Clinical Trials /

Ipilimumab and Nivolumab in Patients With Anti-PD-1-axis Therapy-resistant Advanced Non-small Cell Lung Cancer.

NCT03262779

Description:

The investigators propose a trial to evaluate if the addition of ipilimumab to nivolumab after primary resistance to anti- programmed death 1 (PD-1) axis therapy can lead to objective radiographic tumor regression.

Related Conditions:
  • Non-Small Cell Lung Carcinoma
Recruiting Status:

Recruiting

Phase:

Phase 2

Trial Eligibility

Document

Title

  • Brief Title: Ipilimumab and Nivolumab in Patients With Anti-PD-1-axis Therapy-resistant Advanced Non-small Cell Lung Cancer.
  • Official Title: A Phase II Study of Combination Immunotherapy With Ipilimumab and Nivolumab in Patients With Advanced Non-small Cell Lung Cancer Resistant to Anti-PD-1-axis Therapy

Clinical Trial IDs

  • ORG STUDY ID: 2000020343
  • NCT ID: NCT03262779

Conditions

  • Carcinoma, Non-Small-Cell Lung

Interventions

DrugSynonymsArms
combination nivolumab and ipilimumabcombination nivolumab and ipilimumab

Purpose

The investigators propose a trial to evaluate if the addition of ipilimumab to nivolumab after primary resistance to anti- programmed death 1 (PD-1) axis therapy can lead to objective radiographic tumor regression.

Detailed Description

      Approximately 20 percent of unselected patients with advanced non-small cell lung cancer
      (NSCLC) and progression during or after standard first line chemotherapy will experience
      tumor response to nivolumab. Treatment options for patients who are not responsive to
      programmed death 1 (PD-1) axis inhibitor therapy are limited, and the mechanisms of primary
      resistance are poorly understood.

      The combination of nivolumab and ipilimumab is currently FDA approved for the treatment of
      advanced melanoma based on superiority to either agent alone5. The results of a phase I study
      evaluating combination therapy with nivolumab and ipilimumab in patients with advanced NSCLC
      (NCT01454102) were presented at the annual American Society of Clinical Oncology (ASCO)
      meeting in 20166. Dosing of nivolumab 3 mg/kg every 2 weeks and ipilimumab 1 mg/kg every 6
      weeks yielded an objective response rate (ORR) by Response Evaluation Criteria in Solid
      Tumors (RECIST) v1.1 of 39%, with one-year survival rate of 69% and grade 3-4
      treatment-related adverse event rate of 33%. These results prompted an ongoing phase III
      study comparing this regimen to standard first line chemotherapy, nivolumab monotherapy or
      combination therapy with chemotherapy and nivolumab for patients with advanced NSCLC
      (NCT02477826).

      The investigators propose a trial to evaluate if the addition of ipilimumab to nivolumab
      after primary resistance to anti-PD-1 axis therapy can lead to objective radiographic tumor
      regression. It is hypothesized that ipilimumab will enable more effective immune priming in
      some patients, resulting in the trafficking of tumor-specific cytotoxic T cells to the tumor,
      as well as depletion of tumor-permissive T regulatory cells. With concurrent nivolumab, PD-1
      inhibition in the tumor will enable effective anti-tumor attack by tumor-specific T cells.
      Serial tumor biopsies and blood collections will allow interrogation of changes in the tumor
      microenvironment (and periphery) that support this hypothesis.

      The investigators will primarily enroll patients who have experienced progression of NSCLC
      after anti-PD-1- axis therapy without initial response to such therapy ('primary
      resistance'). A smaller cohort of patients with acquired resistance to anti-PD-1 axis therapy
      (i.e. progression after initial response) will additionally be accrued.
    

Trial Arms

NameTypeDescriptionInterventions
combination nivolumab and ipilimumabExperimentalCombination therapy with nivolumab 3 mg/kg administered intravenously (IV) every 2 weeks, and ipilimumab 1 mg/kg administered IV every 6 weeks.
  • combination nivolumab and ipilimumab

Eligibility Criteria

        Inclusion Criteria

        A. Signed Informed Consent B. Ability to comply with the protocol C. Age ≥18 years D.
        Histologically or cytologically documented, locally advanced or metastatic (i.e., Stage
        IIIB not eligible for definitive chemoradiotherapy, Stage IV, or recurrent) NSCLC (per the
        American Joint Committee /AJCC staging system) E. ECOG performance status of 0 to 2 F.
        Measurable disease, as defined by RECIST v1.1. Previously irradiated lesions can be counted
        as target lesions if clearly progressing after radiation.

        G. Chemotherapy-naive and treated patients will be eligible, with no limit on number of
        prior therapies. Patients with NSCLC known to harbor an ALK rearrangement, or EGFR mutation
        known to be sensitive to FDA-approved tyrosine kinase inhibitors (TKI), are only eligible
        after experiencing disease progression (during or after treatment) or intolerance to an FDA
        approved EGFR TKI or ALK TKI, respectively.

          1. Patients with TKI-treated EGFR mutant NSCLC harboring the secondary EGFR T790M tumor
             must have received prior osimertinib

          2. Patients with crizotinib-treated ALK rearranged NSCLC must have received a next
             generation ALK inhibitor (e.g. ceritinib, alectinib or brigatinib) H. Prior palliative
             radiotherapy must have been completed at least 2 weeks before the first dose of study
             drug.

        I. Anti- PD-1 Axis therapy (anti-PD-1 or anti-PD-L1, e.g. nivolumab, pembrolizumab,
        atezolizumab, durvalumab, avelumab) must be the most recent systemic anti-tumor treatment
        received in all patients, with documented progressive disease. Last administration of
        anti-PD-1 axis therapy must have been at least 3 weeks before the first dose of study drug.

        a. Patients to be enrolled to the primary cohort (primary resistance) must have had
        progressive disease or stable disease less than 24 weeks as the best clinical response to
        anti-PD-1-axis monotherapy b. Patients to be enrolled to the exploratory cohort (acquired
        resistance) must have had stable disease for at least 24 weeks, partial response, or
        complete response as the best clinical response to anti-PD-1-axis monotherapy, with
        subsequent progression of disease J. At least one tumor amenable to incisional, excisional,
        core or forceps (transbronchial) biopsy. Patients must be willing to undergo tumor biopsies
        before starting trial therapy, and 9 to 10 weeks after initiation of therapy.

        a. If the initial biopsy will be excisional, the excised tumor cannot be counted as a
        target lesion and there must be another lesion amenable to incisional, excisional, core or
        forceps biopsy. In this scenario, the second biopsy can only be excisional if the lesion to
        be excised is not a target lesion. b. Cytology tumor specimens (e.g. from fine-needle
        biopsies, or drainage of pleural/ pericardial or ascites fluid) are not acceptable.
        Biopsies of bone lesions that do not have a soft tissue component are also not acceptable
        (i.e. decalcified tumor samples are not acceptable).

        K. For female patients of childbearing potential and male patients with partners of
        childbearing potential, agreement (by patient and/or partner) to use a highly effective
        form(s) of contraception (i.e., one that results in a low failure rate [<1% per year] when
        used consistently and correctly) and to continue its use for 6 months after the last dose
        of trial therapy. Highly effective contraception is one with a failure rate of <0.1%. Birth
        control pills on their own do not achieve that rate.

          1. Women of childbearing potential must have a negative pregnancy test (serum or urine)
             within 72 hours of the start of study drug administration

          2. Women who have recently given birth must no longer be breastfeeding

        L. Adequate hematologic and end-organ function, defined by the following laboratory results
        obtained within 14 days prior to the first study treatment:

        - Neutrophils ≥1500 cells/μL (without granulocyte colony-stimulating factor support within
        2 weeks prior to Cycle 1, Day 1)

          -  Platelets ≥75,000/μL (transfusion to achieve this level is not permitted within 2
             weeks of the first study drug administration)

          -  Hemoglobin ≥9.0 g/dL

          -  Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤3 x institutional
             upper limit of normal (ULN) with the following exceptions: Patients with documented
             liver metastases: AST and/or ALT≤5 x ULN

          -  Serum bilirubin ≤1.5 x ULN (Patients with known Gilbert disease who have serum
             bilirubin level ≤3 x ULN may be enrolled)

          -  Serum creatinine ≤1.5 x ULN or creatinine clearance ≥50 mL/min

        Exclusion Criteria

        A. Has an active autoimmune disease requiring systemic treatment within the past 3 months
        or a documented history of clinically severe autoimmune disease, or a syndrome that
        requires systemic steroids or immunosuppressive agents. Subjects with vitiligo or resolved
        childhood asthma/atopy would be an exception to this rule. Subjects who require
        intermittent use of inhaled steroids or local steroid injections would not be excluded from
        the study. Subjects with hypothyroidism stable on hormone replacement, or psoriasis not
        requiring systemic therapy (within the past 3 years) will not be excluded from the study.
        B. Interstitial lung disease that is symptomatic or may interfere with the detection or
        management of suspected drug-related pulmonary toxicity C. Subjects must not have a history
        of life-threatening toxicity related to prior anti-PD-1 axis therapy a. Subjects with
        history of anti-PD-1 axis therapy toxicities that are unlikely to recur with standard
        countermeasures (e.g., hormone replacement after adrenal crisis) are eligible.

        D. Prior treatment with anti-CTLA-4 therapeutic antibodies

        E. Symptomatic or untreated CNS metastases. Patients with a history of treated asymptomatic
        CNS metastases are eligible, provided they meet all of the following criteria:

          1. No evidence of interim progression between the completion of CNS-directed therapy and
             the start of trial therapy.

          2. No ongoing requirement for dexamethasone as therapy for CNS disease; anticonvulsants
             at a stable dose are allowed.

          3. Completed stereotactic radiosurgery at least 1 week prior to Cycle 1, Day 1 or
             wholebrain radiation at least 2 weeks prior to Cycle 1, Day 1 F. History of
             leptomeningeal carcinomatosis G. Prior palliative radiotherapy outside the CNS within
             2 weeks of the first dose of study drug.

        H. Treatment with systemic immunosuppressive medications (including but not limited to,
        dexamethasone at doses > 2 mg daily (or equivalent dose of other corticosteroids),
        cyclophosphamide, tacrolimus, sirolimus, azathioprine, methotrexate, thalidomide, and
        antitumor necrosis factor [anti-TNF] agents) within 2 weeks prior to initiating trial
        therapy (Inhaled or topically applied steroids, and acute and chronic standard-dose NSAIDs
        are permitted. Replacement steroids are also permitted).

        I. Subjects must not have received vaccines containing live virus for prevention of
        infectious diseases within 12 weeks prior to the first dose of study drug.

        a. The use of inactivated seasonal influenza vaccines (eg, Fluzone®) will be permitted on
        study without restriction.

        J. Any approved systemic anti-cancer therapy, within 3 weeks prior to initiation of study
        treatment; the following exception is allowed:

          -  TKIs approved for treatment of NSCLC discontinued > 7 days prior to Cycle 1, Day 1.
             The baseline scan must be obtained after discontinuation of prior TKIs.

        K. Treatment with any other investigational agent or participation in another clinical
        trial with therapeutic intent within 28 days prior to enrollment; the following exceptions
        are allowed:

          -  Unapproved/experimental TKIs discontinued 14 days prior to Cycle 1, Day 1 L. Known
             infection with HIV, HBV or HCV. Patients with prior exposure to hepatitis, but no
             evidence of active or chronic infection, may be eligible.

          -  Subjects with positive hepatitis C antibody and negative quantitative hepatitis C by
             polymerase chain reaction are eligible.

        M. Active systemic infection requiring systemic antibiotic treatment within 72 hours prior
        to first dose of study treatment N. Uncontrolled intercurrent illness including, but not
        limited to, symptomatic congestive heart failure, unstable angina pectoris, or psychiatric
        illness/social situations that would limit compliance with study requirements O. Major
        surgery or traumatic injury within 4 weeks of starting study drug P. Women who are pregnant
        or lactating. Q. Any underlying medical condition that in the Principal Investigator's
        opinion will make the administration of study drug hazardous to the patient or would
        obscure the interpretation of adverse events.
      
Maximum Eligible Age:N/A
Minimum Eligible Age:18 Years
Eligible Gender:All
Healthy Volunteers:No

Primary Outcome Measures

Measure:Objective response rate using RECIST v1.1 to nivolumab and ipilimumab when administered in combination to patients with pre-treated advanced NSCLC who have experienced primary resistance to anti-PD-1 axis therapy as their last line of systemic therapy.
Time Frame:Tumor response assessment will occur every 8 weeks after initiating trial therapy for the first 24 weeks, and thereafter every 12 weeks up to 4 years.
Safety Issue:
Description:Objective response is defined as a complete or partial response, as determined by investigator assessment using Response Evaluation Criteria in Solid Tumors (RECIST) v1.1 confirmed by repeat assessment ≥4 weeks after initial documentation.

Secondary Outcome Measures

Measure:Progression-free survival with nivolumab and ipilimumab when administered in combination to patients with pre- treated advanced NSCLC who have experienced primary resistance to anti-PD-1 axis therapy as their last line of systemic therapy
Time Frame:Until disease progression, unacceptable toxicity, or study termination, up to four years.
Safety Issue:
Description:Progression free survival is defined as the time from the first day of nivolumab treatment until progression of disease using RECIST v1.1 and immune related Response Criteria (irRC)
Measure:Overall survival (OS) with nivolumab and ipilimumab when administered in combination to patients with pre- treated advanced NSCLC who have experienced PRIMARY resistance to anti-PD-1 axis therapy as their last line of systemic therapy.
Time Frame:Until death or day of last follow-up, up to four years from enrollment.
Safety Issue:
Description:Overall survival is defined as the time from the first day of treatment until death from any cause. If a patient has not experienced death, OS will be censored at the day of last follow-up.
Measure:Objective response rate using irRC to nivolumab and ipilimumab when administered in combination to patients with pre-treated advanced NSCLC who have experienced primary resistance to anti-PD-1 axis therapy as their last line of systemic therapy.
Time Frame:Tumor response assessment will occur every 9 weeks after initiating trial therapy for the first 24 weeks, and thereafter every 12 weeks, up to four years.
Safety Issue:
Description:Objective response is defined as a complete or partial response, as determined by investigator assessment using irRC and confirmed by repeat assessment ≥4 weeks after initial documentation.
Measure:Objective response rate in in advanced non-small cell lung cancer (NSCLC) with ACQUIRED resistance to anti-programmed death (PD)-1 axis therapy as their last line of systemic therapy.
Time Frame:Tumor response assessment will occur every 9 weeks after initiating trial therapy for the first 24 weeks, and thereafter every 12 weeks, up to four years.
Safety Issue:
Description:Objective response is defined as a complete or partial response, as determined by investigator assessment using Response Evaluation Criteria in Solid Tumors (RECIST) v1.1 and immune-related Response Criteria and confirmed by repeat assessment ≥4 weeks after initial documentation.
Measure:Progression free survival by RECIST v1.1 with nivolumab and ipilimumab in patients with pre-treated advanced NSCLC who have experienced acquired resistance to anti-PD-1 axis therapy as their last line of systemic therapy.
Time Frame:Until disease progression, unacceptable toxicity, or study termination, up to four years from enrollment.
Safety Issue:
Description:Progression free survival is defined as the time from the first day of nivolumab treatment until progression of disease using RECIST v1.1 and immune related Response Criteria
Measure:Overall survival with nivolumab and ipilimumab in patients with pre-treated advanced NSCLC who have experienced ACQUIRED resistance to anti-PD-1 axis therapy as their last line of systemic therapy.
Time Frame:Until death or day of last follow-up (up to four years from study enrollment).
Safety Issue:
Description:Overall survival is defined as the time from the first day of treatment until death from any cause. If a patient has not experienced death, OS will be censored at the day of last follow-up.
Measure:Safety of nivolumab and ipilimumab when administered in combination in patients with pre-treated advanced NSCLC who have experienced PRIMARY or ACQUIRED resistance to anti-PD-1 axis therapy as their last line of systemic therapy.
Time Frame:From date of first treatment until 100 days from discontinuation of treatment.
Safety Issue:
Description:Determined based on adverse events which will be graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events v4.0.
Measure:Feasibility of sequential biopsies (performed or not performed) in patients with pre-treated advanced NSCLC who have experienced PRIMARY or ACQUIRED resistance to anti-PD-1 axis therapy as their last line of systemic therapy,
Time Frame:Tumor biopsies will be performed just prior to initiating trial therapy, and 9 to 10 weeks after receiving first dose of trial therapy.
Safety Issue:
Description:

Details

Phase:Phase 2
Primary Purpose:Interventional
Overall Status:Recruiting
Lead Sponsor:Yale University

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