Description: 
            
            
              
                
      This phase II trial studies how well the combination of decitabine, venetoclax, and ponatinib
      work for the treatment of Philadelphia chromosome-positive acute myeloid leukemia or myeloid
      blast phase or accelerated phase chronic myelogenous leukemia. Drugs used in chemotherapy
      such as decitabine, work in different ways to stop the growth of cancer cells, either by
      killing the cells, by stopping them from dividing, or by stopping them from spreading.
      Venetoclax may stop the growth of cancer cells by blocking Bcl-2, a protein needed for cancer
      cell survival. Ponatinib may stop the growth of cancer cells by blocking some of the enzymes
      needed for cell growth. Giving decitabine, venetoclax, and ponatinib may help to control
      Philadelphia chromosome-positive acute myeloid leukemia or myeloid blast phase or accelerated
      phase chronic myelogenous leukemia.
    
              
             
           
        
      
        
          
      
        
          
Title
- Brief Title: Decitabine, Venetoclax, and Ponatinib for the Treatment of Philadelphia Chromosome-Positive Acute Myeloid Leukemia or Myeloid Blast Phase or Accelerated Phase Chronic Myelogenous Leukemia
- Official Title: A Phase II Study of the Combination of Decitabine, Venetoclax, and Ponatinib in Patients With Philadelphia Chromosome-Positive Acute Myeloid Leukemia or Myeloid Blast Phase Chronic Myelogenous Leukemia
Clinical Trial IDs
- ORG STUDY ID:
                2019-0610
- SECONDARY ID:
                NCI-2019-07594
- SECONDARY ID:
                2019-0610
- NCT ID:
                NCT04188405
Conditions
- Accelerated Phase Chronic Myelogenous Leukemia, BCR-ABL1 Positive
- Acute Myeloid Leukemia
- Blast Phase Chronic Myelogenous Leukemia, BCR-ABL1 Positive
- Recurrent Acute Myeloid Leukemia
- Recurrent Chronic Myelogenous Leukemia, BCR-ABL1 Positive
- Refractory Acute Myeloid Leukemia
- Refractory Chronic Myelogenous Leukemia, BCR-ABL1 Positive
Interventions
| Drug | Synonyms | Arms | 
|---|
| Decitabine | 5-Aza-2''-deoxycytidine, Dacogen, Decitabine for Injection, Deoxyazacytidine, Dezocitidine | Treatment (ponatinib, venetoclax, decitabine) | 
| Ponatinib | AP-24534, AP24534 | Treatment (ponatinib, venetoclax, decitabine) | 
| Venetoclax | ABT-0199, ABT-199, ABT199, GDC-0199, RG7601, Venclexta, Venclyxto | Treatment (ponatinib, venetoclax, decitabine) | 
Purpose
      This phase II trial studies how well the combination of decitabine, venetoclax, and ponatinib
      work for the treatment of Philadelphia chromosome-positive acute myeloid leukemia or myeloid
      blast phase or accelerated phase chronic myelogenous leukemia. Drugs used in chemotherapy
      such as decitabine, work in different ways to stop the growth of cancer cells, either by
      killing the cells, by stopping them from dividing, or by stopping them from spreading.
      Venetoclax may stop the growth of cancer cells by blocking Bcl-2, a protein needed for cancer
      cell survival. Ponatinib may stop the growth of cancer cells by blocking some of the enzymes
      needed for cell growth. Giving decitabine, venetoclax, and ponatinib may help to control
      Philadelphia chromosome-positive acute myeloid leukemia or myeloid blast phase or accelerated
      phase chronic myelogenous leukemia.
    
Detailed Description
      PRIMARY OBJECTIVE:
      I. To determine the efficacy of the regimen, as defined by the rate of complete remission
      (CR) or CR with incomplete count recovery (CRi).
      SECONDARY OBJECTIVES:
      I. To determine efficacy outcomes, including rate of minimal residual disease negativity by
      flow cytometry and polymerase chain reaction (PCR) for BCR-ABL1 transcripts, median
      relapse-free survival, and median overall survival.
      II. To determine the proportion of patients proceeding to allogeneic stem cell transplant
      (ASCT).
      III. To preliminarily determine the safety of the combination regimen.
      EXPLORATORY OBJECTIVES:
      I. To evaluate the effect of single-agent ponatinib on apoptotic proteins and Bcl-2
      dependency.
      II. To correlate apoptotic protein expression and Bcl-2 dependency on response and resistance
      to the combination regimen.
      OUTLINE:
      Patients recently (within 2 weeks of anticipated start date) treated with ponatinib receive
      ponatinib orally (PO) daily on days 1-21 of cycle 1 and days 1-28 of subsequent cycles,
      venetoclax PO daily on days 1-21, and decitabine intravenously (IV) over 60 minutes on days
      1-5. Treatment repeats every 28 days for up to 24 cycles in the absence of disease
      progression or unacceptable toxicity. Patients who have not been recently (within 2 weeks of
      anticipated start date) treated with ponatinib may receive ponatinib monotherapy PO daily on
      days 1-7 before starting combination therapy with venetoclax in cycle 1. After completion of
      ponatinib lead-in, patients will receive ponatinib PO daily on days 1-21 of cycle 1 and on
      days 1-28 of subsequent cycles, venetoclax PO daily on days 8-28 of cycle 1 and days 1-21 of
      subsequent cycles, and decitabine IV over 60 minutes on days 8-12 of cycle 1 and days 1-5 of
      subsequent cycles. For these patients, cycle 1 is 35 days in duration and cycles 2-24 repeat
      every 28 days in the absence of disease progression or unacceptable toxicity.
      After completion of study treatment, patients are followed up at 30 days then every 6 months
      thereafter.
    Trial Arms
| Name | Type | Description | Interventions | 
|---|
| Treatment (ponatinib, venetoclax, decitabine) | Experimental | See Detailed Description. | DecitabinePonatinibVenetoclax
 | 
Eligibility Criteria
        Inclusion Criteria:
          -  Patients with Philadelphia (Ph)+ acute myeloid leukemia (AML) or myeloid accelerated
             phase (AP)-chronic myelogenous leukemia (CML) or blast phase (BP)-CML (either t[9;22]
             and/or BCR-ABL1 positive by fluorescent in situ hybridization or polymerase chain
             reaction). Both untreated and relapsed/refractory patients are eligible
          -  Performance status =< 3 (Eastern Cooperative Oncology Group [ECOG] scale)
          -  Total serum bilirubin =< 2 x upper limit of normal (ULN), unless due to Gilbert's
             syndrome, hemolysis or the underlying leukemia approved by the principal investigator
             (PI)
          -  Alanine aminotransferase (ALT) =< 1.5 x ULN, unless due to the underlying leukemia
             approved by the PI
          -  Aspartate aminotransferase (AST) =< 1.5 x ULN unless due to the underlying leukemia
             approved by the PI
          -  Creatinine clearance >= 30 mL/min
          -  Serum lipase =< 1.5 x ULN
          -  Amylase =< 1.5 x ULN
          -  Ability to swallow
          -  Signed informed consent
        Exclusion Criteria:
          -  Active serious infection not controlled by oral or intravenous antibiotics (e.g.
             persistent fever or lack of improvement despite antimicrobial treatment)
          -  History of acute pancreatitis within 6 months of study or history of chronic
             pancreatitis
          -  Uncontrolled hypertriglyceridemia (triglycerides > 450 mg/dL)
          -  Active secondary malignancy that in the investigator's opinion will shorten survival
             to less than 1 year
          -  Active grade III-V cardiac failure as defined by the New York Heart Association
             criteria
          -  Clinically significant, uncontrolled, or active cardiovascular disease, specifically
             including, but not restricted to:
               -  Myocardial infarction (MI), stroke, revascularization, unstable angina or
                  transient ischemic attack within 6 months
               -  Left ventricular ejection fraction (LVEF) less than lower limit of normal per
                  local institutional standards prior to enrollment
               -  Diagnosed or suspected congenital long QT syndrome
               -  Clinically significant atrial or ventricular arrhythmias (such as uncontrolled,
                  clinically significant atrial fibrillation, ventricular tachycardia, ventricular
                  fibrillation, or torsades de pointes) as determined by the treating physician
               -  Prolonged corrected QT (QTc) interval on pre-entry electrocardiogram (> 480 msec)
                  unless corrected after electrolyte replacement
               -  History of venous thromboembolism including deep venous thrombosis or pulmonary
                  embolism within the past 3 months, excluding line-associated deep venous
                  thrombosis (DVT) of the upper extremity
               -  Uncontrolled hypertension (diastolic blood pressure > 100 mmHg; systolic > 150
                  mmHg)
          -  Consumed grapefruit, grapefruit products, Seville oranges, or star fruit within 3 days
             prior to starting venetoclax
          -  Treatment with any investigational antileukemic agents or chemotherapy agents in the
             last 7 days before study entry, unless full recovery from side effects has occurred or
             patient has rapidly progressive disease judged to be life-threatening by the
             investigator. Prior recent treatment with corticosteroids, hydroxyurea, or a Food and
             Drug Administration (FDA)-approved BCR-ABL tyrosine kinase inhibitor (TKI) is
             permitted
          -  Pregnant and lactating women will not be eligible; women of childbearing potential
             should have a negative pregnancy test prior to entering on the study and be willing to
             practice methods of contraception throughout the study period. Women do not have
             childbearing potential if they have had a hysterectomy or are postmenopausal without
             menses for 12 months. In addition, men enrolled on this study should understand the
             risks to any sexual partner of childbearing potential and should practice an effective
             method of birth control
      | Maximum Eligible Age: | N/A | 
| Minimum Eligible Age: | 18 Years | 
| Eligible Gender: | All | 
| Healthy Volunteers: | No | 
Primary Outcome Measures
| Measure: | Overall response rate | 
| Time Frame: | End of cycle 2 (each cycle is 28 days) | 
| Safety Issue: |  | 
| Description: | Defined as the proportion of patients achieving complete remission (CR) + CR with incomplete count recovery (CRi) occurring at the end of 2 cycles of treatment. Will be estimated along with the 95% credible interval. Patients who drop out of the study before completing 2 cycles and have been treated will be censored for the primary endpoint analysis. | 
Secondary Outcome Measures
| Measure: | Rate of minimal residual disease negativity | 
| Time Frame: | Up to 4.5 years | 
| Safety Issue: |  | 
| Description: | Will be estimated along with the 95% credible interval. | 
| Measure: | Proportion of patients proceeding to allogeneic stem cell transplant | 
| Time Frame: | Up to 4.5 years | 
| Safety Issue: |  | 
| Description: | Will be estimated along with the 95% credible interval. | 
| Measure: | Relapse-free survival (RFS) | 
| Time Frame: | From the date of treatment initiation to the date of documented treatment relapses from CR/CRi or death from any cause, whichever occurs first, assessed up to 4.5 years | 
| Safety Issue: |  | 
| Description: | The distribution of RFS will be estimated using the method of Kaplan and Meier. Comparisons by important subgroups will be made using the log-rank tests. | 
| Measure: | Overall survival (OS) | 
| Time Frame: | From treatment start till death or last follow-up, assessed up to 4.5 years | 
| Safety Issue: |  | 
| Description: | The distribution of OS will be estimated using the method of Kaplan and Meier. Comparisons by important subgroups will be made using the log-rank tests. | 
| Measure: | Incidence of adverse events | 
| Time Frame: | Up to 4.5 years | 
| Safety Issue: |  | 
| Description: | Safety data will be summarized by category, severity and frequency. | 
Details
| Phase: | Phase 2 | 
| Primary Purpose: | Interventional | 
| Overall Status: | Recruiting | 
| Lead Sponsor: | M.D. Anderson Cancer Center | 
Last Updated
April 20, 2021