PRIMARY OBJECTIVES:
I. To determine the recommended phase 2 dose (RP2D)/maximum tolerated dose (MTD) of
capecitabine when administered with pembrolizumab and bevacizumab. (Safety Lead-In Cohort)
II. To evaluate the overall response rate (ORR) to pembrolizumab plus capecitabine and
bevacizumab (complete or partial response rate per Response Evaluation Criteria in Solid
Tumors [RECIST] 1.1) in subjects with metastatic or locally advanced unresectable
microsatellite stable (MSS)/mismatch repair proficient (pMMR) colorectal carcinoma (CRC) that
is stable or progressing on fluorouracil (5FU)-based therapy. (Phase II Expansion Cohort)
SECONDARY OBJECTIVES (Phase II Expansion Cohort):
I. To determine the safety and tolerability of pembrolizumab in combination with capecitabine
and bevacizumab.
II. To evaluate ORR per immune-related RECIST (irRECIST). III. To evaluate duration of
response (DOR), disease control rate (DCR) and progression-free survival (PFS) per RECIST 1.1
and irRECIST and overall survival (OS).
EXPLORATORY OBJECTIVES:
I. Correlation of outcomes to line of therapy; stable disease or progression on a prior
regimen containing infusional 5-FU or capecitabine; prior exposure to bevacizumab; and
primary tumor location.
II. To explore baseline immune profiles via PD-L1, and multiplex Immunohistochemistry (IHC)
for identification of potentially predictive biomarkers in patients with metastatic or
locally advanced, unresectable CRC treated with pembrolizumab-based combination therapy.
III. To characterize the change in the populations of tumor-infiltrating immune cells (TIICs)
by IHC induced by pembrolizumab-based combination therapy in paired pre- and on-treatment
tumor biopsies from patients with metastatic or locally advanced, unresectable MSS / pMMR
CRC.
IV. To determine the change in T cell repertoire via next generation sequencing (NGS) within
blood and tumor biopsy samples induced by pembrolizumab-based combination therapy in patients
with metastatic or locally advanced, unresectable MSS/pMMR CRC.
V. To establish human immune system (HIS) patient-derived xenograft (PDX) models from
pre-treatment biopsies to a) analyze change in immune cell profiles HIS PDX models using the
same techniques as described for corresponding patients, above and b) correlate response to
pembrolizumab-containing therapy in patients and HIS PDX.
OUTLINE:
An initial safety lead-in will be performed to define the maximum tolerated dose
(MTD)/recommended phase 2 dose (RP2D). Patients receive pembrolizumab intravenously (IV) over
30 minutes on day 1, bevacizumab IV over 30-90 minutes on day 1, and capecitabine orally (PO)
twice daily (BID) on days 1-14. Treatment repeats every 3 weeks for up to 35 courses in the
absence of disease progression or unacceptable toxicity.
After completion of study treatment, patients are followed up at 30 days, every 9 weeks until
disease progression, start of new anti-cancer therapy, death, or end of the study whichever
comes first
Inclusion Criteria:
1. Have histologically confirmed, locally advanced unresectable or metastatic (stage IV)
colorectal adenocarcinoma
2. Have locally confirmed MSS or pMMR CRC; MSS is defined as 0-1 allelic shifts among 3-5
tumor microsatellite loci using a PCR-based assay; pMMR is defined as presence of
protein expression of 4 MMR enzymes (MLH1, MSH2, MSH6 and PMS2) by
immunohistochemistry
3. Have stable disease or progression on a prior regimen containing infusional 5-FU or
capecitabine according to the interpretation of the treating provider
4. Be willing and able to provide written informed consent/assent for the trial
5. Be 18 years of age on day of signing informed consent
6. Have measurable disease based on RECIST 1.1
7. Be willing to provide tissue from a newly obtained core or excisional biopsy of a
tumor lesion (phase II dose expansion cohort only); newly-obtained is defined as a
specimen obtained up to 6 weeks (42 days) prior to initiation of treatment on day 1;
subjects for whom newly-obtained samples cannot be provided (e.g. inaccessible or
subject safety concern) may submit an archived specimen only upon agreement from the
Sponsor
8. Have a performance status of 0 or 1 on the Eastern Cooperative Oncology Group (ECOG)
performance scale
9. Demonstrate adequate organ function performed within 10 days of treatment initiation
as defined below:
1. Absolute neutrophil count (ANC) >= 1,500 /mcL
2. Platelets >= 100,000 / microliter (mcL)
3. Hemoglobin >= 9 g/dL or >= 5.6 mmol/L without transfusion or erythropoietin (EPO)
dependency (within 7 days of assessment)
4. Serum creatinine =< 1.5 X upper limit of normal (ULN) OR measured or calculated
creatinine clearance >= 60 mL/min for subject with creatinine levels > 1.5 X
institutional ULN. Glomerular filtration rate (GFR) can also be used in place of
creatinine or creatinine clearance (CrCl)). Creatinine clearance should be
calculated per institutional standard
5. Serum total bilirubin =< 1.5 X ULN OR direct bilirubin =< ULN for subjects with
total bilirubin levels > 1.5 ULN. Patients with Gilbert's disease may be included
if their direct bilirubin is ≤ 1.5 X ULN.
6. Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase (SGOT))
and alanine aminotransferase (ALT) (serum glutamic pyruvic transaminase (SGPT))
=< 2.5 X ULN OR =< 5 X ULN for subjects with liver metastases
7. Albumin >= 2.5 mg/dL
8. International normalized ratio (INR) or prothrombin time (PT) =< 1.5 X ULN unless
subject is receiving anticoagulant therapy as long as PT or PTT is within
therapeutic range of intended use of anticoagulants
9. Activated partial thromboplastin time (aPTT) =< 1.5 X ULN unless subject is
receiving anticoagulant therapy; as long as PT or PTT is within therapeutic range
of intended use of anticoagulants
10. Female subject of childbearing potential should have a negative urine or serum
pregnancy within 72 hours prior to receiving the first dose of study medication; if
the urine test is positive or cannot be confirmed as negative, a serum pregnancy test
will be required
11. Female subjects of childbearing potential must be willing to use an adequate method of
contraception for the course of the study through 120 days after the last dose of
study medication
12. Male subjects of childbearing potential must agree to use an adequate method of
contraception, starting with the first dose of study therapy through 120 days after
the last dose of study therapy
- Note: Abstinence is acceptable if this is the usual lifestyle and preferred
contraception for the subject
Exclusion Criteria:
1. Is currently participating and receiving study therapy or has participated in a study
of an investigational agent and received study therapy or used an investigational
device within 4 weeks of the first dose of treatment
2. Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any
other form of immunosuppressive therapy within 7 days prior to the first dose of trial
treatment
3. Has a known history of active tuberculosis (TB) (Bacillus Tuberculosis)
4. Hypersensitivity to pembrolizumab or any of its excipients
5. Hypersensitivity/intolerance to capecitabine, Infusional 5-Fluorouracil (5-FU), or
bevacizumab
6. Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study
day 1 or who has not recovered (i.e., =< grade 1 or at baseline) from adverse events
due to agents administered more than 4 weeks earlier
7. Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy
within 2 weeks prior to study day 1 or who has not recovered (i.e., =< grade 1 or at
baseline) from adverse events due to a previously administered agent
- Note: Subjects with =< grade 2 neuropathy are an exception to this criterion and
may qualify for the study
- Note: If subject received major surgery, they must have recovered adequately from
the toxicity and/or complications from the intervention prior to starting therapy
8. Has a known additional malignancy that is progressing or requires active treatment;
exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the
skin that has undergone potentially curative therapy or in situ cervical cancer
9. Has known active central nervous system (CNS) metastases and/or carcinomatous
meningitis; subjects with previously treated brain metastases may participate provided
they are stable (without evidence of progression by imaging for at least four weeks
prior to the first dose of trial treatment and any neurologic symptoms have returned
to baseline), have no evidence of new or enlarging brain metastases, and are not using
steroids for at least 7 days prior to trial treatment; this exception does not include
carcinomatous meningitis which is excluded regardless of clinical stability
10. Has active autoimmune disease that has required systemic treatment in the past 2 years
(i.e., with use of disease modifying agents, corticosteroids or immunosuppressive
drugs); replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a
form of systemic treatment
11. Has known history of (non-infectious) pneumonitis/interstitial lung disease that
required steroids or current pneumonitis/interstitial lung disease.
12. Has an active infection at the time of cycle 1 day 1 requiring systemic therapy
13. Has a history or current evidence of any condition, therapy, or laboratory abnormality
that might confound the results of the trial, interfere with the subject's
participation for the full duration of the trial, or is not in the best interest of
the subject to participate, in the opinion of the treating investigator
14. Has known psychiatric or substance abuse disorders that would interfere with
cooperation with the requirements of the trial
15. Is pregnant or breastfeeding, or expecting to conceive or father children within the
projected duration of the trial, starting with the pre-screening or screening visit
through 120 days after the last dose of trial treatment
16. Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent
17. Has a known history of human immunodeficiency virus (HIV) (HIV 1/2 antibodies)
18. Has known active hepatitis B (e.g., hepatitis B surface antigen (HBsAg) reactive) or
hepatitis C (e.g., hepatitis C virus (HCV) ribonucleic acid [RNA] [qualitative] is
detected)
19. Requires therapeutic anticoagulation with warfarin at baseline. Patients must be off
warfarin or warfarin-derivative anti-coagulants for at least 7 days prior to starting
study drug, however, therapeutic or prophylactic therapy with low-molecular weight
heparin is allowed
20. Has history of known coagulopathy that increases risk of bleeding or a history of
clinically significant hemorrhage within 12 months of start of study drug
21. Known bleeding risk including serious hemorrhage or hemoptysis within the last 3
months; major surgery within the past 8 weeks or minor surgery within the past 4 weeks
22. Has known gastrointestinal bleeding or any other hemorrhage/bleeding event Common
Terminology Criteria for Adverse Events (CTCAE) grade > 3 within 6 months of start of
study drug
23. Has greater than 1+ proteinuria on a urine dipstick or equivalent routine laboratory
analysis will require further testing with a urine protein to creatinine ratio (UPCR);
UPCR must be calculated as follows: UPCR = protein concentration (mg/dL)/creatinine
(mg/dL); if the UPCR >= 1, then the patient will not be eligible for study entry;
however, if urinalysis or equivalent routine laboratory analysis shows no protein,
then UPCR testing is not required
24. Has a history of non-healing wounds or ulcers, or bone re-fractures within 3 months of
fracture
25. Has a history of arterial thromboembolism within 12 months of start of study drug
26. Has inadequately controlled hypertension (defined as systolic blood pressure greater
than 150 mm Hg or diastolic blood pressure greater than 95 mm Hg). The use of
anti-hypertensive medications to control blood pressure is permitted. Retesting is
permitted.
27. Has a history of hypertensive crisis or hypertensive encephalopathy within 6 months
prior to planned start of study drug
28. Has had clinically significant cardiovascular disease within 12 months of planned
start of study drug, including myocardial infarction, unstable angina, grade 2 or
greater peripheral vascular disease, cerebrovascular accident, transient ischemic
attack, congestive heart failure, or arrhythmias not controlled by outpatient
medication, percutaneous transluminal coronary angioplasty/stent
29. Has a known history of abdominal fistula, gastrointestinal perforation, or
intra-abdominal abscess within 6 months prior to planned start of study drug
30. Known reversible posterior leukoencephalopathy syndrome (RPLS)
31. Difficulty swallowing, malabsorption, active partial or complete bowel obstruction, or
other chronic gastrointestinal disease or conditions that may hamper compliance and/or
absorption of capecitabine
32. Has received a live vaccine or live-attenuated vaccine within 30 days prior to the
first dose of study drug. Administration of killed vaccines is allowed.
