Description:
Prostate Cancer (PC) is the most frequent cancer in men, accounting for 21% of new cases of
cancer in men in the United States. Among the four most incident tumors (breast, lung and
colorectal cancer); prostate cancer is the only that does not have any predictive biomarker
to guide the treatment. Even though the molecular heterogeneity of PC is well-documented,
treatment has not been molecularly stratified and the need for genetic prognostic and
predictive markers is critical.
DNA repair defects (DRD), mainly in the Homologous Recombination (HR) pathway (such as BRCA1,
BRCA2, ATM and CHEK2) are emerging as potential biomarkers in prostate cancer. It is well
known BRCA1 and BRCA2 carriers have better Progression-Free Survival (PFS) and Overall
Survival (OS) than non-carriers in ovarian cancer. Differently than ovarian tumors that BRCA
mutations provides a good prognosis, PC patients who harbor HR defects have a higher Gleason
score 6, an increased risk of recurrence and poor prognosis. The predictive role of DRD in PC
was demonstrated in a recent trial using Olaparib, a PARP inhibitor, in DRD carriers. This
trial showed 88% of response rate with Olaparib, a PARP inhibitor that acts in HR pathway by
synthetic lethality.
Recent data demonstrated important association between HR deficient high-grade serous ovarian
cancer (HGSOC), high neoantigen load and high expression of PD-1/PD-L1 compared with HR
proficient HGSOCs 10. This study showed that BRCA1 and BRCA2 mutations increase the number of
tumor-infiltrating lymphocytes (TILs) and confer a better prognosis. The unprecedented
success of immunotherapy in malignant disorders has provided evidence that the patient's
immune system can be improved to attack established tumors, mainly melanoma, non-small cell
lung cancer and kidney cancer. A high mutational burden increases the likelihood of the
development of specific neoepitopes that would confer clinical benefit from CTLA-4 and PD-1
blockade.
These data showed that specific DNA repair defects increase the mutational burden, the
expression of PD-1/PD-L1 and TILs; and could improve the response to immunotherapy in cancer.
This rationale was already tested in a trial that evaluated the PD-1 checkpoint inhibitor
Pembrolizumab in mismatch-repair deficient patients, a kind of DNA repair defect by
definition. This important trial showed that this DRD predicted clinical benefit of immune
checkpoint blockade in many types of cancer, especially colorectal cancer.
Title
- Brief Title: Nivolumab in Prostate Cancer With DNA Repair Defects (ImmunoProst Trial)
- Official Title: Nivolumab in Prostate Cancer With DNA Repair Defects (ImmunoProst Trial)
Clinical Trial IDs
- ORG STUDY ID:
64121317.4.1001.5330
- NCT ID:
NCT03040791
Conditions
Interventions
Drug | Synonyms | Arms |
---|
Nivolumab | BMS-936558 | Nivolumab |
Purpose
Prostate Cancer (PC) is the most frequent cancer in men, accounting for 21% of new cases of
cancer in men in the United States. Among the four most incident tumors (breast, lung and
colorectal cancer); prostate cancer is the only that does not have any predictive biomarker
to guide the treatment. Even though the molecular heterogeneity of PC is well-documented,
treatment has not been molecularly stratified and the need for genetic prognostic and
predictive markers is critical.
DNA repair defects (DRD), mainly in the Homologous Recombination (HR) pathway (such as BRCA1,
BRCA2, ATM and CHEK2) are emerging as potential biomarkers in prostate cancer. It is well
known BRCA1 and BRCA2 carriers have better Progression-Free Survival (PFS) and Overall
Survival (OS) than non-carriers in ovarian cancer. Differently than ovarian tumors that BRCA
mutations provides a good prognosis, PC patients who harbor HR defects have a higher Gleason
score 6, an increased risk of recurrence and poor prognosis. The predictive role of DRD in PC
was demonstrated in a recent trial using Olaparib, a PARP inhibitor, in DRD carriers. This
trial showed 88% of response rate with Olaparib, a PARP inhibitor that acts in HR pathway by
synthetic lethality.
Recent data demonstrated important association between HR deficient high-grade serous ovarian
cancer (HGSOC), high neoantigen load and high expression of PD-1/PD-L1 compared with HR
proficient HGSOCs 10. This study showed that BRCA1 and BRCA2 mutations increase the number of
tumor-infiltrating lymphocytes (TILs) and confer a better prognosis. The unprecedented
success of immunotherapy in malignant disorders has provided evidence that the patient's
immune system can be improved to attack established tumors, mainly melanoma, non-small cell
lung cancer and kidney cancer. A high mutational burden increases the likelihood of the
development of specific neoepitopes that would confer clinical benefit from CTLA-4 and PD-1
blockade.
These data showed that specific DNA repair defects increase the mutational burden, the
expression of PD-1/PD-L1 and TILs; and could improve the response to immunotherapy in cancer.
This rationale was already tested in a trial that evaluated the PD-1 checkpoint inhibitor
Pembrolizumab in mismatch-repair deficient patients, a kind of DNA repair defect by
definition. This important trial showed that this DRD predicted clinical benefit of immune
checkpoint blockade in many types of cancer, especially colorectal cancer.
Detailed Description
This is a Phase II, two-stage, multi-center, single-arm, and open-label trial of Nivolumab
(BMS-936558) in patients with metastatic castration-resistant prostate cancer (mCRPC) who
have progressed to a taxane-based chemotherapy regimen previously. Eligible patients must
have ECOG 0-2 and material for biomarker analysis. Prior enzalutamide, abiraterone and
cabazitaxel are permitted but not necessary to enrollment. The germline and somatic DRD
(BRCA1, BRCA2, ATM, PTEN, CHEK2, RAD51C, RAD51D, PALB2, MLH1, MSH2, MSH6, PMS2.) will be
assessed by T-NGS of metastatic sites or by liquid biopsy. The primary endpoint is PSA 50
response rate (PSA50, following the Prostate Cancer Working Group 3 criteria). The trial will
meet its endpoint if ≥ 3/29 men achieve a PSA50 response. The secondary endpoints will
include progression-free survival (PFS), overall survival, radiologic PFS, PSA response rate
at 6 and 12 months.
Trial Arms
Name | Type | Description | Interventions |
---|
Nivolumab | Experimental | All patients will receive Nivolumab 240 mg every 14 days until progression or unacceptable toxicity | |
Eligibility Criteria
Inclusion Criteria:
1. Histologically confirmed adenocarcinoma of the prostate with tumor tissue available
for molecular analyses. If archival tissue for biomarker analysis is not available
then the patient must be willing to have a further biopsy to obtain tumor tissue for
histological diagnosis.
2. Metastatic Castrate-resistant prostate cancer (mCRPC), defined by:
- Disease progression despite androgen deprivation therapy (ADT) and may present as
either a continuous rise in serum prostate-specific antigen (PSA) levels, the
progression of pre-existing disease, and/or the appearance of new metastases.
- Surgically or medically castrated, with testosterone levels of < 50 ng/dL (< 2.0
nM). If the patient is being treated with GnRH or LHRH agonists or antagonists
(patient who have not undergone orchiectomy), this therapy should be maintained.
3. Documented prostate cancer progression, during treatment with Docetaxel, as assessed
by the investigator with one of the following:
- PSA progression is defined according the PCWG3 criteria: PSA increase, that is ≥
50% and ≥ 2 ng/mL above the nadir, and which is confirmed by a second value ≥ 3
weeks later (confirmed the rising trend).
- Radiographic progression of visceral lesions or soft tissue disease by modified
RECIST 1.1 criteria.
- Progression of bone metastasis is defined according the Appendix B: Prostate
Cancer Clinical Trials Working Group 3 (Adapted) two or more documented new bone
lesions on a bone scan with or without PSA progression. Confirmation of ambiguous
results by other imaging modalities (eg, CT or MRI) is obligatory. If Docetaxel
chemotherapy is used more than once, this will be considered as one regimen.
4. Eastern Cooperative Oncology Group (ECOG) Performance Status of ≤ 2 Appendix A:
Performance Status Criteria
5. Life expectancy > 24 weeks.
6. Age ≥ 18 years
7. At least 28 days since the completion of any prior anti-cancer therapy (except for
LHRH agonists or antagonists), including chemotherapy (taxane-based). Additionally,
clinically relevant treatment toxicities should have resolved to grade 1 or less prior
to start study treatment.
8. For hormonal treatment must be followed the guideline below:
- No antiandrogens are allowed during the study period. The use of antiandrogens
before study entry is permitted, but at least 28 days since the completion of
prior antiandrogen are required (washout period).
- Corticosteroids dose > Prednisolone 10 mg/day (or equivalent) are allowed only if
clinically indicated for medical conditions. At least 28 days since the
completion of prior corticotherapy are required (washout period).
9. Agreeable to have all the biomarker studies including the fresh tumor biopsies if
needed.
10. Patients must have adequate organ function within 1 weeks prior enrollment to and
evidenced by:
- Hemoglobin ≥ 9.0 g/dL
- WBC > 2.000/mm3
- Absolute neutrophil count ≥ 1.500/mm3
- Platelet count ≥ 100.000/mm3
- Creatinine Clearance ≥ 30 mL/min. Creatinine Clearance (CrCl) must be calculated
at screening using the Cockcroft-Gault formula:
- Bilirubin < 3 x upper limit of normal (ULN) except for patients with known
Gilbert's syndrome.
- Aspartate transaminase (AST) (SGOT) < 3.0 x ULN.
- Alanine transaminase (ALT) (SGPT) < 3.0 x ULN.
- No cardiac disease defined by as active angina, symptomatic congestive heart
failure, or myocardial infarction within previous six months.
Exclusion Criteria:
- Patients with any active known or suspected autoimmune disease. Patients with
vitiligo, type I diabetes mellitus, controlled autoimmune hypothyroidism, psoriasis
not requiring systemic treatment, or other conditions under control are permitted to
enroll.
- Patients with conditions that needs systemic corticosteroids dose > Prednisolone 10
mg/day (or equivalent) or other immunosuppressive medications within 28 days prior to
the first dose of study drug. Inhaled steroids are permitted if necessary.
- Patients with any known active chronic liver disease.
- Patients who have prior history of malignancy treated with curative intention in the
past 2 years with the exception of basal cell carcinoma and squamous cell carcinoma of
the skin, which were allowed in any case. Patients with other malignancies that do not
fulfill the prior criteria could be considered for recruitment if they do not
represent a competitive cause of death and have a low potential to progress to
metastatic progression. Patients in this condition may be enrolled in the trial if
approved after review by principal investigator.
- Known history of testing positive for human immunodeficiency virus (HIV), known
acquired immunodeficiency syndrome (AIDS), or any positive test for hepatitis B or
hepatitis C virus representing acute or chronic disease.
- Preceding treatment with an anti-PD-1, anti-PD-L1 or anti-CTLA-4 antibody, or any
other antibody or drug specifically targeting T-cell co-stimulation or checkpoint
pathways.
- Major surgery less than 28 days prior to the first dose of study drug.
- Radiation therapy less than 14 days prior to the first dose of study drug.
Maximum Eligible Age: | N/A |
Minimum Eligible Age: | 18 Years |
Eligible Gender: | Male |
Healthy Volunteers: | No |
Primary Outcome Measures
Measure: | PSA response rate |
Time Frame: | through study completion, an average of 1 year |
Safety Issue: | |
Description: | PSA partial response is defined as a ≥ 50% decline in PSA from cycle 1 day 1 (baseline) PSA value. This PSA decline must be confirmed as sustained by a second PSA value obtained ≥ 3 weeks later. |
Secondary Outcome Measures
Measure: | Time to PSA progression |
Time Frame: | through study completion, an average of 1 year |
Safety Issue: | |
Description: | |
Measure: | PSA Response Rate at 6 and 12 months |
Time Frame: | through study completion, an average of 1 year |
Safety Issue: | |
Description: | |
Measure: | Radiological progression-free survival (rPFS) |
Time Frame: | through study completion, an average of 1 year |
Safety Issue: | |
Description: | |
Measure: | Time to Radiographic Progression |
Time Frame: | through study completion, an average of 1 year |
Safety Issue: | |
Description: | |
Measure: | Progression free survival (PFS) |
Time Frame: | through study completion, an average of 1 year |
Safety Issue: | |
Description: | |
Measure: | Overall survival |
Time Frame: | through study completion, an average of 1 year |
Safety Issue: | |
Description: | |
Details
Phase: | Phase 2 |
Primary Purpose: | Interventional |
Overall Status: | Active, not recruiting |
Lead Sponsor: | Hospital Moinhos de Vento |
Trial Keywords
Last Updated
August 26, 2021