Alternative dosing schedule for cabozantinib in advanced kidney and neuroendocrine tumors

GU-187: Phase II Trial of Alternative Cabozantinib Dosing Schedule in Metastatic Renal Cell Carcinoma and Neuroendocrine Tumors

This study is testing a new way to give cabozantinib to see if it helps people with advanced kidney cancer and neuroendocrine tumors feel better and stay safe while being treated.

Quick facts

• Phase: PHASE2
• Study type: Interventional
• Enrollment: 111 (estimated)
• Ages: 18 Years and up
• Sex: All
• Sponsor: Fox Chase Cancer Center (other)
• Drugs / interventions: pembrolizumab, nivolumab, cabozantinib, immunotherapy, Radiation, prednisone
• Locations: 1 site (Philadelphia, Pennsylvania)
• Trial ID: NCT05263050 on ClinicalTrials.gov

What this trial studies

This phase II trial evaluates an alternative dosing schedule of cabozantinib in patients with metastatic renal cell carcinoma (mRCC) and neuroendocrine tumors (NETs). The study consists of three cohorts: two cohorts receiving cabozantinib alone and one cohort receiving cabozantinib in combination with nivolumab. Patients will start with a daily dose of 40 mg of cabozantinib, with adjustments made based on pre-specified criteria to optimize treatment. The trial aims to assess the efficacy and safety of this dosing strategy in a total of 111 participants.

Who should consider this trial

Good fit: Ideal candidates include patients with advanced renal cell carcinoma or neuroendocrine tumors who meet specific inclusion criteria regarding prior treatments.

Not a fit: Patients who have received systemic therapy in the metastatic setting prior to enrollment in Cohort B may not benefit from this study.

Why it matters

Potential benefit: If successful, this study could provide a more effective and tolerable treatment regimen for patients with advanced kidney and neuroendocrine tumors.

How similar studies have performed: Other studies have shown promise with cabozantinib in treating similar conditions, but this specific dosing approach is novel.

Eligibility criteria

Inclusion Criteria

* Cohorts A and B: Histologically or cytologically confirmed advanced RCC with any clear cell or non-clear cell component. 100% sarcomatoid is permissible.
* Cohorts A and B: Patient may have had any number of prior therapies for Cohort A, but for Cohort B patients must not have received any systemic therapy in the metastatic setting
* Patients who have received prior (neo)adjuvant immunotherapy with pembrolizumab or similar are eligible for Cohort B IF they completed the adjuvant therapy \> 12 months from start of trial therapy
* Treatment naïve patients may be treated in Cohort A if deemed not candidates for nivolumab or if felt single agent cabozantinib most appropriate by the treating clinician
* Cohort C: Well differentiated NET, grades 1-3 (any primary site) who have progressed on or are not eligible for somatostatin analogs per treating physician discretion
* Cohort C: Disease progression within prior 12 months
* Cohort C: Prior or concurrent treatment with somatostatin analogue allowed but no limit on lines of therapy (stable dose of somatostatin for 2 months)

All Cohorts:

* At least one measurable lesion as defined by RECIST version 1.1
* No evidence of pre-existing uncontrolled hypertension as assessed by investigator. Patients may undergo adjustments or additions to their antihypertensive regimen before or during screening to achieve optimal BP control.
* Age \> 18 years.
* ECOG performance status 0 - 2
* Patients must have normal organ and marrow function as defined below

  * Leukocytes, \> 2,000/mcL
  * Absolute neutrophil count, \> 1,500/mcL
  * Platelets, \> 100,000/mcL
  * Hgb, \> 9 g/dL (\>90 g/L)
  * Total bilirubin, ≤ 1.5 x ULN (with the exception of of individuals with Gilberts syndrome who may have a bilirubin \<3.0 mg/dL)
  * AST/ALT (SGOT/SGPT)/ALP, \< 3 x ULN ALP ≤ 5x ULN with documented bone metastases.
  * Albumin, \> 2.8 g/dL
  * Creatinine clearance, \> 30 Ml/min/1.73 m2 for patients with creatinine levels above institutional normal
  * PT/INR or PTT, \< 1.3 x the laboratory ULN
* Ability to understand and willingness to sign a written informed consent and HIPAA consent document
* Sexually active fertile subjects and their partners must agree to use medically accepted methods of contraception (e.g., barrier methods, including male condom, female condom, or diaphragm with spermicidal gel) during the course of the study and for 4 months after the last dose of study treatment

Exclusion Criteria

* Patients who have had systemic anti-cancer therapy or radiotherapy within 14 days or five half-lives, whichever is shorter, prior to entering the study.
* Radiation therapy for bone metastases within 2 weeks, any other radiation therapy within 4 weeks, or systemic treatment with radionuclides within 6 weeks before first dose of study treatment. Ongoing clinically relevant complications from prior radiation therapy would preclude eligibility.
* Patients with prior therapy with cabozantinib.
* Prior systemic therapy directed at advanced RCC is not allowed for patients enrolled to Cohort B (treatment-naïve group).
* Cohort B only: Active, known or suspected autoimmune disease. Subjects are permitted to enroll if they have vitiligo, type I diabetes mellitus, residual hypothyroidism due to autoimmune condition only requiring hormone replacement, psoriasis not requiring systemic treatment, or conditions not expected to recur in the absence of an external trigger
* Cohort B only: Patients have a condition requiring systemic treatment with either corticosteroids (\> 10 mg daily prednisone or equivalent) or other immunosuppressive medications within 14 days of study drug administration. Inhaled or topical steroids and adrenal replacement doses \> 10 mg daily prednisone equivalents are permitted in the absence of active autoimmune disease.
* Patients may not be receiving any other investigational agents
* History of allergic reactions or hypersensitivity attributed to compound of similar chemical or biologic composition to the agent(s) used in this study
* Current use or anticipated need for treatment with drugs or foods that are known strong CYP3A4 inhibitors and inducers. Refer to Section 5.3.2 for detailed information. The topical use of these medications (if applicable), such as 2% ketoconazole cream, is allowed.
* Concomitant anticoagulation with coumarin agents (e.g., warfarin), direct thrombin inhibitors (e.g., dabigatran), direct factor Xa inhibitor betrixaban, or platelet inhibitors (e.g., clopidogrel). Allowed anticoagulants are the following:
* Prophylactic use of low-dose aspirin for cardio-protection (per local applicable guidelines) and low-dose low molecular weight heparins (LMWH).
* Therapeutic doses of LMWH or anticoagulation with direct factor Xa inhibitors rivaroxaban, edoxaban, or apixaban in subjects without known brain metastases who are on a stable dose of the anticoagulant for at least 1 week before first dose of study treatment without clinically significant hemorrhagic complications from the anticoagulation regimen or the tumor.
* Uncontrolled intercurrent 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.
* Cardiovascular disorders:
* Congestive heart failure New York Heart Association Class 3 or 4, unstable angina pectoris, serious cardiac arrhythmias.
* QTcF \> 500 msec within 28 days before first dose of study treatment.
* Uncontrolled hypertension defined as sustained blood pressure (BP) \> 160 mm Hg systolic or \> 100 mm Hg diastolic despite optimal antihypertensive treatment.
* Stroke (including transient ischemic attack \[TIA\]), myocardial infarction (MI), or other ischemic event, or thromboembolic event (e.g., deep venous thrombosis, pulmonary embolism) within 6 months before first dose of study treatment.
* Subjects with a diagnosis of incidental, sub-segmental PE or DVT within 6 months are allowed if stable, asymptomatic, and treated with a stable dose of permitted anticoagulation (see exclusion criterion #6) for at least 1 week before first dose of study treatment.
* Gastrointestinal (GI) disorders including those associated with a high risk of perforation or fistula formation:
* The subject has evidence of tumor invading the GI tract, active peptic ulcer disease, inflammatory bowel disease (e.g., Crohn's disease), diverticulitis, cholecystitis, symptomatic cholangitis or appendicitis, acute pancreatitis, acute obstruction of the pancreatic duct or common bile duct, or gastric outlet obstruction.
* Abdominal fistula, GI perforation, bowel obstruction, or intra-abdominal abscess within 6 months before first dose of study treatment.

Note: Complete healing of an intra-abdominal abscess must be confirmed before first dose of study treatment.

* Cavitating pulmonary lesion(s) or known endotracheal or endobronchial disease manifestation.
* Lesions invading or encasing any major blood vessels. Subjects with lesions invading the intrahepatic vasculature, including portal vein, hepatic vein, and hepatic artery, are eligible.

Where this trial is running

Philadelphia, Pennsylvania

• Fox Chase Cancer Center — Philadelphia, Pennsylvania, United States (RECRUITING)

Study contacts

• Principal investigator: Matthew Zibelman, MD — Fox Chase Cancer Center
• Study coordinator: Ryan Romasko, MBA

Conditions: Metastatic Renal Cell Carcinoma, Clear-cell Metastatic Renal Cell Carcinoma, Neuroendocrine Tumors, Carcinoid Tumor