Trial of mFOLFOX6 + Trastuzumab + Avelumab in Gastric and Esophageal Adenocarcinomas

• ClinicalTrials.gov Identifier: NCT03783936
• Recruitment Status: Active, not recruiting
• First Posted: December 21, 2018
• Last Update Posted: May 12, 2021
• Sponsor: Autumn McRee, MD
• Collaborators: EMD Serono; University of North Carolina, Chapel Hill
• Information provided by (Responsible Party): Autumn McRee, MD, Hoosier Cancer Research Network

Study Description

Brief Summary:

The initial intent of the study was to be a multi-center single-arm open-label Simon's two-stage Phase II clinical trial of first-line mFOLFOX6 + trastuzumab + avelumab in metastatic HER2-amplified gastric and esophageal adenocarcinomas.

Accrual will halt after completion of Stage I (enrollment of 18 patients). This decision is not due to safety issues. Subjects currently on treatment will continue until criteria as defined in the protocol is met.

Condition or disease	Intervention/treatment	Phase
Gastric Adenocarcinoma; Esophageal Adenocarcinoma; Metastasis; HER-2 Gene Amplification	Drug: Oxaliplatin; Drug: Leucovorin; Drug: 5 fluorouracil; Drug: Trastuzumab; Drug: Avelumab	Phase 2

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 18 participants
• Allocation: N/A
• Intervention Model: Single Group Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: A Single Arm, Multi-center Phase 2 Trial of mFOLFOX6 + Trastuzumab + Avelumab in First-line, Metastatic, HER2-amplified Gastric and Esophageal Adenocarcinomas
• Actual Study Start Date: January 24, 2019
• Actual Primary Completion Date: September 11, 2020
• Estimated Study Completion Date: January 2022

Arms and Interventions

Arm

Intervention/treatment

Induction and Maintenance; Cycles 1-9; Induction; Cycle = 14 days mFOLFOX6; oxaliplatin 85 mg/m2 IV Day 1 and; leucovorin 400 mg/m2 IV Day 1 and; 5 fluorouracil 400 mg/m2 IV bolus and 2400 mg/m2 IV over 46 hours Day 1 and Trastuzumab 6 mg/kg IV loading dose C1D1 then Trastuzumab 4 mg/kg IV Day 1 and Avelumab 800 mg IV Day 1 Cycles 10 and subsequent; Maintenance; Cycle = 14 days Trastuzumab 4 mg/kg Day 1 and Avelumab 800 mg Day 1

Drug: Oxaliplatin; Oxaliplatin 85 mg/m2; Drug: Leucovorin; Leucovorin 400 mg/m2; Drug: 5 fluorouracil; 5 fluorouracil 400 mg/m2 bolus and 2400 mg/m2 continuous infusion; Drug: Trastuzumab; Trastuzumab 6 mg/kg loading dose C1D1 then 4 mg/kg Day 1; Drug: Avelumab; Avelumab 800 mg

Outcome Measures

Primary Outcome Measures :

1. Best Objective Response Rate (bORR) [ Time Frame: 24 weeks ]
   The best objective response rate will be defined as the total number of patients whose best response by 24 weeks are either a CR or PR divided by the number of response evaluable patients

Secondary Outcome Measures :

1. Progression Free Survival (PFS) [ Time Frame: 2 years ]
   Progression Free Survival (PFS) by RECIST 1.1 will be defined as the time from the start date of treatment to the date of documented progression as determined by RECIST 1.1 or death from any cause.
2. Progression Free Survival (iPFS) [ Time Frame: 2 years ]
   Progression Free Survival by iRECIST (iPFS) will be defined as the time from the start date of treatment to the date of documented progression as determined by iRECIST criteria or death from any cause.
3. Overall Survival (OS) [ Time Frame: 2 years ]
   Overall Survival (OS) will be defined as the time from start of treatment to the date of death. If the patient has not died, survival will be censored on last date the patient was known to be alive.
4. Disease Control Rate (DCR) [ Time Frame: 24 weeks ]
   Disease Control Rate (DCR) used to help determine clinical benefit will be defined as the total number of patients whose best responses are either a CR, PR, or SD divided by the number of response evaluable patients. Patients with best response of SD will need to maintain SD by 24 weeks to be considered to have received clinical benefit from the treatment regimen
5. Assess adverse events [ Time Frame: 2 years ]
   Adverse events will be summarized by frequency and severity using CTCAE version 5.

Eligibility Criteria

• Ages Eligible for Study: 18 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: Female
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

1. Written informed consent and HIPAA authorization for release of personal health information prior to registration.
2. Age ≥ 18 years at the time of consent.
3. ECOG Performance Status of 0 or 1.
4. Histologically confirmed esophageal, gastroesophageal junction, or gastric adenocarcinoma, with unresectable or metastatic disease documented on diagnostic imaging studies.
5. HER2 amplification confirmed by standard of care testing of tumor specimen (3+ by immunohistochemistry, or 2+ on IHC with ISH with HER2/CEP17 ratio ≥2).
6. Radiographically measurable disease according to RECIST 1.1 within 28 days prior to registration.

7. Adequate organ function as defined in the table below. All screening labs to be obtained within 28 days prior to registration.

   • Absolute Neutrophil Count ≥ 1.5 x 109/L
   • Hemoglobin (Hgb) ≥ 9 g/dL (may have been transfused)
   • Platelets ≥ 100 x 109/L OR ≥ 75 x 109/L for patients who received Cycle 1 of mFOLFOX6 +/- trastuzumab prior to registration
   • Calculated creatinine clearance1 ≥ 30 mL/min OR creatinine ≤ 1.5 × upper limit of normal (ULN)
   • Bilirubin ≤ 1.5 × upper limit of normal (ULN) (Subjects with Gilbert's syndrome may be enrolled despite a total bilirubin level >1.5 mg/dL, if their conjugated bilirubin is < 1.5× ULN)
   • Aspartate aminotransferase (AST) ≤ 2.5 × ULN OR ≤ 5x ULN in patients with known liver metastases
   • Alanine aminotransferase (ALT) ≤ 2.5 × ULN OR ≤ 5x ULN in patients with known liver metastases
8. Left ventricular ejection fraction (LVEF) ≥ 50% or above the lower limit of the institutional normal range, whichever is lower.
9. Females of childbearing potential must have a negative serum pregnancy test at screening. NOTE: Females are considered of child bearing potential unless they are surgically sterile (have undergone a hysterectomy, bilateral tubal ligation, or bilateral oophorectomy) or they are naturally postmenopausal for at least 12 consecutive months.
10. Females of childbearing potential and males must be willing to abstain from heterosexual activity or to use 2 forms of effective methods of contraception from the time of informed consent until 210 days after treatment discontinuation. The two contraception methods can be comprised of two barrier methods, or a barrier method plus a hormonal method.
11. As determined by the enrolling physician or protocol designee, ability of the subject to understand and comply with study procedures for the entire length of the study.

Exclusion Criteria:

1. Previous systemic therapy for stage IV disease - EXCEPT that patient may have received one cycle of mFOLFOX6 +/- trastuzumab within the 4 weeks prior to registration.
2. Active infection requiring intravenous systemic therapy.
3. Pregnant or breastfeeding (NOTE: breast milk cannot be stored for future use while the mother is being treated on study).
4. Treatment with any investigational drug within 28 days prior to registration.
5. Prior immune checkpoint inhibitor therapy (i.e. anti-CTLA-4, anti-PD-L1, anti-PD-1), or HER2-directed therapy (including trastuzumab)
6. Evidence of interstitial lung disease or active, non-infectious pneumonitis
7. Untreated brain metastasis or brain metastasis treated within 4 weeks prior to enrollment.
8. Known additional malignancy that is active and/or progressive requiring treatment; exceptions include basal cell or squamous cell skin cancer, in situ cervical or bladder cancer, or other cancer for which the subject has been disease-free for at least five years.
9. Serious cardiovascular event within 6 months prior to study entry, including myocardial infarction, malignant hypertension, severe/unstable angina, symptomatic congestive heart failure (≥ New York Heart Association Classification Class II), cerebral vascular accident, transient ischemic attack, or serious cardiac arrhythmia requiring medication.
10. History of organ allograft or allogeneic stem cell transplantation

11. Active autoimmune disease requiring systemic treatment in the past 3 months (for example with disease modifying agents, corticosteroids, or immunosuppressive drugs).

    Exceptions Include:

    • Subjects with endocrine diseases stable on replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) or hormone suppression.
    • Subjects that require intermittent use of bronchodilators, local steroid injections, or inhaled or topical steroids
    • Subjects with vitiligo, psoriasis, Sjogren's syndrome, or resolved childhood asthma/atopy
12. Current use of immunosuppressive medication, EXCEPT for the following: a. intranasal, inhaled, topical steroids, or local steroid injection (e.g., intra-articular injection); b. Systemic corticosteroids at physiologic doses ≤ 10 mg/day of prednisone or equivalent; c. Steroids as premedication for hypersensitivity reactions (e.g., CT scan premedication).
13. Known history of testing positive for HIV or known acquired immunodeficiency syndrome.
14. Known history of Hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. Subjects with laboratory evidence of cleared HBV and HCV infection will be permitted.
15. Vaccination within 4 weeks of the first dose of avelumab and while on trials is prohibited except for administration of inactivated vaccines.
16. Known prior severe hypersensitivity to investigational product or any component in its formulations, including known severe hypersensitivity reactions to monoclonal antibodies (NCI CTCAE v5 Grade ≥ 3).
17. Persisting toxicity related to prior therapy (NCI CTCAE v5 Grade > 1); however, alopecia, sensory neuropathy Grade ≤ 2, or other Grade ≤ 2 not constituting a safety risk based on investigator's judgment are acceptable.
18. Other severe acute or chronic medical conditions including immune colitis, inflammatory bowel disease, immune pneumonitis, pulmonary fibrosis or psychiatric conditions including recent (within the past year) or active suicidal ideation or behavior; or laboratory abnormalities that may increase the risk associated with study participation or study treatment administration or may interfere with informed consent, the interpretation of study results and, in the judgment of the investigator, would make the patient inappropriate for entry into this study.

Contacts and Locations

Locations

United States, California

City of Hope

Duarte, California, United States, 91010

United States, Georgia

Winship Cancer Insititute of Emory University

Atlanta, Georgia, United States, 30322

United States, Illinois

Northwestern University Feinberg School of Medicine

Chicago, Illinois, United States, 60611

United States, Iowa

University of Iowa Hospital and Clinics

Iowa City, Iowa, United States, 52242

United States, New Jersey

Atlantic Health System

Morristown, New Jersey, United States, 07960

United States, New York

Roswell Park Cancer Institute

Buffalo, New York, United States, 14263

United States, North Carolina

University of North Carolina at Chapel Hill

Chapel Hill, North Carolina, United States, 27599

Sponsors and Collaborators

Autumn McRee, MD

EMD Serono

University of North Carolina, Chapel Hill

Investigators

• Principal Investigator: Autumn McRee, MD; University of North Carolina, Chapel Hill

More Information

• Responsible Party: Autumn McRee, MD, Sponsor-Investigator, Hoosier Cancer Research Network
• ClinicalTrials.gov Identifier: NCT03783936
• Other Study ID Numbers: HCRN GI17-319
• First Posted: December 21, 2018
• Last Update Posted: May 12, 2021
• Last Verified: May 2021

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: Undecided

• Studies a U.S. FDA-regulated Drug Product: Yes
• Studies a U.S. FDA-regulated Device Product: No

Additional relevant MeSH terms:

Adenocarcinoma; Esophageal Neoplasms; Carcinoma; Neoplasms, Glandular and Epithelial; Neoplasms by Histologic Type; Neoplasms; Gastrointestinal Neoplasms; Digestive System Neoplasms; Neoplasms by Site; Head and Neck Neoplasms; Digestive System Diseases; Esophageal Diseases; Gastrointestinal Diseases; Leucovorin; Fluorouracil; Oxaliplatin; Trastuzumab; Avelumab; Antimetabolites; Molecular Mechanisms of Pharmacological Action; Antimetabolites, Antineoplastic; Antineoplastic Agents; Immunosuppressive Agents; Immunologic Factors; Physiological Effects of Drugs; Antineoplastic Agents, Immunological; Antidotes; Protective Agents; Vitamin B Complex; Vitamins