Clinical Trials /

Fecal Microbiota Transplant and Re-introduction of Anti-PD-1 Therapy (Pembrolizumab or Nivolumab) for the Treatment of Metastatic Colorectal Cancer in Anti-PD-1 Non-responders

NCT04729322

Description:

This phase II trial studies the effect of fecal microbiota transplant and re-introduction of anti-PD-1 therapy (pembrolizumab or nivolumab) in treating anti-PD-1 non-responders with colorectal cancer that has spread to other places in the body (metastatic). Fecal microbiota transplants contain the normal bacteria and viruses found in fecal (stool) material. Immunotherapy with monoclonal antibodies, such as pembrolizumab and nivolumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Giving pembrolizumab or nivolumab with fecal microbiota transplants may help to control the disease.

Related Conditions:
  • Colorectal Adenocarcinoma
  • Small Intestinal Adenocarcinoma
Recruiting Status:

Not yet recruiting

Phase:

Early Phase 1

Trial Eligibility

Document

Title

  • Brief Title: Fecal Microbiota Transplant and Re-introduction of Anti-PD-1 Therapy (Pembrolizumab or Nivolumab) for the Treatment of Metastatic Colorectal Cancer in Anti-PD-1 Non-responders
  • Official Title: Pilot Trial of Fecal Microbiota Transplantation and Re-Introduction of Anti-PD-1 Therapy in dMMR Colorectal Adenocarcinoma Anti-PD-1 Non-Responders

Clinical Trial IDs

  • ORG STUDY ID: 2020-0186
  • SECONDARY ID: NCI-2020-13897
  • SECONDARY ID: 2020-0186
  • SECONDARY ID: P50CA221707
  • NCT ID: NCT04729322

Conditions

  • Metastatic Colorectal Adenocarcinoma
  • Metastatic Small Intestinal Adenocarcinoma
  • Stage IV Colorectal Cancer AJCC v8
  • Stage IV Small Intestinal Adenocarcinoma AJCC v8
  • Stage IVA Colorectal Cancer AJCC v8
  • Stage IVB Colorectal Cancer AJCC v8
  • Stage IVC Colorectal Cancer AJCC v8

Interventions

DrugSynonymsArms
Fecal Microbiota Transplantation CapsuleFecal Microbiota Preparation Delivery Capsule, FMPCapDE, FMT Capsule DE, FMT Capsule Delivery, FMT DE CapsuleArm I (FMT, pembrolizumab)
MetronidazoleFlagyl, Flagyl I.V. RTU, TricomArm I (FMT, pembrolizumab)
NeomycinNeomycin ComplexArm I (FMT, pembrolizumab)
NivolumabBMS-936558, MDX-1106, NIVO, ONO-4538, OpdivoArm II (FMT, nivolumab)
PembrolizumabKeytruda, Lambrolizumab, MK-3475, SCH 900475Arm I (FMT, pembrolizumab)
VancomycinArm I (FMT, pembrolizumab)

Purpose

This phase II trial studies the effect of fecal microbiota transplant and re-introduction of anti-PD-1 therapy (pembrolizumab or nivolumab) in treating anti-PD-1 non-responders with colorectal cancer that has spread to other places in the body (metastatic). Fecal microbiota transplants contain the normal bacteria and viruses found in fecal (stool) material. Immunotherapy with monoclonal antibodies, such as pembrolizumab and nivolumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Giving pembrolizumab or nivolumab with fecal microbiota transplants may help to control the disease.

Detailed Description

      PRIMARY OBJECTIVE:

      I. To evaluate the efficacy of pembrolizumab or nivolumab in conjunction with fecal
      microbiota transplant (FMT) from PD-1 responding mismatch-repair deficiency (dMMR) colorectal
      cancer (CRC) patients for treatment of PD-1 non-responding dMMR CRC patient.

      OUTLINE:

      Patients receive metronidazole orally (PO) every 8 hours (Q8H) on days -14 to -8 and then
      vancomycin PO every 6 hours (Q6H) and neomycin PO Q6H on days -8 to -6. Patients then undergo
      colonoscopic FMT on day -5.

      Patients are then assigned to 1 of 2 arms.

      ARM I: Patients receive standard of care pembrolizumab intravenously (IV) over 30 minutes on
      day 1. Patients also receive fecal microbiota transplantation capsule PO on days 1, 8, and 15
      of cycle 1. Beginning in cycle 2, patients receive fecal microbiota transplantation capsule
      PO on day 1. Cycles repeat every 21 days for up to 6 months in the absence of disease
      progression or unacceptable toxicity.

      ARM II: Patients receive standard of care nivolumab IV over 30 minutes on day 1. Patients
      also receive fecal microbiota transplantation capsule PO on days 1 and 8 of cycles 1-2.
      Beginning in cycle 4, patients receive fecal microbiota transplantation capsule PO on day 1
      of every other cycle. Cycles repeat every 14 days for up to 6 months in the absence of
      disease progression or unacceptable toxicity.

      After completion of study treatment, patients are followed up at 30 days and then every 24
      weeks for up to 3 years.
    

Trial Arms

NameTypeDescriptionInterventions
Arm I (FMT, pembrolizumab)ExperimentalPatients receive metronidazole PO Q8H on days -14 to -8 and then vancomycin PO Q6H and neomycin PO Q6H on days -8 to -6. Patients then undergo colonoscopic FMT on day -5. POST-COLONOSCOPIC FMT: Patients receive standard of care pembrolizumab IV over 30 minutes on day 1. Patients also receive fecal microbiota transplantation capsule PO on days 1, 8, and 15 of cycle 1. Beginning in cycle 2, patients receive fecal microbiota transplantation capsule PO on day 1. Cycles repeat every 21 days for up to 6 months in the absence of disease progression or unacceptable toxicity.
  • Fecal Microbiota Transplantation Capsule
  • Metronidazole
  • Neomycin
  • Pembrolizumab
  • Vancomycin
Arm II (FMT, nivolumab)ExperimentalPatients receive metronidazole PO Q8H on days -14 to -8 and then vancomycin PO Q6H and neomycin PO Q6H on days -8 to -6. Patients then undergo colonoscopic FMT on day -5. POST-COLONOSCOPIC FMT: Patients receive standard of care nivolumab IV over 30 minutes on day 1. Patients also receive fecal microbiota transplantation capsule PO on days 1 and 8 of cycles 1-2. Beginning in cycle 4, patients receive fecal microbiota transplantation capsule PO on day 1 of every other cycle. Cycles repeat every 14 days for up to 6 months in the absence of disease progression or unacceptable toxicity.
  • Fecal Microbiota Transplantation Capsule
  • Metronidazole
  • Nivolumab
  • Vancomycin

Eligibility Criteria

        Inclusion Criteria:

          -  At least 18 years of age on the day of signing informed consent

          -  Histologically/cytologically confirmed diagnosis of colorectal adenocarcinoma (in
             addition patients with small bowel adenocarcinoma will be allowed given rarity and
             management similar to colorectal adenocarcinoma)

          -  Tumor that is deficient in mismatch repair (dMMR) or microsatellite instability high
             (MSI-H) as determined by one of three methods:

               -  Immunohistochemistry determined dMMR by complete loss of MLH1, PMS2, MSH2 or MSH6

               -  Polymerase chain reaction (PCR) determined microsatellite instability at > 30% of
                  tested microsatellites

               -  Next-generation determined MSI-H based upon instability at multiple
                  microsatellites as determined by the specific next generation sequencing panel

          -  Have metastatic disease that is measurable based on Immune-Modified Response
             Evaluation Criteria in Solid Tumors (iRECIST) version (v)1.1

          -  Demonstrated prior progression on anti-PD1/L1 based therapy by radiographic
             progression. The potential for pseudoprogression should be excluded by concurrent
             carcinoembryonic antigen (CEA) or other tumor marker or circulating tumor-derived
             deoxyribonucleic acid (ctDNA) elevation, or clinical symptom progression, or short
             interval repeat imaging confirming progression

               -  Must have received at least 2 doses of a PD1/PD-L1 inhibitor

               -  Progressive disease either during therapy or within 2 months of last dose of
                  therapy

          -  An Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 1. Evaluation
             of ECOG is to be performed within 7 days prior to the date of signing study consent

          -  Patients must be willing to undergone mandatory tumor biopsies at pre-treatment, at
             time of colonoscopy if possible and on-treatment (unless deemed unsafe by
             interventional radiology or by approval by study principal investigator [PI])

          -  The participant (or legally acceptable representative if applicable) provides written
             informed consent for the trial

          -  Estimated life-expectancy of > 4 months

          -  White blood cell (WBC) count >= 3,000/microL

          -  Platelet count >= 75,000/microL

          -  Hemoglobin (Hgb) >= 8 g/dL

          -  Total bilirubin level =< 1.5 x the upper limit of normal (ULN) (except if Gilberts
             syndrome and then total bilirubin =< 3 x is allowed)

          -  Aspartate aminotransferase (AST), level =< 2.5 x ULN, and an alanine aminotransferase
             (ALT) level =< 2.5 x ULN. If liver metastases are present, then AST and ALT levels
             must be =< 4 x ULN

          -  Estimated creatinine clearance > 30 mL/min according to the Cockcroft-Gault formula or
             by a creatinine clearance measurement from a 24-hour urine collection

          -  Highly effective contraception for both male and female subjects if the risk of
             conception exists. Highly effective contraception must be used 30 days prior to first
             study-drug administration, for the duration of trial treatment, and for at least for 6
             months (women and men after taking your last dose of any of the trial drugs. Should a
             female patient (or male patient's sexual partner) become pregnant or should either the
             female patient (or male patient's partner) suspect she is pregnant while the patient's
             study-participation is ongoing, the treating physician should be informed immediately

        Exclusion Criteria:

          -  Has received prior systemic anti-cancer therapy including investigational agents
             within 2 weeks of study treatment (excluding continuation of ongoing nivolumab or
             pembrolizumab therapy)

          -  If participant received major surgery within last 4 weeks, they must have recovered
             adequately from the toxicity and/or complications from the intervention prior to
             starting study treatment

          -  Has received prior radiotherapy within 2 weeks of start of study treatment.
             Participants must have recovered from all radiation-related toxicities (excluding skin
             toxicity), not require corticosteroids, and not have had radiation pneumonitis

          -  Has received a live vaccine within 30 days prior to the first dose of study drug.
             Examples of live vaccines include, but are not limited to, the following: measles,
             mumps, rubella, varicella/zoster (chicken pox), yellow fever, rabies, Bacillus
             Calmette-Guerin (BCG), and typhoid vaccine. Seasonal influenza vaccines for injection
             are generally killed virus vaccines and are allowed; however, intranasal influenza
             vaccines (e.g., FluMist) are live attenuated vaccines and are not allowed

          -  Has a diagnosis of immunodeficiency (excluding immunoglobulin A [IgA] deficiency)

          -  Has an active autoimmune condition and is receiving chronic systemic steroid therapy
             (in dosing exceeding 10 mg daily of prednisone equivalent) or any other form of
             immunosuppressive therapy within 7 days prior to the first dose of study drug

               -  Subjects requiring hormone replacement with corticosteroids are eligible if the
                  steroids are administered only for the purpose of hormonal replacement and at
                  doses =< 10 mg of prednisone or equivalent per day

               -  Administration of steroids for other conditions through a route known to result
                  in a minimal systemic exposure (topical, intranasal, intro-ocular, or inhalation)
                  is acceptable

          -  Has severe hypersensitivity (>= grade 3) to pembrolizumab or nivolumab and/or any of
             its excipients

          -  Serious adverse immune related adverse events (grade 3 or 4) with previous immune
             checkpoint therapy, that were symptomatic and required prolong immunosuppression (> 6
             weeks)

          -  Has an active infection requiring systemic therapy

          -  Has a history or current evidence of any condition, therapy, or laboratory abnormality
             that might confound the results of the study, interfere with the subject's
             participation for the full duration of the study, or is not in the study subject's
             best interest to participate, in the opinion of the treating investigator

          -  Has known psychiatric or substance abuse disorders that would interfere with
             cooperation with the requirements of the trial

          -  Pregnant or nursing women

          -  For women of childbearing age, a positive urine pregnancy test within 72 hours prior
             to enrollment. If the urine test is positive or cannot be confirmed as negative, a
             serum pregnancy test will be required
      
Maximum Eligible Age:N/A
Minimum Eligible Age:18 Years
Eligible Gender:All
Healthy Volunteers:No

Primary Outcome Measures

Measure:Objective response rate
Time Frame:Up to 3 years post-treatment
Safety Issue:
Description:Assessed by Immune-Modified Response Evaluation Criteria in Solid Tumors (iRECIST). Will be summarized by mean, standard error, and 95% confidence interval.

Details

Phase:Early Phase 1
Primary Purpose:Interventional
Overall Status:Not yet recruiting
Lead Sponsor:M.D. Anderson Cancer Center

Last Updated

January 28, 2021