PRIMARY OBJECTIVE:
I. To evaluate the anti-tumor activity of the combination of propranolol hydrochloride and
pembrolizumab by assessing the overall response rate (ORR) as measured by Response Evaluation
Criteria in Solid Tumors (RECIST 1.1.).
SECONDARY OBJECTIVE:
I. To evaluate the efficacy of the combination as measured by progression free survival (PFS;
from treatment initiation until disease progression, death due to disease, or lost to follow
up) and overall survival (OS; from treatment initiation until death due to any cause or loss
to follow up), and safety as measured by incidence of adverse events assessed up to 2 years.
TERTIARY/EXPLORATORY OBJECTIVE:
I. To assess tissue-based assays in archival tissue and correlative changes in peripheral
T-cell subsets, myeloid derived suppressor cells (MDSC), blood inflammatory markers and
cytokines.
OUTLINE:
Patients receive propranolol hydrochloride orally (PO) twice daily (BID) on days 1-21 and
pembrolizumab intravenously (IV) over 30 minutes on day 1. Cycles repeat every 21 days for
propranolol hydrochloride and every 3 or 6 weeks for pembrolizumab for up to 2 years in the
absence of disease progression or unacceptable toxicity.
After completion of study treatment, patients are followed up at 30 days, then every 12 weeks
for up to 2 years.
Inclusion Criteria:
- Age ≥ 18 years
- Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2 (Karnofsky ≥ 60%)
- Patients must have histologically confirmed recurrent or metastatic urothelial
carcinoma (renal pelvis, ureter, bladder, or urethra), planned for treatment with
pembrolizumab under an Food and Drug Administration (FDA) approved indication (listed
below) at the genitourinary oncology clinics of Emory University's Winship Cancer
Institute:
- First line: locally advanced or metastatic urothelial carcinoma who are not
eligible for cisplatin-containing chemotherapy and whose tumors express PD-L1
(Combined Positive Score [CPS] ≥ 10) as determined by an FDA-approved test, or in
patients who are not eligible for any platinum-containing chemotherapy regardless
of PD-L1 status
- Second line: locally advanced or metastatic urothelial carcinoma after
progression on platinum-based chemotherapy
- Patients must have measurable disease as defined by RECIST criteria as at least one
lesion that can be accurately measured in at least one dimension (longest diameter to
be recorded as ≥ 10 mm (≥ 1 cm) on computed tomography (CT) scan or magnetic resonance
imaging (MRI)
- Patients must have adequate organ and marrow function, within 28 days of cycle 1 day
1, at the discretion of the investigator
- The effects of study drugs on the developing human fetus are unknown. For this reason,
female of child-bearing potential (FCBP) must have a negative serum or urine pregnancy
test prior to starting therapy
- FCBP and men treated or enrolled on this protocol must agree to use adequate
contraception (hormonal or barrier method of birth control; abstinence) prior to study
entry, for the duration of study participation, and 3 months after completion of study
drug administration. Should a woman become pregnant or suspect she is pregnant while
she or her partner is participating in this study, she should inform her treating
physician immediately.
- A female of childbearing potential (FCBP) is a sexually mature woman who: 1) has
not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been
naturally postmenopausal for at least 24 consecutive months (i.e., has had menses
at any time in the preceding 24 consecutive months)
- Completion of all previous therapy (including surgery, radiotherapy, chemotherapy,
immunotherapy, or investigational therapy) for the treatment of cancer ≥ 4 weeks
before the start of study therapy
- Patients with known history or current symptoms of cardiac disease, or history of
treatment with cardiotoxic agents, should have a clinical risk assessment of cardiac
function using the New York Heart Association Functional Classification. To be
eligible for this trial, patients should be class IIB or better
- Patients without existing cardiac disease that raise the risk of complications
who consent for the trial will proceed with trial participation
- Patients with existing cardiac disease that could raise the risk of complications
will be referred at the discretion of the investigator to a cardio-oncologist who
is a co-investigator on the trial (or general cardiologist) for cardiac
optimization prior to starting propranolol
- Life expectancy > 12 weeks as determined by the investigator
- Willingness and ability of the subject to comply with scheduled visits, drug
administration plan, protocol-specified laboratory tests, other study procedures, and
study restrictions
- Evidence of a personally signed informed consent indicating that the subject is aware
of the neoplastic nature of the disease and has been informed of the procedures to be
followed, the experimental nature of the therapy, alternatives, potential risks and
discomforts, potential benefits, and other pertinent aspects of study participation
Exclusion Criteria:
- Patients who have had chemotherapy or radiotherapy within 4 weeks prior to entering
the study or those who have not recovered from adverse events due to agents
administered more than 4 weeks earlier (i.e., have residual toxicities > grade 1)
- Patients who are receiving any other investigational agents or an investigational
device within 21 days before administration of first dose of study drugs
- History of allergic reactions attributed to compounds of similar chemical or biologic
composition to the agents used in study
- Contraindication to pembrolizumab per investigator discretion
- Uncontrolled current illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance with
study requirements
- Significant cardiovascular disease (e.g., myocardial infarction, arterial
thromboembolism, cerebrovascular thromboembolism) within 3 months prior to start of
study therapy; angina requiring therapy; symptomatic peripheral vascular disease; New
York Heart Association class 3 or 4 congestive heart failure; or uncontrolled grade ≥
3 hypertension (diastolic blood pressure ≥ 100 mmHg or systolic blood pressure ≥ 160
mmHg) despite antihypertensive therapy
- Contraindication to a beta blocker: cardiac conditions that significantly raise the
risk of cardiopulmonary complications, including unstable angina, uncontrolled heart
failure, symptomatic bradycardia, and severe asthma
- Current use of an oral or intravenous beta blocker (e.g. atenolol, bisoprolol,
carvedilol, labetalol, metoprolol, nadolol, sotalol, among other beta blockers) with
inability to safely switch to a non-beta blocker agent. The washout for current users
should be at least 14 days with enough transition period
