Description:
This phase III trial compares the effect of adding surgery to a standard of care
immunotherapy-based drug combination versus a standard of care immunotherapy-based drug
combination alone in treating patients with kidney cancer that has spread to other places in
the body (metastatic). Immunotherapy with monoclonal antibodies, such as nivolumab,
ipilimumab, pembrolizumab, and avelumab, may help the body's immune system attack the cancer,
and may interfere with the ability of tumor cells to grow and spread. Axitinib may stop the
growth of tumor cells by blocking some of the enzymes needed for cell growth. Surgery to
remove the kidney, called a nephrectomy, is also considered standard of care; however,
doctors who treat kidney cancer do not agree on its benefits. It is not yet known if the
addition of surgery to an immunotherapy-based drug combination works better than an
immunotherapy-based drug combination alone in treating patients with kidney cancer.
Title
- Brief Title: Comparing the Outcome of Immunotherapy-Based Drug Combination Therapy With or Without Surgery to Remove the Kidney in Metastatic Kidney Cancer, the PROBE Trial
- Official Title: Phase III Trial of Immunotherapy-Based Combination Therapy With or Without Cytoreductive Nephrectomy for Metastatic Renal Cell Carcinoma (PROBE Trial)
Clinical Trial IDs
- ORG STUDY ID:
S1931
- SECONDARY ID:
NCI-2020-04442
- NCT ID:
NCT04510597
Conditions
- Metastatic Clear Cell Renal Cell Carcinoma
- Metastatic Renal Cell Carcinoma
- Stage IV Renal Cell Cancer AJCC v8
Interventions
| Drug | Synonyms | Arms |
|---|
| Active Comparator | | Arm 1: Continued Systemic Therapy Only |
Purpose
This phase III trial compares the effect of adding surgery to a standard of care
immunotherapy-based drug combination versus a standard of care immunotherapy-based drug
combination alone in treating patients with kidney cancer that has spread to other places in
the body (metastatic). Immunotherapy with monoclonal antibodies, such as nivolumab,
ipilimumab, pembrolizumab, and avelumab, may help the body's immune system attack the cancer,
and may interfere with the ability of tumor cells to grow and spread. Axitinib may stop the
growth of tumor cells by blocking some of the enzymes needed for cell growth. Surgery to
remove the kidney, called a nephrectomy, is also considered standard of care; however,
doctors who treat kidney cancer do not agree on its benefits. It is not yet known if the
addition of surgery to an immunotherapy-based drug combination works better than an
immunotherapy-based drug combination alone in treating patients with kidney cancer.
Detailed Description
PRIMARY OBJECTIVE:
I. To compare overall survival in participants with newly diagnosed metastatic renal cell
carcinoma who are randomized to receive immune checkpoint inhibitor-based combination
treatment plus cytoreductive nephrectomy versus immune checkpoint inhibitor-based combination
treatment alone.
SECONDARY OBJECTIVES:
I. To compare overall survival between arms in the subset who received their assigned
protocol treatment.
II. To assess complications of nephrectomy and post-randomization drug toxicities.
III. To compare objective response rate in metastatic sites between the arms in participants
with measurable metastatic disease.
IV. To assess change in diameter of primary tumor at week 12 disease assessment in
participants who have received pre-randomization treatment.
BANKING OBJECTIVE:
I. To bank specimens for future correlative studies.
OUTLINE:
PRE-RANDOMIZATION TREATMENT: Treatment naive patients are assigned to 1 of 3 treatment
regimens per standard of care.
REGIMEN I: Patients receive nivolumab intravenously (IV) and ipilimumab IV. Treatment repeats
every 3 weeks for up to 4 cycles in the absence of disease progression or unacceptable
toxicity. Patients then receive nivolumab IV on day 1. Cycles repeat every 2-4 weeks in the
absence of disease progression or unacceptable toxicity.
REGIMEN II: Patients receive pembrolizumab IV on day 1 and axitinib orally (PO) twice daily
(BID) on days 1-21. Cycles repeat every 3 weeks in the absence of disease progression or
unacceptable toxicity.
REGIMEN III: Patients receive avelumab IV on day 1 and axitinib PO BID on days 1-14. Cycles
repeat every 2 weeks in the absence of disease progression or unacceptable toxicity.
NOTE: Some patients may have already completed the standard of care pre-randomization
treatment specified above off-trial.
RANDOMIZATION TREATMENT: Between 10-14 weeks from the start of on-trial or off-trial
pre-randomization treatment, patients are randomized to 1 of 2 arms.
ARM I: Patients receive nivolumab IV, pembrolizumab IV, or avelumab IV on day 1. Patients
also receive axitinib PO BID. Cycles with nivolumab repeat every 2 or 4 weeks, cycles with
pembrolizumab repeat every 3 weeks, and cycles with avelumab repeat every 2 weeks in the
absence of disease progression or unacceptable toxicity.
ARM II: Within 42 days following randomization, patients undergo radical or partial
nephrectomy in addition to nivolumab, pembrolizumab, avelumab, and axitinib as in Arm I in
the absence of disease progression or unacceptable toxicity. Axitinib should be stopped at
least 24 hours prior to surgery.
After completion of trial treatment, patients are followed up every 3 months for the first
year, every 6 months for years 2 and 3, and then annually for up to 7 years from
randomization.
Trial Arms
| Name | Type | Description | Interventions |
|---|
| Arm 1: Continued Systemic Therapy Only | Active Comparator | Nivolumab 240 mg IV 1 q 2 weeks
OR
Nivolumab 480 mg IV 1 q 4 weeks
OR
Pembrolizumab 200 mg IV 1 q 3 weeks Axitinib 5 mg oral Daily BID
OR
Avelumab 10 mg/kg IV 1 q 2 weeks Axitinib 5 mg oral Daily BID | |
| Arm 2: Nephrectomy and Continued Systemic Therapy | Experimental | Continued systemic therapy as above, plus:
Radical or partial nephrectomy may be performed using laparoscopic, open, or robotic approaches. Surgery should be performed within 8 weeks of randomization. | |
Eligibility Criteria
Inclusion Criteria:
- STEP 1 REGISTRATION: Participants must have a histologically proven diagnosis of clear
cell or non-clear cell renal cell carcinoma. Participants with collecting duct
carcinoma histology are not eligible. Participants with multifocal or bilateral tumors
are eligible
- STEP 1 REGISTRATION: Participants must have primary tumor in place
- STEP 1 REGISTRATION: Participants must have the following scans performed, showing
clinical evidence of measurable or non-measurable metastatic disease:
- Computed tomography (CT) scan of the chest (can be performed without contrast if
CT contrast cannot be given)
- CT of abdomen and pelvis with contrast OR magnetic resonance imaging (MRI) of the
abdomen and pelvis with or without contrast
Scans must be performed within the following timeframes:
- Treatment naive participants must have scans documenting metastatic disease completed
within 90 days prior to study registration
- Previously treated participants must have scans documenting metastatic disease
completed within 90 days prior to first dose of systemic treatment
- STEP 1 REGISTRATION: Participants with symptomatic metastases may have received
palliative radiotherapy or receive palliative radiotherapy after registration
- STEP 1 REGISTRATION: Participants must have no clear contraindications to
nephrectomy
- STEP 1 REGISTRATION: Participants must be offered the opportunity to participate
in specimen bank. With participant consent, specimens must be collected and
submitted via the Southwest Oncology Group (SWOG) Specimen Tracking System
- STEP 1 REGISTRATION: Participants must be informed of the investigational nature
of this study and must sign and give informed consent in accordance with
institutional and federal guidelines
- STEP 1 REGISTRATION: As part of the Oncology Patient Enrollment Network (OPEN)
registration process the treating institution's identity is provided in order to
ensure that the current (within 365 days) date of institutional review board
approval for this study has been entered in the system
- STEP 2 REGISTRATION: Participants must have at least one of the following scans
performed 12 weeks (+/- 2 weeks) after starting pre-randomization treatment
- CT scan of the chest (can be performed without contrast if CT contrast cannot be
given)
- CT of abdomen and pelvis with contrast OR MRI of the abdomen and pelvis with or
without contrast Scans must be performed within 28 days prior to randomization.
Response should be assessed by comparing with a CT or MRI of the chest, abdomen and
pelvis obtained prior to starting pre-randomization treatment. Participants with
complete response in all metastatic sites are not eligible to randomize to Step 2
• STEP 2 REGISTRATION: Participants must have one of the following objective statuses
after 12 weeks of pre-randomization treatment
- Stable disease
- Partial response
- The treating investigator believes the patient is deriving clinical benefit from
systemic therapy AND have Zubrod performance status 0-1
- STEP 2 REGISTRATION: Participants must plan to continue the immune-based therapy
received during pre-randomization treatment
- STEP 2 REGISTRATION: Participants must be randomized on or between the 11th and
14th week of protocol-directed pre-randomization treatment therapy
- STEP 2 REGISTRATION: Participants must have received at least one of the minimum
amounts of immunotherapy:
- 2 infusions of nivolumab + 1 infusion of ipilimumab
- 2 infusions of pembrolizumab
- 2 infusions of avelumab
- STEP 2 REGISTRATION: Participants must have a planned surgery date within 42 days
of randomization
- STEP 2 REGISTRATION: Participants must be a surgical candidate as determined by
study urologist. The urology consult should be done within 42 days prior to
randomization
- STEP 2 REGISTRATION: Participants must have a complete physical examination and
medical history within 28 days prior to randomization
- STEP 2 REGISTRATION: Participants must have a Zubrod performance status of 0-1
within 28 days prior to randomization
- STEP 2 REGISTRATION: Total bilirubin =< institutional upper limit of normal (ULN)
(within 28 days prior to randomization)
- STEP 2 REGISTRATION: Aspartate aminotransferase (AST)/alanine aminotransferase
(ALT) =< 3 x institutional upper limit of normal (ULN) (within 28 days prior to
randomization)
- STEP 2 REGISTRATION: Serum creatinine =< 1.5 x the institutional upper limit of
normal (IULN) OR measured OR calculated creatinine clearance >= 50 mL/min using
the Cockcroft-Gault Formula) (must have been drawn and processed within 28 days
prior to randomization)
Exclusion Criteria:
- STEP 1 REGISTRATION: Participants must not have known active brain metastases.
Participants with previously treated brain metastases are eligible if participant has
no neurologic signs or symptoms suggestive of brain metastasis. Brain imaging studies
are not required. If brain imaging studies are performed, they must be negative for
disease
- STEP 1 REGISTRATION: Participants must not have received the following prior treatment
of metastatic renal cell carcinoma:
- Treatment naive participants must not have received any prior lines of systemic
therapy for metastatic renal cell carcinoma beyond the line intended as part of
protocol therapy
- Previously treated participants must not have received any systemic therapy for
metastatic renal cell carcinoma beyond the one regimen received off protocol as
specified in Step 1 pre-randomization treatment
- STEP 1 REGISTRATION: Participants must not have received more than the following
amounts protocol-directed pre-randomization treatment:
- Treatment naive participants must not have received any pre-randomization
treatment.
- Previously treated participants must not be planning to receive any additional
treatment prior to Step 2 randomization, and must not have received more than the
following amounts of pre-randomization treatment:
- 4 infusions of nivolumab
- 4 infusions of ipilimumab
- 4 infusions of pembrolizumab
- 7 infusions of avelumab
- STEP 1 REGISTRATION: Participants must not have received immunotherapy for any cancer
within the following timeframes:
- Treatment naive participants must not have received any immunotherapy within a
year of registration
- Previously treated participants must not have received any other immunotherapy
within a year of the start of off protocol specified pre-randomization treatment
- STEP 1 REGISTRATION: Participants must not have a solitary kidney and not have a
transplanted kidney
- STEP 1 REGISTRATION: No other prior malignancy is allowed except for the following:
adequately treated basal cell or squamous cell skin cancer, any in situ or T1 cancer,
adequately treated stage I or II cancer from which the participant is currently in
complete remission, or any other cancer from which the participant has been disease
free for at least two years
- STEP 1 REGISTRATION: Participants must not have been previously diagnosed with a
medical condition that makes them ineligible for immune based combination therapy or
nephrectomy
- STEP 2 REGISTRATION: Participants must not show progression in the primary tumor.
Participants who are considered to have pseudo progression are allowed
- STEP 2 REGISTRATION: Participants must not have known active brain metastases.
Participants with previously treated brain metastases are eligible if participant has
no neurologic signs or symptoms suggestive of brain metastasis. Brain imaging studies
are not required. If brain imaging studies are performed, they must be negative for
disease
- STEP 2 REGISTRATION: No other prior malignancy is allowed except for the following:
adequately treated basal cell or squamous cell skin cancer, in situ cervical cancer,
adequately treated stage I or II cancer from which the participant is currently in
complete remission, or any other cancer from which the participant has been disease
free for two years
| Maximum Eligible Age: | N/A |
| Minimum Eligible Age: | 18 Years |
| Eligible Gender: | All |
| Healthy Volunteers: | No |
Primary Outcome Measures
| Measure: | Overall survival |
| Time Frame: | From date of randomization to date of death due to any cause, assessed up to 7 years. |
| Safety Issue: | |
| Description: | Analysis will be intent-to-treat. Evidence suggesting early termination of the trial and a conclusion that the cytoreductive nephrectomy (CN) approach is superior to treatment alone would be if the null hypothesis is rejected at the one-sided 0.005 level. For the second and third interim analyses, the null and alternative hypotheses with respect to survival will be tested, with superiority tested at the one-sided 0.005 level, and futility determined to be met if the (CN versus no CN) hazard ratio is greater than or equal to 1. A proportional hazards model will be fit to estimate the hazard ratio adjusting for the stratification factors as covariates in the model. Will evaluate whether each of the stratification factors are predictive factors of cytoreductive nephrectomy by placing an interaction term corresponding to each stratification factor and treatment arm in the proportional hazards survival model. |
Secondary Outcome Measures
| Measure: | Overall survival in subset who received assigned protocol treatment |
| Time Frame: | From date of randomization to date of death due to any cause, assessed up to 7 years |
| Safety Issue: | |
| Description: | Will be included in the proportional hazards regression model adjusting for stratification factors as covariates. |
| Measure: | Progression-free survival |
| Time Frame: | From date of randomization to date of first documentation of progression, or death due to any cause, assessed up to 7 years |
| Safety Issue: | |
| Description: | A proportional hazards model will be used to compare progression-free survival between arms, adjusting for the stratification factors as covariates. |
| Measure: | Objective response |
| Time Frame: | Up to 7 years |
| Safety Issue: | |
| Description: | Objective response includes all confirmed and unconfirmed partial and complete responses. Baseline will be disease assessment at randomization. Response Evaluation Criteria in Solid Tumors response rates will be evaluated, excluding the primary tumor in the kidney because that disease will be removed in half the participant's post-randomization. Comparison of response rates will be performed using logistic regression with stratification factors as covariates and an indicator for treatment arm. |
| Measure: | Change in maximum diameter of primary tumor |
| Time Frame: | From the disease assessment just prior to the start of immunotherapy to the week 12 disease assessment |
| Safety Issue: | |
| Description: | Descriptive statistics will be provided including stratified results by treatment regimen received. Potential additional analyses may include assessment of the interaction between change in primary tumor and randomized treatment arm. This will be modeled as an interaction term in the proportional hazards survival model. |
Details
| Phase: | Phase 3 |
| Primary Purpose: | Interventional |
| Overall Status: | Recruiting |
| Lead Sponsor: | Southwest Oncology Group |
Last Updated
May 13, 2021
