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T-DM1 and Osimertinib Combination Treatment to Target HER2 Bypass Track Resistance in EGFR Mutation Positive NSCLC (TRAEMOS)

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ClinicalTrials.gov Identifier: NCT03784599
Recruitment Status : Recruiting
First Posted : December 24, 2018
Last Update Posted : January 20, 2021
Sponsor:
Collaborators:
AstraZeneca
Roche Pharma AG
Information provided by (Responsible Party):
The Netherlands Cancer Institute

Brief Summary:
This is a single arm open-label multi-center phase II study, investigating disease control rate after 3 months of treatment with trastuzumab-emtansine/osimertinib combination therapy in patients with advanced EGFR mutation positive non-small cell lung cancer (NSCLC) with HER2 bypass track resistance.

Condition or disease Intervention/treatment Phase
Carcinoma, Non-Small-Cell Lung Drug: Trastuzumab emtansine Drug: Osimertinib Phase 2

Detailed Description:

This study is a multicenter single arm phase II study with a phase I run in to study the toxicity and efficacy of T-DM1 and osimertinib combination treatment in patients with EGFR mutated NSCLC and HER2 bypass track activation (HER2 immunohistochemistry (IHC) ≥2+ and/or HER2 amplification) after progression on an EGFR TKI.

In the phase I run in, study safety will be assessed in a classical 3+3 design. Because of potential for overlapping hematologic and non-hematologic adverse events (AE), the first 3 patients will receive a reduced dose of T-DM1 3.0 mg/kg IV every 3 weeks combined with osimertinib 80 mg once daily. Dose-limiting toxicity (DLT) is defined as a grade 3 AE toxicity according to CTC AE 4.03 that does not recover to grade ≤2 before the next cycle of T-DM1. DLT's will be collected up to 6 weeks after treatment initiation (2 T-DM1 cycles). Dose escalation within patients is not allowed.

If 1 patient develops a dose-limiting toxicity (DLT), 3 more will be included and treated with T-DM1 3.0 mg/kg. If ≥2 of the 6 patients develop a DLT, further study of the combination will be halted. Otherwise, T-DM1 3.0 mg/kg IV every 3 weeks combined with osimertinib 80 mg once daily will be the maximum tolerated dose (MTD) to put forward in the phase II part of this study.

If none of the first three patients develops a DLT, the T-DM1 dose will be escalated to the standard dose of 3.6 mg/kg. If ≤1 patient experiences a DLT in 6 patients (3+3), T-DM1 3.6 mg/kg IV every 3 weeks and osimertinib 80 mg once daily will be the MTD. If ≥2 patients develop a DLT, the T-DM1 will be lowered to 3.0 mg/kg and three more patients will be enrolled in this dose cohort. When ≤1 of these patients develops a DLT, this will be the MTD.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 58 participants
Allocation: N/A
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Trastuzumab-emtansine and Osimertinib Combination Treatment to Target HER2 Bypass Track Resistance in EGFR Mutation Positive NSCLC
Actual Study Start Date : December 18, 2018
Estimated Primary Completion Date : December 18, 2021
Estimated Study Completion Date : April 1, 2022

Resource links provided by the National Library of Medicine


Arm Intervention/treatment
Experimental: Trastuzumab-emtansine and osimertinib

Trastuzumab-emtansine 3.6 mg/kg, intravenously, every 3 weeks

Osimertinib 80 mg once daily, orally, continuous

Treatment will be continued until tumor progression (according to RECIST v1.1) confirmed by tumor imaging, unacceptable toxicity, or death occurs.

Drug: Trastuzumab emtansine
Infusion

Drug: Osimertinib
Tablet




Primary Outcome Measures :
  1. Safety (intensity and incidence of adverse events) [ Time Frame: Up to 30 days after last study drug intake ]
    Safety as indicated by intensity and incidence of adverse events, graded according to NCI CTCAE Version 4.03

  2. Objective response rate according to RECIST v1.1 after 3 months of treatment [ Time Frame: From date of registration until 3 months. ]
    Complete response and partial response after 3 months of treatment


Secondary Outcome Measures :
  1. Progression-free survival [ Time Frame: From date of registration until the date of first documented progression up to 100 months ]
    PFS, defined as the time from first administration of the study drug combination to disease progression by RECIST v1.1. or lost to follow up or death, whichever comes first

  2. Disease control rate, after 3 months of treatment [ Time Frame: From date of registration until 3 months. ]
    DCR, defined as the percentage of patients with stable disease (SD), partial response (PR) or complete response (CR)

  3. Overall survival [ Time Frame: From date of registration until the date of death from any cause, assessed up to 100 months. ]
    OS, defined as the time from first administration of the study drug combination to lost to follow up or death, whichever comes first


Other Outcome Measures:
  1. Genetic profiling to assess predictors of response and resistance - circulating free (cf)DNA [ Time Frame: At baseline, every 6 weeks and at treatment discontinuation (expected 6 months after start) ]
    cfDNA samples will be collected to assess predictors of response and resistance



Information from the National Library of Medicine

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

Inclusion Criteria:

  1. Histologically or cytologically confirmed stage IV non-squamous NSCLC, characterized by an activating EGFR mutation.
  2. Progressive disease according to RECIST 1.1 on first (gefitinib, erlotinib), second (afatinib) or third (osimertinib) generation EGFR TKI and still receiving the drug.
  3. A rebiopsy after having acquired resistance to a first, second or third generation TKI-treatment must have been performed and be:

    1. Negative for T790M in case of treatment with a first or second generation EGFR TKI. After progression on a third generation EGFR TKI patients may either be positive or negative for T790M.
    2. Positive for HER2-overexpression (positive membranous immunohistochemistry staining IHC ≥2+ (on a scale of 0-3) in ≥10% of the cells) must have been detected.
  4. There must be at least one measurable disease site, according to RECIST 1.1 criteria.

    Patients need At least one lesion, not previously irradiated, that can be accurately measured at baseline as ≥ 10 mm in the longest diameter (except lymph nodes which must have short axis ≥ 15 mm) with computed tomography (CT) or magnetic resonance imaging (MRI) and which is suitable for accurate repeated measurements.

  5. Absence of symptomatic brain metastases. All patients will be scanned at baseline with a brain MRI.
  6. Patients must be willing and able to comply with the protocol for the duration of the study including undergoing treatment and scheduled visits and examinations.
  7. World Health Organization (WHO) performance status 0-2.
  8. Patients must have a life expectancy ≥12 weeks.
  9. Ability to give written informed consent before patient screening.
  10. Patients must be ≥18 years of age.
  11. Men and women of child bearing potential should be willing to take adequate contraceptive measures during the study and until three months after study drug discontinuation

Exclusion Criteria:

  1. Uncontrolled infectious disease.
  2. Other active malignancy. Patients with a history of cancer for which treatment is complete and with no evidence of malignant disease currently cannot be enrolled if their chemotherapy was completed less than 6 months prior and/or have received a bone marrow transplant less than 2 years before the first day of study treatment.
  3. Major surgery (excluding diagnostic procedures like e.g. mediastinoscopy or VATS biopsy) in the previous 4 weeks.
  4. Known hypersensitivity to T-DM1 or osimertinib (or drugs with a similar chemical structure or class) or any excipients of these agents.
  5. Previous treatment with a HER2 monoclonal antibody.
  6. Clinically significant cardiac disease or:

    • Patients with pre-treatment LVEF < 55%.
    • Prior history of congestive cardiac failure; LVEF decline to <50% on previous treatment with HER2 agents
    • Conditions impairing LV function e.g. uncontrolled hypertension
    • MI/unstable angina within 6 months or serious cardiac arrhythmia
  7. Any of the following cardiac criteria:

    • Mean resting corrected QT interval (QTc) > 470 msec obtained from 3 electrocardiograms (ECGs), using the screening clinic ECG machine derived QTc value
    • Any clinically important abnormalities in rhythm, conduction or morphology of resting ECG e.g. complete left bundle branch block, third degree heart block and second degree heart block.
    • Any factors that increase the risk of QTc prolongation or risk of arrhythmic events such as heart failure, hypokalaemia, congenital long QT syndrome, family history of long QT syndrome or unexplained sudden death under 40 years of age in first degree relatives or any concomitant medication known to prolong the QT interval.
  8. Inadequate bone marrow reserve or organ function, as demonstrated by any of the following laboratory values:

    • Hematology: hemoglobin <5.6 mmol/L, absolute neutrophil count <1.5 x 10^9/L, platelet count <100 x 10^9/L.
    • Biochemistry: alanine aminotransferase, aspartate aminotransferase and bilirubin ≤ 2.5 x ULN, except in the case of liver metastases where these values must be ≤ 5x ULN.
    • Kidney function: serum creatinine >1.5 x ULN concurrent with creatinine clearance <50 ml/min (measured or calculated by Cockroft and Gault equation).
  9. Patients with symptomatic central nervous system metastases who are neurologically unstable. Unstable brain metastases except for those who have completed definitive therapy and have had a stable neurological status for 2 weeks after completion of definitive therapy. Patients may be on corticosteroids to control brain metastases if they have been on a stable dose for 2 weeks prior to the start of study treatment and are clinically asymptomatic.
  10. Refractory nausea and vomiting, chronic gastrointestinal diseases, inability to swallow osimertinib or previous significant bowel resection that would preclude adequate resorption of osimertinib.
  11. Males and females of reproductive potential who are not using an effective method of birth control and females who are pregnant or breastfeeding or have a positive (serum) pregnancy test prior to study entry.
  12. Judgment by the investigator that the patient should not participate in the study if the patient is unlikely to comply with study procedures, restrictions and requirements.
  13. Treatment with an investigational drug within five half-lives of the compound or 3 months, whichever is greater
  14. Currently receiving (or unable to stop use prior to receiving the first dose of study treatment) medications or herbal supplements known to be potent inducers of CYP3A4 (at least 3 week prior) (Appendix C). All patients must try to avoid concomitant use of any medications, herbal supplements and/or ingestion of foods with known inducer effects on CYP3A4.
  15. Any unresolved toxicities from prior therapy greater than CTCAE grade 1 at the time of starting study treatment, with the exception of alopecia and grade 2, prior platinum-therapy-related neuropathy.
  16. Any evidence of severe or uncontrolled systemic diseases, including uncontrolled hypertension and active bleeding diatheses, which in the investigator's opinion makes it undesirable for the patient to participate in the trial or which would jeopardise compliance with the protocol, or active infection including hepatitis B, hepatitis C and human immunodeficiency virus (HIV). Screening for chronic conditions is not required.
  17. Past medical history of interstitial lung disease, drug-induced interstitial lung disease, radiation pneumonitis which required steroid treatment or any evidence of clinically active interstitial lung disease.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03784599


Contacts
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Contact: J. de Langen, MD, PhD 0031205129111 j.d.langen@nki.nl
Contact: M. Jebbink, MD 0031205129111 m.jebbink@nki.nl

Locations
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Netherlands
Maastricht UMC+ Not yet recruiting
Maastricht, Limburg, Netherlands, 6229 HX
Contact: A. Dingemans, MD, PhD    0031433876543    a.dingemans@mumc.nl   
VU medical center Not yet recruiting
Amsterdam, Noord Holland, Netherlands, 1007 MD
Contact: S. Hashemi, MD    0031204443999    s.hashemi@vumc.nl   
Antoni van Leeuwenhoek ziekenhuis - Netherlands Cancer Institute Recruiting
Amsterdam, Noord Holland, Netherlands, 1066 CX
Contact: J. de Langen, MD, PhD    0031205129111    j.d.langen@nki.nl   
Contact: M. Jebbink, MD    0031205129111    m.jebbink@nki.nl   
Erasmus MC Not yet recruiting
Rotterdam, Zuid Holland, Netherlands, 3015 GD
Contact: J. Aerts, MD, PhD    0031107034862    j.aerts@erasmusmc.nl   
Univercity Medical Center Groningen Not yet recruiting
Groningen, Netherlands, 9713 GZ
Contact: A. J. van der Wekken, MD, PhD    0031503616161    a.j.van.der.wekken@umcg.nl   
Sponsors and Collaborators
The Netherlands Cancer Institute
AstraZeneca
Roche Pharma AG
Investigators
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Principal Investigator: J. de Langen, MD, PhD NKI-AvL
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Responsible Party: The Netherlands Cancer Institute
ClinicalTrials.gov Identifier: NCT03784599    
Other Study ID Numbers: M18TEO
First Posted: December 24, 2018    Key Record Dates
Last Update Posted: January 20, 2021
Last Verified: January 2021
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Additional relevant MeSH terms:
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Carcinoma, Non-Small-Cell Lung
Carcinoma, Bronchogenic
Bronchial Neoplasms
Lung Neoplasms
Respiratory Tract Neoplasms
Thoracic Neoplasms
Neoplasms by Site
Neoplasms
Lung Diseases
Respiratory Tract Diseases
Trastuzumab
Ado-trastuzumab emtansine
Osimertinib
Maytansine
Antineoplastic Agents, Immunological
Antineoplastic Agents
Protein Kinase Inhibitors
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents, Phytogenic
Tubulin Modulators
Antimitotic Agents
Mitosis Modulators