Clinical Trials Corner

Dear Readers,

The Clinical Trials Corner of the Bladder Cancer Journal is a section devoted towards highlighting ongoing trials or recently completed trials in urothelial cancer. Our hope is to encourage accrual for ongoing trials and to educate readers on the results of completed trials. If you feel that you would like to draw attention to a specific trial, please feel free to email us at: piyush.agarwal@nih.gov and/or cnsternberg@corasternberg.com.

Sincerely,

Piyush K. Agarwal Cora N. Sternberg
Piyush K. Agarwal, MD Cora N. Sternberg, MD, FACP
Associate Editor, Bladder Cancer Associate Editor, Bladder Cancer
Head, Bladder Cancer Section Chair, Department of Medical Oncology
Urologic Oncology Branch San Camillo Forlanini Hospital
National Cancer Institute Rome, Italy
Bethesda, MD, USA

Genetic Susceptibility to Tumor Recurrence and Progression in Patients With Non-Muscle Invasive Bladder Cancer

Status: 
Completed
Sponsor: 
Memorial Sloan Kettering Cancer Center
Participating centers: 
New York, NY
Accrual: 
116
Study Design: 
Observational cohort study of patients with non-muscle invasive bladder cancer that includes genetic assessment of tumors and behavioral questionnaires to establish whether they can enhance the ability to predict tumor recurrence and progression over tumor grade and stage.
Rationale: 
Tumor and grade are not adequate predictors of recurrence and progression in NMIBC and so by identifying behavioral risk factors from questionnaires and genetic susceptibility genes in DNA repair, cell cycle, and detoxifying pathways; perhaps, better prediction of NMIBC outcomes can occur.
Comments: 
Samples will be obtained from blood, urine, and tumor tissue. The study hopes to predict the 40% of patients with NMIBC that may never recur or progress with tumor. The study has accrued 116 patients and analysis is pending. One concern is that often very little tumor tissue is present in NMIBC specimens and instrumented urine may not contain enough urothelial cancer cells for analysis.

Study of Bacillus Calmette-Guerin (BCG) Combined With PANVAC Versus BCG Alone in Adults With High Grade Non-Muscle Invasive Bladder Cancer Who Failed At Least 1 Course of BCG

Status: 
Recruiting
Sponsor: 
National Cancer Institute
Participating centers: 
Bethesda and New Brunswick
Accrual: 
54
Study Design: 
Phase 2, randomized trial comparing BCG alone to BCG and PANVAC in high-grade BCG-refractory NMIBC patients. The primary endpoint is 12 month DFS rate. The secondary endpoints are time to recurrence, progression-free survival, and immunologic correlates.
Rationale: 
PANVAC is a vaccine with transgenes for CEA and MUC-1. These tumor antigens are overexpressed on the surface of high-grade urothelial tumors. Also PANVAC contains three co-stimulatory molecules that can augment a T-cell immune response. In theory, the vaccine should augment a T-cell response against cells expressing CEA and MUC-1. Therefore, it is postulated that it will augment the response to BCG when combined with BCG.
Comments: 
An immune response can be triggered either by inhibiting blockade or augmenting T-cell stimulation. PANVAC attempts the latter with three co-stimulatory molecules. By using a systemic vaccine with a local immunotherapeutic agent, this trial attempts to establish greater efficacy than BCG alone.

Mycobacterial Cell Wall-DNA Complex in Treatment of BCG-refractory Patients With Non-muscle Invasive Bladder Cancer

Status: 
Completed
Sponsor: 
Bioniche Life Sciences Inc.
Enrollment: 
129
Study Design: 
Phase II/III, single arm trial of mycobacterium phlei cell wall – nucleic acid complex (MCNA) in patients with non-muscle invasive bladder cancer (high grade papillary tumors and/or CIS) who are refractory to BCG therapy. Patients treated with an induction course followed by maintenance therapy up to 2 years. The primary endpoint was 1-year DFS and secondary endpoints were duration of disease-free survival (DFS), progression-free survival (PFS), and overall survival.
Rationale: 
MCNA is a nonpathogenic and nonviable strain of mycobacterium that may potentially offer the benefits of BCG without the potential toxicity. Furthermore, it may be a viable substitute for BCG shortages.
Comments: 
After publishing the results, the drug was presented to a FDA panel for a biologics license application and voted down 18-6. Unfortunately the primary endpoint fell short of the intended result (1 year DFS ≥ 40%). Furthermore, the FDA calculated the true DFS to be 20.9% at 1 year. In the FDA analysis, DFS in CIS-containing patients was also evaluated separately as the absence of tumor in these patients is unlikely to result from bladder biopsy/TURBTs (as opposed to papillary tumors). By looking at only CIS containing tumors, DFS did not appear as robust (18.8% DFS at 1 year). Finally, we now know that the intended endpoint of improvement in DFS was much higher than it needed to be as an absolute improvement of 10-15% in BCG-unresponsive patients may be clinically significant. The two main learning points were a) that studies should enrich their population with CIS-containing patients and b) that studies should aim for an absolute improvement of 10-15% over historical controls in endpoints even though this will require the enrollment of more patients.
Results: 
Overall DFS was 25% at 1 year and 19% at 2 years. PFS was 87.3% at 1 year. The median time to cystectomy was 263 days in MCNA responders vs. 174 days in non-responders. Overall, 15 patients (11.6%) developed metastatic bladder cancer.

A Phase II Clinical Trial of Pembrolizumab (MK-3475) in Subjects With Advanced/Unresectable or Metastatic Urothelial Cancer (MK- 3475-052/KEYNOTE-52)

Status: 
Open
Sponsor: 
Merck Sharp & Dohme Corp
Participating centers: 
United States (several centers), Australia, Canada, Denmark, Guatemala, Hungary, Ireland, Israel, Italy, Korea, Malaysia, Puerto Rico, Singapore, Spain, Taiwan, United Kingdom
Accrual: 
350
Study Design: 
Phase II, single arm interventional trial using pembrolizumab in cisplatin-ineligible, chemotherapy- naïve patients with inoperable and/or metastatic urothelial cancer
Rationale: 
In a recently reported multi-cohort Phase 1b Trial, pembrolizumab (PD-1 inhibitor) demonstrated ~15% grade 3-5 adverse events and 28% overall response rate in advanced urothelial cancer failing 2 or more systemic therapies. Therefore, pembrolizumab is being evaluated in a previously untreated population (except neoadjuvant chemotherapy >12 months prior) with aggressive disease.
Comments: 
At least two trials now demonstrate the safety and efficacy of checkpoint blockade inhibitors (both PD-1 and PD-L1 inhibition) in urothelial cancer. This new trial will evaluate the impact of PD-1 inhibition in patients with aggressive urothelial cancer who have not been pre-treated. A possible concern with this trial is that PD-1 expression in tumors and tumor infiltrating immune cells may be limited as PD-1 expression increases in response to IFN-γ which can be released from prior treatments. In the absence of prior treatments, up regulation of PD-1 may not be as robust.

A Phase III, Open-Label, Multicenter, Randomized Study of Atezolizumab (Anti-PD-L1 Antibody) Versus Observation as Adjuvant Therapy in Patients With PD-L1-Selected, High-Risk Muscle-Invasive Bladder Cancer After Cystectomy

Status: 
Open
Sponsor: 
Hoffman-La Roche
Participating centers: 
United States (several centers), Australia, Belarus, Belgium, Canada, Czech Republic, Finland, France, Denmark, Germany, Greece, Israel, Italy, Korea, Netherlands, Poland, Russian Federation, Serbia, Spain, Switzerland, Taiwan, Turkey, Ukraine, United Kingdom
Accrual: 
440
Study Design: 
Phase III, randomized trial comparing adjuvant atezolizumab versus observation in patients with PD-L1 positive muscle invasive bladder cancer (urothelial histology) status post cystectomy. On the study patients may have had no neo-adjuvant chemotherapy or may have had neo-adjuvant chemotherapy and then after cystectomy are pT2-T4a or N+. No prior adjuvant RT or chemotherapy is allowed.
Rationale: 
In a recently reported Phase I trial with update at ASCO 2015 Annual Meeting, Powles et al reported 26% overall response rate with MPDL3280A (atezolizumab) in patients with metastatic urothelial cancer. Results are impressive considering that at least 72% of patients failed 2 or more prior regimens. Therefore, PD-L1 inhibition is being evaluated in patients in an earlier stage of disease in this current trial.
Comments: 
Emerging literature demonstrates that immunotherapies are more effective in patients with limited tumor burden. Given the impressive efficacy from the Phase I trial (as high as 43% in patients with strong PD-L1 expression), this trial optimizes atezolizumab therapy for patients with low tumor burden and PD-L1 expression.

A Study of Pembrolizumab (MK-3475) Versus Paclitaxel, Docetaxel, or Vinflunine for Participants With Advanced Urothelial Cancer (MK-3475-045/KEYNOTE-045)

Status: 
Closed
Sponsor: 
Merck Sharp & Dohme Corp
Participating centers: 
United States (several centers), Australia, Austria, Belgium, Canada, Chile, Denmark, France, Germany, Hungary, Ireland, Israel, Italy, Japan, Korea, Netherlands, Norway, New Zealand, Peru, Poland, Portugal, Puerto Rico, Romania, Singapore, Spain, Sweden, Taiwan, Turkey, United Kingdom
Accrual: 
450
Rationale: 
In a recently reported multi-cohort Phase 1b Trial, pembrolizumab (PD-1 inhibitor) demonstrated ~15% grade 3-5 adverse events and 28% overall response rate in advanced urothelial cancer failing 2 or more systemic therapies. Therefore, pembrolizumab is being evaluated in a previously treated population. Participants with metastatic or locally advanced/unresectable urothelial cancer that has recurred or progressed following platinum-based chemotherapy will be randomly assigned to receive pembrolizumab or investigator’s choice of paclitaxel, docetaxel, or vinflunine. The primary study hypotheses are that pembrolizumab will prolong OS and PFS.
Comments: 
Checkpoint blockade inhibitors (both PD-1 and PD-L1 inhibition) appear to be active in urothelial cancer. In the USA there is no standard second line therapy for patients who have failed first line cisplatin based chemotherapy. In Europe, vinflunine is approved in this setting. For this reason patients will be randomized between pembrolizumab and the investigator’s choice of chemotherapy.

Randomized Phase III Trial Comparing Immediate Versus Deferred Chemotherapy After Radical Cystectomy in Patients With pT3-pT4, and/or N+M0 Transitional Cell Carcinoma (TCC) of the Bladder

Status: 
Completed
Sponsor: 
EORTC with collaboration from GETUG, NCRI, NCIC and AUO
Primary Investigator(s): 
Cora N. Sternberg, MD
Accrual: 
284
Study Design: 
Patients at least 90 days out of cystectomy with pT3-T4 and/or node positive urothelial cancer of the bladder were randomized to either immediate chemotherapy or deferred chemotherapy (latter being given at clinical relapse of disease)
Rationale: 
Adjuvant chemotherapy has been evaluated in small single center studies and the trials have never been powered adequately to demonstrate a benefit with adjuvant chemotherapy. This large, multi-center trial was designed through the EORTC to try to evaluate adjuvant chemotherapy more rigorously
Comments: 
Unfortunately, the trial was closed early due to difficulties with accrual. One can only speculate that the trend in OS may have become significant if more patients had been enrolled. A meta analysis of the literature suggests a benefit of adjuvant chemotherapy but is limited by severe between trial heterogeneity. An updated individual patient data meta-analysis and biomarker research are needed to further elucidate the potential for survival in subgroups of patients. Although immediate chemotherapy after radical cystectomy led to a significant improvement in PFS, overall survival was not improved. However, immediate chemotherapy might extend survival in patients without lymph-node involvement.
Results: 
This is the largest randomized trial ever reported of adjuvant chemotherapy in patients with muscle invasive bladder cancer. Immediate adjuvant cisplatin based combination chemotherapy after radical cystectomy led to a statistically significant improvement in PFS. 5 yr PFS was 47.6% vs 31.8% on the deferred arm. The median PFS was 3.11 years vs 0.99 years on the deferred arm (HR =0.54 p = 0.54 (95% CI : 0.40 – 0.73) P < 0.0001). A non-significant reduction of 22.2% in the risk of death was also observed.

A Study of Nivolumab in Participants With Metastatic or Unresectable Bladder Cancer

Status: 
Closed
Sponsor: 
Bristol-Myers Squibb
Participating centers: 
United States (several centers), Australia, Belgium, Czech Republic, Finland, Germany, Italy, Japan, Poland, Spain, Sweden
Accrual: 
242
Study Design: 
Phase II, single arm trial of nivolumab in patients with metastatic or unresectable urothelial cancer who have progressed or recurred after platinum-based chemotherapy
Rationale: 
Nivolumab is a monoclonal antibody against PD-1 and is being evaluated in a Phase I/II in combination with ipilimumab in advanced or metastatic solid tumors including patients with urothelial cancer. It has demonstrated activity in melanoma, lung cancer, and renal cancer. This trial aims to look at the efficacy of nivolumab as a second line therapy in platinum-recurrent or -resistant urothelial tumors.
Comments: 
Patients were stratified in this trial based on their PD-L1 expression. Nivolumab has been approved by the FDA for patients with lung cancer and more recently for second line renal cell cancer after a comparison with everolimus revealed a clear improvement in overall survival (Checkmate 025 Phase III trial; Motzer RJ, et al. N Engl J Med. 2015: 373; 1803-13).

An Efficacy and Safety Study of JNJ-42756493 in Participants With Urothelial Cancer

Status: 
Recruiting
Sponsor: 
Janssen Research & Development, LLC
Participating centers: 
United States (several centers), France, United Kingdom, Belgium, Germany, Italy, Korea, Russia, Spain, Taiwan, Germany, Austria, Romania, Moldova
Accrual: 
estimated 165
Study Design: 
A Phase 2, Two-arm Multicenter, Open-Label Study to Determine the Efficacy and the Safety of Two Different Dose Regimens of a Pan-FGFR Tyrosine Kinase Inhibitor JNJ-42756493 in Subjects With Metastatic or Surgically Unresectable Urothelial Cancer With FGFR Genomic Alterations. Patients who have failed first line chemotherapy for metastatic disease or unresectable urothelial cancer or patients who are ineligible for cisplatin based chemotherapy (GFR < 60 mL/min) will be included.
Rationale: 
JNJ-42756493 is a selective and potent orally administered pan-fibroblast growth factor receptor (FGFR) tyrosine kinase inhibitor with demonstrated activity in patients with solid tumors with alterations in the FGFR pathway including urothelial carcinoma (Tabernero J et al., ASCO 2015), indicating the potential to be a new therapeutic option for these patients. Thus far no molecularly targeted agents have been approved for the treatment of this disease. However, recent advances in genomic profiling of urothelial carcinomas have identified potential therapeutic molecular targets in 69% of tumors (The Cancer Genome Atlas Project Nature 2014). Of the molecular alterations identified, FGFR signaling in particular is altered in a high proportion of bladder tumors in both muscle invasive (15–20%) and non-invasive tumors (70–80%).

A Study of Ramucirumab (LY3009806) Plus Docetaxel in Participants With Urothelial Cancer (RANGE)

Status: 
Closed
Sponsor: 
Eli Lilly and Company
Participating centers: 
123 locations: United States (several centers), Australia, Belgium, Canada, Denmark, France, Germany, Greece, Hungary, Israel, Italy, Japan, South Korea, Netherlands, Poland, Romania, Russia, Spain, Taiwan, Turkey, United Kingdom
Accrual: 
expected 524
Study Design: 
A Phase 3, Randomized, Double-Blind, Placebo-Controlled Study of Ramucirumab Plus Docetaxel Versus Placebo Plus Docetaxel in Patients With Locally Advanced or Unresectable or Metastatic Urothelial Carcinoma Who Progressed on or After Platinum-Based Therapy. Patient must have had disease progression while on a platinum containing regimen in the first-line setting or within 14 months after completing the first-line platinum regimen. Participants who received treatment with one immune checkpoint inhibitor regimen are eligible (for example PD-1, PDL1, or CTLA4) and may have a longer interval since prior platinum-containing therapy (≤24 months). Patients are excluded who have received prior systemic taxane therapy.
Rationale: 
Ramucirumab is a monoclonal antibody that acts to inhibit vascular endothelial growth factor (VEGF); ramucirumab acts on VEGF-2. Adding this new antiangiogenic agent ramucirumab to docetaxel chemotherapy has shown promising results as a second-line therapy in advanced or metastatic urothelial carcinoma. At the Genitourinary Cancers Symposium (GUCS) in 2015. Petrylak et al. presented a planned interim analysis of a phase 2 randomized trial that showed that the combination regimen significantly increased progression-free survival (22 weeks) as compared with docetaxel alone (10.4 weeks). The ramucirumab plus docetaxel combination conferred a statistically significant progression-free survival improvement of greater than 11.5 weeks and reduced the risk of disease progression by 61%. Results were consistent across pre-specified subgroups and it showed an acceptable safety profile. Ramucirumab has been approved for use in gastric cancer and non–small cell lung cancer after it was shown to prolong overall survival in phase 3 second-line studies.

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