Maintenance Chemotherapy With or Without Local Consolidative Therapy in Treating Patients With Stage IV Non-small Cell Lung Cancer

• ClinicalTrials.gov Identifier: NCT03137771
• Recruitment Status: Suspended
• First Posted: May 3, 2017
• Last Update Posted: July 11, 2022
• Sponsor: NRG Oncology
• Collaborator: National Cancer Institute (NCI)
• Information provided by (Responsible Party): NRG Oncology

Tracking Information

• First Submitted Date: April 26, 2017
• First Posted Date: May 3, 2017
• Last Update Posted Date: July 11, 2022
• Actual Study Start Date: April 7, 2017
• Estimated Primary Completion Date: October 31, 2026 (Final data collection date for primary outcome measure)

Current Primary Outcome Measures (submitted: April 28, 2017)

• Phase II - Progression-Free Survival (PFS) [ Time Frame: From the time of randomization to date any documented progression or death due to any cause, whichever occurs first. Assessed for up to 3 years. ]
  Progression-Free Survival
• Phase III - Overall Survival (OS) [ Time Frame: From the time of randomization to date of death due to any cause. Assessed up to 3 years. ]
  Overall Survival

• Original Primary Outcome Measures: Same as current

Current Secondary Outcome Measures (submitted: February 7, 2019)

• Time to In-Field Failure [ Time Frame: Time from randomization to progression within the irradiated field at any time, assessed for up to 3 years ]
  The time it takes for disease progression to occur within the radiation treatment field of disease will be measured.
• Incidence of adverse events graded per National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version (v) 5 [ Time Frame: Up to 3 years ]
  Will be reported with the frequency and severity (e.g., type, grade, and attribution) by arm.
• Duration of Maintenance Chemotherapy Usage [ Time Frame: Up to 3 years ]
  Will be performed on an intent to treat basis.
• Time to Development of New Lesions [ Time Frame: Time from randomization to the first occurrence of any new lesions that have not been treated with local consolidative therapy, assessed for up to 3 years ]
  Will be performed on an intent to treat basis.

Original Secondary Outcome Measures (submitted: April 28, 2017)

• Time to In-Field Failure [ Time Frame: Time from randomization to progression within the irradiated field at any time, assessed for up to 3 years ]
  The time it takes for disease progression to occur within the radiation treatment field of disease will be measured.
• Time to Out-of-Field Failure [ Time Frame: Time from randomization to out-field disease progression, assessed for up to 3 years ]
  The time is takes for disease progression to occur outside of the radiation treatment field of disease will be measured.
• Incidence of adverse events graded per National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version (v) 4 [ Time Frame: Up to 3 years ]
  Will be reported with the frequency and severity (e.g., type, grade, and attribution) by arm.
• Duration of Maintenance Chemotherapy Usage [ Time Frame: Up to 3 years ]
  Will be performed on an intent to treat basis.

• Current Other Pre-specified Outcome Measures: Not Provided
• Original Other Pre-specified Outcome Measures: Not Provided

Descriptive Information

• Brief Title: Maintenance Chemotherapy With or Without Local Consolidative Therapy in Treating Patients With Stage IV Non-small Cell Lung Cancer
• Official Title: Maintenance Systemic Therapy Versus Local Consolidative Therapy (LCT) Plus Maintenance Systemic Therapy for Limited Metastatic Non-Small Cell Lung Cancer (NSCLC): A Randomized Phase II/III Trial
• Brief Summary: This randomized phase II/III trial studies how well giving maintenance chemotherapy with or without local consolidation therapy works in treating patients with stage IV non-small cell lung cancer. Drugs used in maintenance chemotherapy, such as docetaxel, pemetrexed disodium, erlotinib hydrochloride, and gemcitabine work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Local consolidation therapy such as radiation/stereotactic body radiation or surgery may kill cancer cells left after initial treatment. Giving maintenance chemotherapy and local consolidation therapy together may work better than maintenance chemotherapy alone in treating patients with stage IV non-small cell lung cancer.

Detailed Description

PRIMARY OBJECTIVES:

Phase II

To evaluate the impact of adding local consolidative therapy (LCT) to maintenance systemic therapy versus maintenance systemic therapy alone on progression-free survival for patients with metastatic non-small cell lung cancer (NSCLC) with no evidence of progression and limited metastatic sites after first-line systemic therapy.

Phase III

To evaluate the impact of adding LCT to maintenance systemic therapy versus maintenance systemic therapy alone on overall survival for patients with metastatic NSCLC with no evidence of progression and limited metastatic sites after first-line systemic therapy.

SECONDARY OBJECTIVES:

I. To evaluate the impact of adding LCT to maintenance systemic therapy versus maintenance systemic therapy alone on in-field local failure.

II. To evaluate the impact of adding LCT to maintenance systemic therapy versus maintenance systemic therapy alone on the time to development of new lesions.

III. To evaluate the impact of adding LCT to maintenance systemic therapy versus maintenance systemic therapy alone on toxicity.

IV. To evaluate the impact of adding LCT to maintenance systemic therapy versus maintenance systemic therapy alone on duration of maintenance systemic therapy usage.

V. To evaluate the effect of adding LCT to systemic therapy in limited stage IV NSCLC on Quality of Life (QOL) VI. To collect biospecimens and evaluate the correlation between clinical outcomes and circulating tumor DNA (ctDNA).

OUTLINE: Patients are randomized into 1 of 2 arms.

ARM 1 (CHEMOTHERAPY ALONE): ): Patients may receive docetaxel intravenously (IV) over 60 minutes on Day 1, erlotinib hydrochloride orally (PO) once daily (QD), or gemcitabine IV over 30 minutes on Days 1 and 8. Patients with non-squamous non-small cell lung cancer may receive pemetrexed disodium IV over 10 minutes on Day 1 alone or in combination with pembrolizumab IV over 30 minutes. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.

ARM 2 (SBRT AND CHEMOTHERAPY): Patients undergo LCT over 2-4 weeks. If LCT cannot be used to treat primary disease sites, patients also undergo intensity-modulated radiation therapy (IMRT) or 3-dimensional conformal radiation therapy (3DCRT) over 3-5 weeks. Within 2 weeks after completion of radiation therapy, patients receive chemotherapy as in Arm 1. Patients may possibly undergo surgery.

After completion of study treatment, patients are followed up every 3 months for 2 years, every 6 months for 3 years, then annually thereafter.

• Study Type: Interventional
• Study Phase: Phase 2
• Study Design: Allocation: Randomized; Intervention Model: Parallel Assignment; Masking: None (Open Label); Primary Purpose: Treatment

Condition

• Recurrent Non-Small Cell Lung Carcinoma
• Stage IV Non-Small Cell Lung Cancer

Intervention

• Radiation: 3-Dimensional Conformal Radiation Therapy (3D-CRT)
  Undergo 3DCRT
  Other Names:

  • 3-dimensional conformal radiation therapy
  • 3-dimensional radiation therapy
  • 3D CONFORMAL RADIATION THERAPY
  • 3D CRT
  • 3D-CRT
  • Conformal Therapy
  • Radiation Conformal Therapy
• Drug: Docetaxel
  Given IV
  Other Names:

  • Docecad
  • RP56976
  • Taxotere
  • Taxotere Injection Concentrate
• Drug: Gemcitabine
  Given IV
  Other Names:

  • dFdC
  • dFdCyd
  • Difluorodeoxycytidine
• Radiation: Intensity-Modulated Radiation Therapy (IMRT)
  Undergo IMRT
  Other Names:

  • IMRT
  • Intensity Modulated RT
  • INTENSITY-MODULATED RADIATION THERAPY
  • Intensity-Modulated Radiotherapy
• Drug: Pemetrexed Disodium
  Given IV
  Other Names:

  • Alimta
  • LY231514
  • N-[4-[2-(2-Amino-4,7-dihydro-4-oxo-1H-pyrrolo[2,3-d]pyrimidin-5-yl)ethyl]benzoyl]-L-glutamic Acid Disodium Salt
• Radiation: Stereotactic Body Radiation Therapy (SBRT)
  Undergo SBRT
  Other Names:

  • SBRT
  • stereotactic body radiation therapy
• Drug: Erlotinib Hydrochloride
  Given PO
  Other Name: Tarceva
• Drug: Pembrolizumab
  Given IV
  Other Name: Keytruda

Study Arms

• Active Comparator: Arm 1 (maintenance chemotherapy)
  Patients may receive docetaxel IV over 60 minutes on day 1, erlotinib hydrochloride PO QD, or gemcitabine IV over 30 minutes on days 1 and 8. Patients with non-squamous non-small cell lung cancer may receive pemetrexed disodium IV over 10 minutes on day 1 alone or in combination with pembrolizumab IV over 30 minutes. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.
  Interventions:

  • Drug: Docetaxel
  • Drug: Gemcitabine
  • Drug: Pemetrexed Disodium
  • Drug: Erlotinib Hydrochloride
  • Drug: Pembrolizumab
• Experimental: Arm 2 (SBRT + maintenance chemotherapy)
  Patients undergo LCT over 2-4 weeks. If LCT cannot be used to treat primary disease sites, patients also undergo IMRT or 3DCRT over 3-5 weeks. Within 2 weeks after completion of radiation therapy, patients receive chemotherapy as in Arm 1. Patients may possibly undergo surgery.
  Interventions:

  • Radiation: 3-Dimensional Conformal Radiation Therapy (3D-CRT)
  • Drug: Docetaxel
  • Drug: Gemcitabine
  • Radiation: Intensity-Modulated Radiation Therapy (IMRT)
  • Drug: Pemetrexed Disodium
  • Radiation: Stereotactic Body Radiation Therapy (SBRT)
  • Drug: Erlotinib Hydrochloride
  • Drug: Pembrolizumab

• Publications *: Mattes MD, Eubank TD, Almubarak M, Wen S, Marano GD, Jacobson GM, Ma PC. A Prospective Trial Evaluating the Safety and Systemic Response From the Concurrent Use of Radiation Therapy with Checkpoint Inhibitor Immunotherapy in Metastatic Non-Small Cell Lung Cancer. Clin Lung Cancer. 2021 Jul;22(4):268-273. doi: 10.1016/j.cllc.2021.01.012. Epub 2021 Jan 25.

Recruitment Information

• Recruitment Status: Suspended
• Estimated Enrollment (submitted: December 7, 2020): 400
• Original Estimated Enrollment (submitted: April 28, 2017): 300
• Estimated Study Completion Date: October 2031
• Estimated Primary Completion Date: October 31, 2026 (Final data collection date for primary outcome measure)

Eligibility Criteria

Inclusion Criteria:

• Patients must have the psychological ability and general health that permits completion of the study requirements and required follow up
• Women of childbearing potential and men who are sexually active should be willing and able to use medically acceptable forms of contraception during the trial and for up to 180 days after completion of all treatment to prevent pregnancy or fathering a child.
• Pathologically proven diagnosis of NSCLC, with metastases (stage IV disease) present prior to registration; this includes patients newly diagnosed with metastatic disease or those initially diagnosed and treated for stage I-III NSCLC who ultimately develop metastases

• Appropriate stage for study entry based on the following diagnostic workup:

  • History/physical examination within 30 days prior to registration
  • Imaging proof of limited metastatic disease and response to therapy/stable disease, by at least CT chest through the adrenals or PET/CT within 30 days prior to registration
• Zubrod performance status 0, 1, or 2 within 30 days prior to registration
• Aspartate transaminase (AST) and alanine transaminase (ALT) ≤ 2.5 × upper limit of normal (ULN) or ≤ 5 × ULN with metastatic liver disease
• Total bilirubin ≤ 1.5 × ULN
• Absolute neutrophil count (ANC) ≥ 500 cells/mm^3
• Creatinine clearance ≥ 45 mL/min/1.73 m^2 for patients with creatinine levels above institutional normal
• Platelets ≥ 50,000 cells/mm^3
• Negative serum pregnancy test within one week prior to registration for females of childbearing potential
• Patients must have received first-line/induction chemotherapy (4 cycles) and achieved stable disease or a partial response
• Prior systemic chemotherapy as part of concurrent treatment approach for previously diagnosed stage III NSCLC, as adjuvant therapy for previously resected NSCLC, or for other previous cancers is permitted
• Prior radiotherapy for patients with brain metastases prior to enrollment is acceptable
• Patients must have measurable disease at baseline and 3 or fewer discrete, extracranial metastatic disease sites that are technically amenable to SBRT
• For de novo stage IV NSCLC patients (patients with metastatic disease at first presentation), primary disease must be treatable with local therapy in the form of SBRT or hypofractionated radiation; if the primary disease is found in the peripheral or central lung parenchyma without nodal disease for instance, SBRT may be employed; if primary disease is more advanced with involvement of the mediastinum (T4 tumor, N1-N3 disease, etc.), these volumes should be technically treatable with hypofractionated radiation
• If primary disease in the thoracic cavity was previously treated with local therapy in the form of surgery, any local/regional disease recurrence should be technically treatable with SBRT or hypofractionated radiation after induction systemic therapy
• Patients must be registered within 35 days of administration of the last dose of first-line/induction systemic therapy
• The patient or a legally authorized representative must provide study-specific informed consent prior to study entry
• Patients with brain metastases are eligible if these lesions have been previously treated and the patients have no clinical or radiographic evidence of progression prior to enrollment

Exclusion Criteria:

• Clinical or radiologic evidence of untreated and/or progressive brain metastases
• Cutaneous metastasis of NSCLC
• Metastatic disease invading the esophagus, stomach, intestines, or mesenteric lymph nodes if not a candidate for surgery for these lesions
• Prior invasive malignancy (except non-melanomatous skin cancer, low or intermediate risk prostate cancer, or in situ carcinoma of breast, oral cavity, skin, or cervix) unless disease free for a minimum of one year

• Metastases located within 3 cm of previously irradiated (< 3Gy per fraction) structures if if not a candidate for surgery for these lesions and if:

  • Spinal cord previously irradiated to > 40 Gy
  • Brachial plexus previously irradiated to > 50 Gy
  • Small intestine, large intestine, or stomach previously irradiated to > 45 Gy
  • Brainstem previously irradiated to > 50 Gy
  • Lung previously irradiated with prior V20 Gy > 35%
• Patients receiving targeted therapy (non-cytotoxic systemic therapy) for NSCLC in the first-line setting
• If a patient has progressed in previous areas of primary disease that received definitive doses of radiation, these patients would require re-irradiation in previous high dose anatomic areas and are not eligible for this study
• Patients with malignant pleural effusions that do not resolve after first-line systemic therapy; patients with pleural effusions that have become too small for thoracentesis at the time of registration would be permitted on study, indicating a significant response to first-line chemotherapy
• Patients with more than 3 discrete locations of extra-cranial metastatic disease after first-line systemic therapy requiring more than 3 SBRT plans to cover these distinct metastatic disease entities
• Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration
• Patients who are pregnant or nursing
• Participation in any investigational drug study (excluding non-oncology and/or symptom management studies) within 4 weeks prior to registration
• Known human immunodeficiency virus (HIV) positive with cluster of differentiation 4 (CD4) count < 200 cells/microliter; note that patients who are HIV positive are eligible, provided they are under treatment with highly active antiretroviral therapy (HAART) and have a CD4 count ≥ 200 cells/microliter within 30 days prior to registration; note also that HIV testing is not required for eligibility for this protocol
• For patients who received immunotherapy during induction, patients on chronic steroids or who have active autoimmune disease for which they received systemic treatment in the previous 2 years with corticosteroids, disease modifying agents, or immunosuppressive drugs are not eligible. Replacement therapy (thyroxine, insulin or physiological corticosteroid replacement for adrenal or pituitary insufficiency) is allowed. Patients with active interstitial lung disease or who have a history of pneumonitis for which they had received glucocorticoids are not eligible
• Prior bevacizumab therapy or other antiangiogenic therapy in first-line or planned maintenance therapy (due to potential for increased complications from local therapy)

Sex/Gender

• Sexes Eligible for Study: All

• Ages: 18 Years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Contacts: Contact information is only displayed when the study is recruiting subjects
• Listed Location Countries: Canada, Israel, Saudi Arabia, United States

Administrative Information

• NCT Number: NCT03137771
• Other Study ID Numbers: NRG-LU002; NCI-2016-00849 ( Registry Identifier: CTRP (Clinical Trial Reporting Program) ); NRG-LU002 ( Other Identifier: NRG Oncology ); NRG-LU002 ( Other Identifier: CTEP ); U10CA180868 ( U.S. NIH Grant/Contract )
• Has Data Monitoring Committee: Yes

U.S. FDA-regulated Product

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

IPD Sharing Statement

• Plan to Share IPD: No

• Current Responsible Party: NRG Oncology
• Original Responsible Party: Same as current
• Current Study Sponsor: NRG Oncology
• Original Study Sponsor: Same as current
• Collaborators: National Cancer Institute (NCI)

Investigators

• Principal Investigator: Puneeth Iyengar; NRG Oncology

• PRS Account: NRG Oncology
• Verification Date: July 2022