Eric Holmgren

Randomized Phase II Trial Comparing Bevacizumab Plus Carboplatin and Paclitaxel With Carboplatin and Paclitaxel Alone in Previously Untreated Locally Advanced or Metastatic Non-Small-Cell Lung Cancer

PURPOSE To investigate the efficacy and safety of bevacizumab plus carboplatin and paclitaxel in patients with advanced or recurrent non-small-cell lung cancer. PATIENTS AND METHODS In a phase II trial, 99 patients were randomly assigned to bevacizumab 7.5 (n = 32) or 15 mg/kg (n = 35) plus carboplatin (area under the curve = 6) and paclitaxel (200 mg/m(2)) every 3 weeks or carboplatin and paclitaxel alone (n = 32). Primary efficacy end points were time to disease progression and best confirmed response rate. On disease progression, patients in the control arm had the option to receive single-agent bevacizumab 15 mg/kg every 3 weeks. RESULTS Compared with the control arm, treatment with carboplatin and paclitaxel plus bevacizumab (15 mg/kg) resulted in a higher response rate (31.5% v 18.8%), longer median time to progression (7.4 v 4.2 months) and a modest increase in survival (17.7 v 14.9 months). Of the 19 control patients that crossed over to single-agent bevacizumab, five experienced stable disease, and 1-year survival was 47%. Bleeding was the most prominent adverse event and was manifested in two distinct clinical patterns; minor mucocutaneous hemorrhage and major hemoptysis. Major hemoptysis was associated with squamous cell histology, tumor necrosis and cavitation, and disease location close to major blood vessels. CONCLUSION Bevacizumab in combination with carboplatin and paclitaxel improved overall response and time to progression in patients with advanced or recurrent non-small-cell lung cancer. Patients with nonsquamous cell histology appear to be a subpopulation with improved outcome and acceptable safety risks.

Bevacizumab in combination with fluorouracil and leucovorin: an active regimen for first-line metastatic colorectal cancer.

PURPOSE In a phase III trial, combining bevacizumab (BV)--a recombinant, humanized, monoclonal antibody targeting vascular endothelial growth factor--with irinotecan, bolus fluorouracil (FU), and leucovorin (LV; IFL) increased survival compared with IFL alone in first-line treatment of patients with metastatic colorectal cancer (CRC). Results for the parent study of IFL/BV versus IFL/placebo are reported elsewhere. Here, we describe efficacy and safety results for the third patient cohort in this trial, who received BV combined with FU/LV, and compare them with results for concurrently enrolled patients who received IFL. METHODS Patients (N = 923) were randomly assigned to receive IFL/placebo (control), IFL/BV, or FU/LV/BV. Bevacizumab (Avastin; Genentech Inc, South San Francisco, CA) 5 mg/kg was administered intravenously every 2 weeks. Before an interim analysis confirmed acceptable safety for IFL/BV, 313 patients were concurrently randomly assigned to these three arms; after this analysis, the FU/LV/BV arm was discontinued. RESULTS Median overall survivals were 18.3 and 15.1 months with FU/LV/BV (n = 110) and IFL/placebo (n = 100), respectively. Median progression-free survivals were 8.8 and 6.8 months, respectively. Overall response rates were 40.0% and 37.0%, and median response durations were 8.5 and 7.2 months, respectively. Adverse events consistent with those expected from FU/leucovorin- or IFL-based regimens were seen, as were modest increases in hypertension and bleeding in the bevacizumab arm, which were generally easily managed. CONCLUSION The FU/LV/BV regimen seems as effective as IFL and has an acceptable safety profile. FU/LV/BV is an active alternative treatment regimen for patients with previously untreated metastatic CRC.

Impact of Vascular Endothelial Growth Factor-A Expression, Thrombospondin-2 Expression, and Microvessel Density on the Treatment Effect of Bevacizumab in Metastatic Colorectal Cancer

PURPOSE Bevacizumab is a monoclonal antibody to vascular endothelial growth factor-A (VEGF). In the pivotal trial in metastatic colorectal cancer (mCRC), addition of bevacizumab to first-line irinotecan, fluorouracil, and leucovorin (IFL) significantly prolonged median survival. The aim of these retrospective subset analyses was to evaluate VEGF, thrombospondin-2 (THBS-2), and microvessel density (MVD) as prognostic factors and/or predictors of benefit from bevacizumab. PATIENTS AND METHODS In the pivotal trial, 813 patients with untreated mCRC were randomly assigned to receive IFL plus bevacizumab or placebo. Of 312 tissue samples collected (285 primaries, 27 metastases), outcome data were available for 278 (153 bevacizumab, 125 placebo). Epithelial and stromal VEGF expression were assessed by in situ hybridization (ISH) and immunohistochemistry on tissue microarrays and whole sections. Stromal THBS-2 expression was examined by ISH on tissue microarrays. MVD was quantified by Chalkley count. Overall survival was associated with these variables in retrospective subset analyses. RESULTS In all subgroups, estimated hazard ratios (HRs) for risk of death were < 1 for bevacizumab-treated patients regardless of the level of VEGF or THBS-2 expression or MVD. Patients with a high THBS-2 score showed a nonsignificant improvement in survival following bevacizumab treatment (HR = 0.11; 95% CI, 0.02 to 0.51) compared to patients with a low score (HR = 0.65; 95% CI, 0.41 to 1.02); interaction analysis P = .22. VEGF or THBS-2 expression and MVD were not significant prognostic factors. CONCLUSION These exploratory analyses suggest that in patients with mCRC addition of bevacizumab to IFL improves survival regardless of the level of VEGF or THBS-2 expression, or MVD.

ESTABLISHING EQUIVALENCE BY SHOWING THAT A SPECIFIED PERCENTAGE OF THE EFFECT OF THE ACTIVE CONTROL OVER PLACEBO IS MAINTAINED

We propose a procedure for establishing equivalence that determines whether a specified percentage of the treatment effect of a known active agent over placebo is maintained. This procedure accounts for the error in the estimates from the historical studies of the known active agent and placebo as well as the error in the estimates from the equivalence study of the new test treatment versus the active control. After the procedure is presented, it is compared analytically to a procedure in which the equivalence boundary is estimated from historical data and then used with a one-sided test. We address sample size requirements for the proposed equivalence procedure. We also illustrate the use of the proposed procedure with an example from the clinical area of thrombolytic therapy in acute myocardial infarction.

Bevacizumab does not increase bleeding in patients with metastatic colorectal cancer receiving concurrent anticoagulation

3528 Background. Bevacizumab (BV, Avastin), a recombinant, humanized monoclonal antibody directed against VEGF, improves survival in combination with chemotherapy for first line treatment of metastatic colorectal cancer (CRC). The addition of BV to irinotecan/5-FU/leucovorin (IFL) resulted in a significant improvement in survival compared with IFL alone (p=0.00004; median survival increased from 15.6 to 20.3 months). Experience with BV in phase II studies, particularly in NSCLC, suggested that bleeding might be a safety signal. Therefore, patients receiving full-dose anticoagulation (FDAC) were excluded from the phase III CRC study. This analysis assesses the outcomes of patients with metastatic CRC who had a thrombotic event while receiving study treatment (BV or placebo), and remained on study while receiving FDAC. METHODS Patients with previously untreated metastatic CRC were randomized to IFL plus placebo (Arm 1) versus IFL plus BV (5 mg/kg; Arm 2). Thrombotic complications, including deep venous thrombosis, pulmonary embolus, and arterial events, and treatment were analyzed. FDAC was achieved with warfarin. RESULTS The overall rate of arterial and venous thromboembolic events was 16.2% in Arm 1 and 19.4% in Arm 2. Arterial events, such as myocardial infarction and stroke, were rare: 1% Arm 1 and 3.3% in Arm 2. Venous event rates were similar; 15.2% in Arm 1, 16.6% in Arm 2. Of those patients with a thrombotic event treated with FDAC, 30 patients (54.5%) in Arm 1 and 53 patients (82.8%) in Arm 2 continued on study drug. Grade 3/4 bleeding rates for those on FDAC and study drug are shown in Table 1. CONCLUSION Use of concomitant full-dose anticoagulation therapy with Bevacizumab in combination with chemotherapy does not appear to increase the risk of hemorrhagic complications in patients with metastatic colorectal cancer. [Figure: see text] [Table: see text].

Bevacizumab plus irinotecan/5-FU/leucovorin for treatment of metastatic colorectal cancer results in survival benefit in all pre-specified patient subgroups

3617 Background. Bevacizumab [Avastin (BV)], a recombinant, humanized monoclonal antibody against VEGF, has demonstrated efficacy and safety when added to irinotecan/5-fluorouracil/leucovorin (IFL) chemotherapy as first-line therapy for metastatic colorectal cancer (CRC). The results of the primary analysis of a randomized phase III trial demonstrated that the addition of BV to IFL resulted in significant improvement in survival compared with IFL alone (p=0.00004; median survival increased from 15.61 to 20.34 months). Additional sub-group analyses were performed to evaluate the effects of baseline risk factors on survival. METHODS The effects of demographic and baseline prognostic characteristics and selected baseline laboratory values on duration of survival, PFS, and objective response rate were examined. Patient characteristics included baseline ECOG performance status, number of organ sites with metastases, site of primary tumor, age, sex, race, prior adjuvant chemotherapy, prior radiotherapy, duration of metastatic disease, years since diagnosis of CRC, baseline sum of longest diameters of target lesions, baseline levels of albumin, alkaline phosphatase, and LDH. Descriptive summaries of duration of survival and PFS were produced for each level of the categorical variables listed above for each treatment arm. These descriptive summaries consisted of the hazard ratio from unstratified Cox regression and Kaplan-Meier estimates of median time to the event. RESULTS 815 patients were randomized to receive either IFL + placebo or IFL + BV. A survival benefit in the IFL/BV arm was seen across all patient subgroups compared with the IFL/placebo arm (see table). CONCLUSION The addition of Bevacizumab to IFL chemotherapy results in prolonged survival in multiple sub-groups. [Figure: see text] [Table: see text].

Health-Related Quality of Life Impact of Bevacizumab When Combined with Irinotecan, 5-Fluorouracil, and Leucovorin or 5-Fluorouracil and Leucovorin for Metastatic Colorectal Cancer

PURPOSE To compare the time to deterioration in health-related quality of life (HRQoL) in patients with previously untreated metastatic colorectal cancer receiving a 5-fluorouracil (5-FU)-based chemotherapy regimen with or without the addition of bevacizumab (BV) in two randomized, placebo-controlled studies. PATIENTS AND METHODS Prespecified HRQoL endpoints in the phase II (Study 2192) and phase III (Study 2107) studies were time to deterioration in HRQoL, measured by the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) Colorectal Cancer Subscale (CCS), Trial Outcome Index (TOI-C), and FACT-C total score. Time to deterioration in HRQoL was evaluated for patients with baseline and postbaseline assessments, using the stratified log-rank test. RESULTS In the pivotal phase III trial, HRQoL baseline and postbaseline CCS scores were available for 127 patients receiving irinotecan, 5-FU, and leucovorin (LV) (IFL) and 122 patients receiving IFL plus BV. The time to deterioration in HRQoL did not differ significantly between treatment groups as measured by the CCS, TOI-C, or FACT-C total score. In the phase II study, baseline and postbaseline CCS scores were available for 77 and 89 patients receiving 5-FU and LV and 5-FU and LV plus BV, respectively. In that study, the time to deterioration in HRQoL was similar between groups as measured by the CCS and TOI-C scores, but was significantly longer in the 5-FU and LV plus BV arm than in the 5-FU and LV plus placebo arm for the FACT-C total score. CONCLUSIONS When added to 5-FU chemotherapy, BV significantly prolonged overall survival and progression-free survival without compromising HRQoL.

Statistical modeling of dose-response relationships in clinical trials--a case study.

This paper presents a model-based assessment of the relationship between the dose of a test treatment and response. The data set used in the analysis describes the results of two clinical trials that were designed to assess the dose-response relationship of a test treatment. The models described in the paper are fit using weighted regression as implemented by the SAS procedure CATMOD. Relationships between weighted regression and other similar procedures are discussed.

Abstract 1727: Circulating Tumor Cells (CTCs) in patients with extensive stage small cell lung cancer and their association with clinical outcome

Background: The NOTCH pathway has been identified as a key therapeutic pathway in SCLC. Tarextumab (TRXT, anti-Notch2/3, OMP-59R5) is a fully human monoclonal antibody that targets the Notch2 and Notch3 receptors. PINNACLE is a Phase 1b/2 trial of TRXT in combination with etoposide and platinum therapy (EP) in patients with untreated extensive stage small cell lung cancer (ES-SCLC). Baseline CTCs and post treatment changes in CTCs have previously been shown to predict the response to chemotherapy in SCLC. CTCs may also serve as pharmacodynamic biomarkers. Here we describe a study of baseline and longitudinal CTCs in ES-SCLC patients from the PINNACLE phase 1b trial (clinicaltrials.gov:NCT01859741). Materials and methods: CTCs, CTC clusters, apoptotic CTCs and N-Cadherin+ CTCs were identified and enumerated from patient blood samples using Epic Sciences CTC technology. Baseline CTCs from 26 patients were correlated with clinical outcome: progression-free survival (PFS), overall survival (OS) and best overall response, as well as metastatic status. A mixed effects model was used to investigate the post treatment changes in CTCs among the dose groups. Association of CTCs with PFS/OS and best overall response, including CTCs at each time point, as well as temporal changes of CTC status, were studied. Multivariate analysis was performed to identify CTC numbers in a subset of time points to correlate with response to treatment. Results: CTCs were present in 81% of the patients (21/26). CTC clusters and apoptotic CTCs were detected in 38% and 77% of the patients, respectively. At baseline, CTC counts ≥ 5/mL were significantly associated with poor OS (p=0.04). There was a trend that the presence of CTC clusters was associated with worse OS. With a cut-off of 3.4/mL, apoptotic CTCs showed a trend in association with overall survival. CTC numbers in patients with liver metastasis were significantly higher than in patients without liver metastasis. CTCs were also found to be correlated significantly with the number of metastatic sites. When measuring at Day 7 post dosing, CTC numbers were significantly decreased. Conclusions: Our findings suggest that CTCs are frequently detectable in patients and are a prognostic factor in ES-SCLC. CTCs decrease with TRXT and platinum-based chemotherapy. Updated results will be presented. CTCs will be further evaluated in the phase 2 portion of the PINNACLE trial. Citation Format: Chun Zhang, Ryon Graf, Adam Jendrisak, Amanda K. Anderson, Priscilla Ontiveros, Sarah Orr, Anne Chiang, David Spigel, Charles Rudin, Eric Holmgren, Jakob Dupont, Gretchen Argast, Leonardo Faoro, Lei Zhou, John Lewicki, Ann M. Kapoun. Circulating Tumor Cells (CTCs) in patients with extensive stage small cell lung cancer and their association with clinical outcome [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1727. doi:10.1158/1538-7445.AM2017-1727

Making Independence Work: Monitoring the Bevacizumab Colorectal Cancer Clinical Trial

Genentech’s phase III study of colorectal cancer aimed to show that administration of bevacizumab, its recombinant human anti-vascular endothelial growth factor antibody, to patients with metastatic colorectal cancer would reduce mortality. The four-member DMC was responsible for reviewing real-time safety data, selecting the experimental arm of the study at an interim analysis, and assessing efficacy at a second interim analysis. Genentech and the entire study team remained blinded to treatment allocation during the course of the trial. The study, which proceeded to its planned end, showed an estimated hazard ratio for death of 0.66 (p < 0.001). On the basis of this study, the FDA approved bevacizumab for patients with metastatic colon cancer. This example shows how a DMC can make complicated decisions and recommendations even when neither it nor the statisticians reporting to it participate in any other way with the conduct of the study.