab and to assess treatment outcomes, including pathological tumour responses and overall survival. Pharmacodynamic outcomes will be assessed following NG-641 ± pembrolizumab, including characterising immune/inflammatory biomarkers in both tumour and blood. The study is to be conducted at 4 sites in the UK; up to 36 patients will be enrolled.

Abstract 437 Figure 1

MOAT study schematic

Acknowledgements

This study was funded by PsiOxus Therapeutics Ltd.

Trial Registration

This trial is registered as NCT04830592 on clinicaltrials.gov.

References

Uppaluri R, Campbell KM, Egloff AM, et al. Neoadjuvant and Adjuvant Pembrolizumab in Resectable Locally Advanced, Human Papillomavirus-Unrelated Head and Neck Cancer: A Multicenter, Phase II Trial. Clin Cancer Res 2020;26:5140–52.

Cristescu R, Mogg R, Ayers M, et al. Pan-tumor genomic biomarkers for PD-1 checkpoint blockade-based immunotherapy. Science 2018;362:eaar3593.

Dolznig H, Schweifer N, Puri C, et al. Characterization of cancer stroma markers: In silico analysis of an mRNA expression database for fibroblast activation protein and endosialin Cancer Immun 2005;5:10.

Champion BR, Besneux M, Patsalidou M, et al. NG-641: An oncolytic T-SIGn virus targeting cancer-associated fibroblasts in the stromal microenvironment of human carcinomas. Cancer Res 2019;79:5013.

Ethics Approval

This study was approved by a central United Kingdom Research Ethics Committee (South Central - Oxford A Research Ethics Committee); approval reference 20/SC/0425, Integrated Research Application System ID 290504. All participants must provide informed consent prior to enrolment.

Comparison of darbepoetin alfa dosed weekly (QW) vs. extended dosing schedule (EDS) in the treatment of anemia in patients receiving multicycle chemotherapy in a randomized, phase 2, open-label trial

Background

Chemotherapy-induced anemia (CIA) is responsive to treatment with erythropoiesis-stimulating agents (ESAs) such as darbepoetin alfa. Administration of ESAs on a synchronous schedule with chemotherapy administration could benefit patients by reducing clinic visits and potentially enhancing on-time chemotherapy delivery.

Methods

This phase 2, 25-week, open-label study evaluated the noninferiority of darbepoetin alfa administered weekly vs. as an extended dosing schedule (every 2 or 3 weeks) in patients with CIA. Patients were randomized 1:1 to an extended dosing schedule (EDS: darbepoetin alfa 300 μg Q2W if chemotherapy was QW, Q2W, or Q4W or darbepoetin alfa 500 μg Q3W if chemotherapy was Q3W) or weekly (150 μg QW regardless of chemotherapy schedule). Stratification factors included chemotherapy cycle length, screening hemoglobin (<10 g/dL vs. ≥10 g/dL), and tumor type (lung/gynecological vs. other nonmyeloid malignancies). The primary endpoint was change in hemoglobin from baseline to Week 13.

Results

Seven hundred fifty-two patients (374 QW patients; 378 EDS patients) received ≥1 dose of darbepoetin alfa and were included in the analysis. Demographics and disease state were similar between groups. Seventy-one percent of patients in the EDS group and 76% in the QW group achieved the target hemoglobin of ≥11.0 g/dL. There was a minimal difference in the primary endpoint of mean change in hemoglobin (baseline to Week 13) between the QW and the EDS groups (-0.04 g/dL; 95% confidence interval: -0.26, 0.17 g/dL). The upper limit of the 95% confidence interval was less than the prespecified limit of <0.75 g/dL, supporting noninferiority of the EDS dosing schedule. Reported adverse events were similar between groups. A slight increase in transfusions was reported in the QW group.

Conclusion

Darbepoetin alfa, when administered synchronously with chemotherapy, on an EDS appears to be similarly efficacious to darbepoetin alfa weekly dosing with no unexpected adverse events. This study provides prospective data on how multiple dosing regimens available with darbepoetin alfa can be synchronized with chemotherapy administered across a range of dosing schedules.

Trial registration

ClinicalTrials.gov Identifier NCT00144131.

Randomized, double-blind, placebo-controlled trial of every-3-week darbepoetin alfa 300 micrograms for treatment of chemotherapy-induced anemia

OBJECTIVE

Darbepoetin alfa is effective in treating chemotherapy-induced anemia (CIA). Administration of subcutaneous darbepoetin alfa every 3 weeks (Q3W) could simplify treatment through synchronization with common Q3W chemotherapy regimens. We report results from a multicenter, randomized, double-blind, placebo-controlled, phase 3 trial evaluating the efficacy and safety of fixed-dose Q3W darbepoetin alfa in patients with a wide variety of tumor types who experienced CIA.

RESEARCH DESIGN AND METHODS

Patients aged > or = 18 years with anemia (hemoglobin <11 g/dL) being treated for nonmyeloid malignancy were randomized 1:1 to receive darbepoetin alfa 300 microg (n = 193) or placebo (n = 193) subcutaneously Q3W from weeks 1 to 13 in this 16-week study. Doses could be adjusted per prespecified rules.

MAIN OUTCOME MEASURES

The primary endpoint was the proportion of patients who received > or =1 red blood cell (RBC) transfusion between week 5 and the end of the treatment period (EOTP). The study also analyzed the proportions of patients achieving a hemoglobin concentration > or =11 g/dL and subsequently maintaining hemoglobin levels above 11 g/dL, and the change in hemoglobin concentration over time.

RESULTS

The proportion of patients requiring RBC transfusions between week 5 and EOTP was significantly lower in the darbepoetin alfa-treated group than in the placebo-treated group (24 vs. 41% of patients, a 16.3% difference, p < 0.001). There were no differences between the two treatment arms in quality-of-life measures. Cardiovascular/thromboembolic adverse events were uncommon and were not associated with increases in hemoglobin levels. Study limitations suggest caution in the interpretation of these results: transfusions, the primary endpoint, were recommended but not required if hemoglobin concentrations were < or =8.0 g/dL, and protocol deviations (primarily dosing errors) occurred in approximately one-half of the patients in both treatment groups.

CONCLUSIONS

In this study, fixed-dose Q3W darbepoetin alfa appeared to be well-tolerated and effective for the treatment of CIA.

TRIAL REGISTRATION

Study 20030232; ClinicalTrials.Gov Identifier: NCT00110955.

Treating anemia of cancer with every-4-week darbepoetin alfa: final efficacy and safety results from a phase II, randomized, double-blind, placebo-controlled study

Darbepoetin alfa is an erythropoiesis-stimulating agent (ESA) approved for treating chemotherapy-induced anemia. This phase II, double-blind, placebo-controlled study examined the efficacy of darbepoetin alfa for treating anemia of cancer (AoC) in patients not receiving chemotherapy or radiotherapy. Patients were randomized 3:1 to receive darbepoetin alfa (6.75 microg/kg) or placebo every 4 weeks; the end of the study was at week 17. The primary endpoint was the percentage of patients with a hematopoietic response. Secondary endpoints included transfusion incidence and safety parameters. Efficacy analyses were performed on 162 patients in the darbepoetin alfa group and 56 patients in the placebo group. The Kaplan-Meier percentages of patients who achieved a hematopoietic response (darbepoetin alfa, 69%; placebo, 24%) or achieved the target hemoglobin (darbepoetin alfa, 85%; placebo, 50%) differed significantly between treatment groups. The transfusion incidence did not differ between treatment groups probably because of the low baseline transfusion rates in AoC patients. The incidence of adverse events (including on-study deaths) was similar in both groups. In conclusion, darbepoetin alfa appeared to be well tolerated and significantly increased hemoglobin levels in these AoC study patients.

Safety and Efficacy of Darbepoetin Alfa in Previously Untreated Extensive-Stage Small-Cell Lung Cancer Treated With Platinum Plus Etoposide

Purpose

A placebo-controlled, double-blind, randomized, phase III study was conducted in patients with extensive-stage small-cell lung cancer receiving first-line platinum-containing chemotherapy to determine if increasing or maintaining hemoglobin concentration with darbepoetin alfa could increase patient survival.

Patients and Methods

Darbepoetin alfa (300 μg) or placebo was administered once per week for 4 weeks then every 3 weeks for up to six cycles of chemotherapy (carboplatin plus etoposide or cisplatin plus etoposide) plus 3 weeks after the last dose of chemotherapy. Patients with disease progression were observed until death or until all patients completed their end-of-study visit and 496 deaths had occurred. The two coprimary end points were change in hemoglobin concentration from baseline to the end of the chemotherapy period and overall survival; statistical testing of survival was done if change in hemoglobin was significant at P < .05.

Results

The study enrolled 600 patients. Patients' hemoglobin levels dropped due to the myelosuppressive chemotherapy; however, treatment with darbepoetin alfa maintained hemoglobin levels significantly higher than placebo (P < .001). There was no statistically significant difference in overall survival between the treatment groups (hazard ratio [HR], 0.93; 95% CI, 0.78 to 1.11; P = .431). As expected, darbepoetin alfa was associated with a higher incidence of thromboembolic events (darbepoetin alfa, 9%; placebo, 5%). The transfusion risk was lower in the darbepoetin versus placebo group (HR, 0.40; 95% CI, 0.29 to 0.55).

Conclusion

The results of this study did not demonstrate improved survival after treatment with darbepoetin alfa; however, they reinforce the benefit of erythropoiesis-stimulating agents in reducing transfusions and their neutral impact on survival in patients with chemotherapy-induced anemia.

Darbepoetin Alfa for the Treatment of Anemia in Patients With Active Cancer Not Receiving Chemotherapy or Radiotherapy: Results of a Phase III, Multicenter, Randomized, Double-Blind, Placebo-Controlled Study

Purpose

The efficacy and safety of darbepoetin alfa (DA) for treating patients with active cancer and anemia not receiving or planning to receive cytotoxic chemotherapy or myelosuppressive radiotherapy was evaluated.

Patients and Methods

Patients with active cancer and anemia not receiving or planning to receive chemotherapy or radiotherapy were enrolled onto a phase III, multicenter, randomized, placebo-controlled study and administered placebo or DA 6.75 μg/kg every 4 weeks (Q4W) for up to 16 weeks with a 2-year follow-up for survival. Patients who completed 16 weeks of treatment could receive the same treatment as randomized Q4W for an additional 16 weeks. The primary end point was all occurrences of transfusions from weeks 5 through 17; safety end points included incidence of adverse events and survival.

Results

The incidence of transfusions between weeks 5 and 17 was lower in the DA group but was not statistically significantly different from that of placebo. DA was associated with an increased incidence of cardiovascular and thromboembolic events and more deaths during the initial 16-week treatment period. Long-term survival data demonstrated statistically significantly poorer survival in patients treated with DA versus placebo (P = .022). This effect varied by baseline covariates including, sex, tumor type, and geographic region; statistical significance diminished (P = .12) when the analysis was adjusted for baseline imbalances or known prognostic factors.

Conclusion

DA was not associated with a statistically significant reduction in transfusions. Shorter survival was observed in the DA arm; thus, this study does not support the use of erythropoiesis-stimulating agents in this subset of patients with anemia of cancer.

A phase 2 study to evaluate the efficacy of darbepoetin-alfa administered using an extended dose schedule versus weekly dosing in cancer patients with chemotherapy-induced anemia

19501

Background: Chemotherapy-induced anemia (CIA) can be effectively treated with darbepoetin alfa (DA) using different dosing schedules. Since chemotherapy (CTX) regimens involve various dosing schedules, the ability to synchronize DA dose with CTX could be beneficial. Methods: This phase 2, 25-week (wk), randomized, open-label study compares the efficacy and safety of DA administered using an extended dose schedule (EDS) (every 2 wks [Q2W] or every 3 wks [Q3W]) vs weekly (QW) dosing in patients (pts) with CIA. Pts were randomly assigned to receive DA EDS (either 300 mcg Q2W [with CTX QW, Q2W, or Q4W] or 500 mcg Q3W [with CTX Q3W]) vs 150 mcg DA QW (with CTX QW, Q2W, Q3W, or Q4W). Randomization was stratified by length of CTX cycle, screening hemoglobin (Hb) (< 10 vs = 10 g/dL), and type of cancer (lung/gynecological vs other cancers). The primary endpoint was the change in Hb from baseline (BL) to wk 13; other endpoints included the change in Hb from BL to end of study (EOS), percentage of pts with = 1 transfusion (TFN) from BL to wk 13 and EOS, and safety. Results: Final data for the total 25-wk study period will be presented. Results from a planned interim analysis for all pts who were enrolled in the study and received = 1 dose of DA (n = 752) are shown for wk 13 endpoints (Table). The groups had similar mean change in Hb from BL to wk 13, with a difference (QW minus EDS) (95% CL) of 0.2 (-0.1, 0.4) g/dL. The % pts who achieved target Hb were also similar (difference [95% CL] = 0 [-7, 6]). At the time of the interim analysis, the incidence and types of adverse events were similar between the groups. Ten (3%) EDS and 15 (4%) QW pts had thromboembolic events, 5 (1%) EDS and 2 (1%) QW pts had cerebrovascular accidents, and 19 (5%) EDS and 22 (6%) QW pts had died. Conclusions: This is the first trial synchronizing DA dosing (Q2W and Q3W) with CTX schedules. The interim results suggest that DA administered once per CTX cycle is well-tolerated and efficacious in these patients.

[Table: see text]

No significant financial relationships to disclose.

Baseline predictors of response to treatment with darbepoetin-alpha (DA) in anemic patients with low-risk myelodysplastic syndrome (MDS)

7081

Background: Patients (pts) with MDS often develop anemia, resulting in fatigue and an increased requirement for transfusions. The erythropoiesis-stimulating agent (ESA) DA can raise hemoglobin (Hb) levels in low-risk MDS pts. Previous analyses suggest that baseline (BL) endogenous erythropoietin (eEPO) levels and French-American-British (FAB) disease category are predictors of response to ESAs. Methods: This was a phase 2, open-label, 52-week (wk) study of DA administered 500 mcg every 3 wks (Q3W) to anemic (Hb=11g/dL), low- or intermediate-risk MDS pts. Pts received 500 mcg DA Q2W if they did not respond by wk 7. The last DA dose was at wk 52; end of study was wk 53 or 55 for pts receiving DA Q2W or Q3W, respectively. The primary endpoint was % pts with an erythroid response (International Working Group criteria) by wk 13. Other endpoints included change from BL in Hb and FACT-F score. Exploratory analyses examined the incidence of erythroid responses adjusted by FAB category (refractory anemia [RA], RA with ringed sideroblasts [RARS], or RA with excess blasts [RAEB]). Results: Final 53/55 wk data will be presented. Results were stratified by whether pts received an ESA before enrollment (ESA-naive [ESA-N] vs ESA-treated [ESA-T]). ESA-T pts are a heterogeneous group and their data are difficult to interpret; thus, predictors of response will be presented for ESA-N pts only. Of 144 ESA-N pts, 56% had RA, 37% had RARS, and 7% had RAEB. Most ESA-N pts achieved the target Hb and had a major erythroid response ( Table ). Pts with RA were more likely to achieve a major erythroid response than pts with RARS or RAEB. For ESA-T pts, demographics and type/length of ESA treatment will be presented. Of all pts, serious adverse events (SAEs) were reported in 62 (30%) pts and treatment-related SAEs in 2 (1%) pts. Conclusions: FAB category may affect response to DA in MDS pts. Additional data will be presented on the effect of BL eEPO, transfusion needs, and previous ESA treatment on response and duration of response.

[Table: see text]

The Effectiveness of Darbepoetin Alfa Administered Every 3 Weeks on Hematologic Outcomes and Quality of Life in Older Patients With Chemotherapy‐Induced Anemia

Chemotherapy-induced anemia (CIA) may substantially impact the health-related quality of life (HRQoL) of older cancer patients. This exploratory analysis evaluated the effect of darbepoetin alfa administered as a fixed dose (300 microg) every 3 weeks (Q3W) on hematologic outcomes, HRQoL, and safety in older (> or =65 years old) versus younger (<65 years old) patients with CIA (hemoglobin <11 g/dl). Patients were categorized by age at screening: <65, > or =65 to <70, > or =70 to <75, > or =75 to <80, and > or =80 years old. Patients who received at least one dose of darbepoetin alfa were included in the analysis; of 1,493 patients, 724 were > or =65 years old. Age did not appear to influence hematologic outcomes after treatment with darbepoetin alfa; in all age categories, similar percentages of patients (78%-80%) achieved the target hemoglobin in approximately the same time (4-5 weeks). Also, the percentage of patients in each age category who received RBC transfusions was reduced from 10%-13% in month 1 to 2%-4% in month 4. Although younger patients reported the greatest improvement in HRQoL scores, approximately one half in each older age category reported clinically significant improvement in fatigue, and improvement in the Energy and Overall Health Assessment and Work Productivity and Activity Impairment scales. There were no treatment-related deaths. Treatment-related thromboembolic events were reported by <1% of patients <65 years old and <1% of patients > or =65 to <70 and > or =70 to <75 years old. Darbepoetin alfa Q3W appeared well tolerated and effective for treating older patients with CIA.

The effectiveness of darbepoetin alfa administered at 300 mcg every 3 weeks on clinical outcomes in elderly patients with chemotherapy-induced anemia

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Background: Chemotherapy-induced anemia (CIA) is common in patients (pts) receiving chemotherapy, and reduces health-related quality of life. The primary objective of this exploratory analysis was to describe the effectiveness of darbepoetin alfa administered at 300 mcg every 3 weeks (Q3W) in elderly (≥ 65 years old) and younger pts (< 65 years old) with CIA. Methods: We analyzed data on 1493 pts, enrolled in a multicenter, open-label, 16-week study and who received ≥ 1 dose of darbepoetin alfa. Eligible pts were ≥ 18 years old, had a non-myeloid malignancy, and were anemic (hemoglobin [Hb] < 11 g/dL). Pts were analyzed stratified by age (≥ 65 and < 65 years old) and baseline (BL) Hb (< 10 or ≥ 10 g/dL). Hb-based endpoints were analyzed using 2 approaches: the last value carried forward (LVCF) method, where missing Hb values or values within 28 days of a red blood cell (RBC) transfusion were imputed, or an available data approach, where missing Hb values were not imputed. Pt-reported outcomes were assessed using the Functional Assessment of Cancer Therapy-Fatigue (FACT-F) scale. Results: Pt demographics and disease characteristics varied between the age strata: in the ≥ 65-stratum (mean age = 73.7, n = 724), 52% of pts were women and the most common cancer was gastrointestinal (27%); in the < 65-stratum (mean age = 52.1, n = 769), 69% of pts were women and the most common cancer was breast (41%). Mean (SD) BL FACT-F scores for pts ≥ 65 and < 65 were 27.5 (12.8) vs 27.2 (12.1) for the < 10-g/dL strata and 29.0 (12.5) vs 27.5 (12.0) for the ≥ 10-g/dL strata. Study endpoints are shown in the table. The safety profile was as expected for each age group. Conclusions: Darbepoetin alfa 300 mcg Q3W appears to be as effective in achieving and maintaining Hb between 11 to 13 g/dL in elderly pts as in younger pts with CIA. Since chemotherapy is often administered Q3W, synchronizing darbepoetin alfa treatment with pts’ chemotherapy schedules may simplify the treatment of CIA in this pt population.

[Table: see text]

[Table: see text]

Darbepoetin alfa administered at varying intervals compared with weekly epoetin alfa for treating chemotherapy-induced anemia: A pooled analysis of 20 clinical trials

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Background: Cancer patients (pts) often develop chemotherapy-induced anemia (CIA), resulting in an increased risk for transfusions and fatigue. The erythropoiesis-stimulating agents (ESAs) epoetin alfa (EA) and darbepoetin alfa (DA) can reduce transfusion requirements, raise hemoglobin (Hb) levels, and decrease fatigue in pts with CIA. The 74-hour half-life of DA allows for flexible dosing with weekly (QW), every-2-week (Q2W), or every-3-week (Q3W) administration. This study evaluated if the dosing interval used to administer DA affected its efficacy. Methods: Data from 20 clinical trials in the CIA setting were pooled, including single-arm, active-controlled, and placebo-controlled trials (a full description of these studies will be presented). Six studies contributed data for DA QW, 7 studies for DA Q2W, and 5 studies for DA Q3W. Controlled studies used either a placebo or EA as the comparator. Logistic regression with treatment as a random effect was used to analyze the clinical trials. Endpoints included the percentage of pts requiring transfusions (from week 1 to end of the treatment period [EOTP] and from week 5 to EOTP), reaching a target Hb of ≥ 11 g/dL, and achieving ≥ 3 point change in FACT-F score from baseline (BL). Percentages were adjusted for BL Hb levels (< 10 vs ≥ 10 g/dL), whether pts received platinum chemotherapy (no vs yes), and for dosage adjustments. Results: The type of ESA used (EA or DA) did not appear to affect the percentage of study pts who achieved clinically meaningful endpoints (see Table ). The results from these analyses also suggest that the dosing interval at which DA was administered did not affect its efficacy in study pts (see Table ). Conclusions: DA administered at dosing intervals of QW, Q2W, or Q3W has comparable efficacy to EA QW. This flexibility allows DA administration to be synchronized with common chemotherapy schedules, which may increase pt convenience by reducing the number of clinic visits.

[Table: see text]

[Table: see text]

Effectiveness of darbepoetin alfa 300 mcg every 3 weeks in patients with chemotherapy-induced anemia

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Background: Patients (pts) receiving chemotherapy (CTX) often experience anemia resulting in decreased quality of life. We performed a post hoc combined analysis of 2 clinical studies of darbepoetin alfa (DA) 300 mcg every 3 weeks (Q3W), allowing for comparison of larger treatment groups. Methods: Eligibility criteria of the 2 studies were similar: pts ≥ 18 yrs old with nonmyeloid malignancy, anemia (hemoglobin [Hb] < 11 g/dL), and receiving CTX. Study 1 (20030232) was a phase 3, randomized, placebo-controlled, double-blind, study involving 16 wks of treatment with end of treatment phase (EOTP) visit at wk 19. Study 2 (20030206) was a single-arm, open-label, phase 4 study involving 13-wks of treatment with EOTP visit at wk 16. Efficacy endpoints included: percentage of pts achieving target Hb (≥ 11 g/dL without RBC transfusion [TFN] within 28 days), pts requiring TFNs between wk 1 and EOTP, pts requiring TFNs between wk 5 and EOTP, pts with a ≥ 3-point change in FACT-F score, and pts achieving ≥ 1-g/dL increase in Hb after 4 wks of therapy. Results: In both studies, 61% of pts were women and 79% were white. The mean (SD) age was 64.5 years (12.1) for Study 1 and 62.6 years (13.3) for Study 2. The most common tumor type was breast (26% in Study 1; 29% in Study 2). Mean (SD) baseline (BL) Hb values were 10.1 (0.9) and 10.1 (0.7) g/dL for Study 1 and Study 2 respectively, and mean (SD) baseline FACT-F scores were 27.3 (12.8) and 27.9 (12.3) respectively. See Table for endpoints. Combined analysis showed that increasing Hb by ≥ 1 g/dL after 4 wks of therapy was a poor predictor of clinical outcomes (avoidance of TFN, sensitivity = 56.2%; achievement of Hb target, sensitivity = 57.8%). Safety outcomes were similar and expected for this population. DA appeared to be well-tolerated. No pts exhibited neutralizing antibodies to DA. Conclusions: This combined analysis provides further evidence of the effectiveness of DA Q3W dosing in this pt population. This dosing interval may facilitate the administration of DA in synchronization with Q3W CTX regimens.

[Table: see text]

[Table: see text]

Evaluating if darbepoetin alfa efficacy and safety in patients with chemotherapy-induced anemia is affected by the disease stage of the patient

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Background: Cancer patients (pts) often develop chemotherapy-induced anemia (CIA), resulting in increased transfusion incidence and fatigue. Darbepoetin alfa (DA) is an erythropoiesis-stimulating agent that can reduce the incidence of transfusions, increase hemoglobin (Hb) levels to a range of 11 to 13 g/dL (as recommended by evidence-based guidelines), and decrease fatigue in pts with CIA. The 74-hour half-life of DA allows it to be effectively administered weekly (QW), every 2 weeks (Q2W), or every 3 weeks (Q3W). DA treatment can also be synchronized with chemotherapy (Glaspy et al., 2005). Here we examined if the efficacy and safety of DA for treating CIA is affected by the disease stage of the pt. Methods: Eight clinical trials (including single-arm, active-controlled, and placebo-controlled studies) were analyzed that described the administration of DA QW (2 studies), Q2W (3 studies), or Q3W (3 studies) to pts with CIA. Tumor-Nodes-Metastases (TNM) classification was used to define disease stage of I, II, III, or IV. A clinically meaningful endpoint evaluated was the proportion of pts achieving a target Hb of ≥ 11 g/dL. Other endpoints included incidence of transfusions, change in FACT-F score at end of study from baseline, and incidence of adverse events. Results: A high percentage of pts in all disease stages achieved a target Hb of ≥ 11 g/dL in response to DA treatment (see Table ). Early stage pts were seen to benefit at least as much as later stage pts. A similar trend was seen for the other efficacy and safety endpoints (data will be presented). Conclusions: The present analysis suggests that DA administered QW, Q2W, or Q3W can effectively correct anemia when administered to pts in either early or late disease stages. The potential to synchronize DA treatment and chemotherapy regardless of disease stage may increase pt convenience by reducing the number of clinic visits.

[Table: see text]

[Table: see text]

Darbepoetin Alfa Administered Every Three Weeks Is Effective for the Treatment of Chemotherapy‐Induced Anemia

Patients with cancer receiving chemotherapy often have chemotherapy-induced anemia (CIA) and reduced quality of life. Darbepoetin alfa can effectively treat CIA when administered at an extended dosing interval of once every 3 weeks (Q3W). Darbepoetin alfa administered Q3W may allow synchronization of darbepoetin alfa therapy with chemotherapy administered Q3W. This multicenter, open-label, 16-week study evaluated the effectiveness and safety of darbepoetin alfa administered as a fixed dose (300 mug) Q3W in patients with CIA. Eligible patients (> or =18 years) were anemic (hemoglobin <11g/dl), had a nonmyeloid malignancy, and were receiving multicycle chemotherapy. This analysis includes 1,493 patients who received at least one dose of darbepoetin alfa. The effect of baseline hemoglobin (<10 or > or =10 g/dl) on clinical outcomes was evaluated. Patients in the > or =10-g/dl stratum achieved the hemoglobin target range (11-13 g/dl)in less time than patients in the <10-g/dlstratum (3 weeks vs. 9 weeks). More patients in the > or =10-g/dl stratum achieved the hemoglobin target range (87% vs. 66%); however, similar proportions of patients in both strata maintained hemoglobin within the target range (73% vs. 71%). Fewer patients in the > or =10-g/dl stratum received RBC transfusions from week 5 to the end of the study (12% vs. 28%). Over 50% of patients in both strata reported clinically significant improvements (> or =3-point increase) in Functional Assessment of Cancer Therapy-Fatigue score. Twenty-eight percent of patients reported serious adverse events; 3% of all patients had a venous or arterial thrombotic event. This study demonstrates that darbepoetin alfa Q3W is well tolerated and effective for treating CIA.

A harder thing than triumph: roles of fathers of children with disabilities

Researchers have recently begun to address the role of fathers of children with disabilities, which often casts the father as peripheral to the child's development. However, my review of the relevant literature indicates that these fathers express more interest in the needs of their children than customarily thought. Many fathers apparently want more involvement than they currently have but are constrained by "gate-keeping" roles of mothers and the structure of their children's programs. Further, research and popular literature show that although fathers have recognized roles to play, it is difficult for them to receive credit for their efforts, which may be due to the lack of routines to foster father/male involvement in programs for children with disabilities.