Patient case: 64-year-old male with head and neck squamous cell carcinoma; genetic feature: CDKN2A

Clinical trial: Study of Albumin Bound-Paclitaxel for Treatment of Recurrent or Metastatic Head and Neck Cancer With Cetuximab

Summary: Primary Objective: To assess the overall response rate (complete and partial response) to Abraxane in patients with recurrent or metastatic head and neck cancer with the addition of Cetuximab on disease progression.
  Approximately 40,000 new cases of head and neck cancer are diagnosed annually in the United States (Jemal et al, 2003), and over 30% of these patients are expected to die of their malignancy. Squamous cell carcinoma accounts for more than 90% of head and neck cancer cases. Although metastatic disease at the time of diagnosis is rather uncommon, and despite aggressive use of up-front concurrent radiation and cisplatin-based chemotherapy, approximately 20% of the patients will develop metastases. Patients with recurrent or metastatic squamous cell carcinoma of the head and neck (SCCHN) have a poor prognosis
  A subsequent randomized study conducted by ECOG (E1393) compared high-dose paclitaxel (200 mg/m2) as a 24-hour infusion plus cisplatin 75 mg/m2 with G-CSF support, to low dose paclitaxel (135 mg/m2) as a 24-hour infusion, plus cisplatin 75 mg/m2 (Forastiere et al, 2001). Patients with newly diagnosed metastatic or recurrent squamous cell carcinoma of the head and neck, excluding nasopharyngeal primaries were eligible. No prior treatment for recurrent/metastatic disease was allowed, but patients could have received chemotherapy as a part of the initial curative therapy that should have been completed 6 months prior to study.
  No statistically significant difference could be demonstrated either in response rates or survival between the two arms (Murphy et al, 2001). This study, however, indicated that paclitaxel, a member of the taxane class of anti-tumor agent, is active in head and neck cancer.
  New agents to treat head and neck cancer need to be investigated. Abraxane, an albumin-bound formulation of paclitaxel has shown significant single-agent activity in breast cancer and in head and neck cancer. Recently, Abraxane has approved for use in metastatic breast cancer. Given previous randomized phase III trials indicated single agent chemotherapy fared as well as combination chemotherapy regimen in terms of overall survival, this novel formulation should be actively investigated in head and neck cancer.

Detailed description: OBJECTIVES
  Primary Objective: To assess the overall response rate (complete and partial response) to Abraxane in patients with recurrent or metastatic head and neck cancer with the addition of Cetuximab on disease progression.
  Secondary Objectives: 1. To assess the frequency and severity of toxicities associated with this treatment. 2. To evaluate overall survival and progression-free survival in patients with recurrent or metastatic head and neck cancer treated with single agent Abraxane. 3.To assess whether the addition of Centuximab will re-sensitize head and neck cancer to Abraxane after progression on single agent Abraxane.
  BACKGROUND AND RATIONALE
  Approximately 40,000 new cases of head and neck cancer are diagnosed annually in the United States (Jemal et al, 2003), and over 30% of these patients are expected to die of their malignancy. Squamous cell carcinoma accounts for more than 90% of head and neck cancer cases. Although metastatic disease at the time of diagnosis is rather uncommon, and despite aggressive use of up-front concurrent radiation and cisplatin-based chemotherapy, approximately 20% of the patients will develop metastases. Patients with recurrent or metastatic squamous cell carcinoma of the head and neck (SCCHN) have a poor prognosis. Their median survival is about 6-8 months. Selected patients with locally recurrent disease can be treated with a curative intent with locoregional therapies, such as salvage surgery or radiation (De Crevoisier et al, 1998); however the majority of these patients die of their disease. Despite high response rates, combination chemotherapy has not been shown to produce a survival benefit compared to single agents in randomized trials in patients with recurrent/metastatic head and neck cancer (Forastiere et al, 1992; Jacobs et al, 1992; Clavel et al, 1994). A phase III randomized study conducted by SWOG compared cisplatin-based combination chemotherapy to single agent methotrexate (Forastiere et al, 1992). The objective response rates were 32%, 21%, and 10%, for cisplatin/5-Fluorouracil (5-FU), carboplatin/5-FU, and single methotrexate, respectively, but the median overall survival was not statistically different between the three arms (ranged between 5 to 6.6 months). Moreover, toxicity was increased with combination therapy, especially with the cisplatin-based regimen. Another randomized study conducted in the US demonstrated a significantly higher response rate of 32% for the combination of cisplatin and 5-FU versus 17% and 13% for single agent cisplatin and 5-FU, respectively (Jacobs et al, 1992). However, the median survival of all patients was 5.7 months, with no difference between the three arms. Hematologic toxicity was increased in the combination arm.
  A subsequent randomized study conducted by ECOG (E1393) compared high-dose paclitaxel (200 mg/m2) as a 24-hour infusion plus cisplatin 75 mg/m2 with G-CSF support, to low dose paclitaxel (135 mg/m2) as a 24-hour infusion, plus cisplatin 75 mg/m2 (Forastiere et al, 2001). Patients with newly diagnosed metastatic or recurrent squamous cell carcinoma of the head and neck, excluding nasopharyngeal primaries were eligible. No prior treatment for recurrent/metastatic disease was allowed, but patients could have received chemotherapy as a part of the initial curative therapy that should have been completed 6 months prior to study. Tow hundred and ten patients were randomized between the 2 arms. No significant difference in outcome was observed. The response rate was 35% vs 36% and the median survival was 7.6 vs 6.8 months, in the high-dose vs low-dose paclitaxel arms respectively. Patients with metastatic disease performed worse in terms of survival. Previously untreated patients achieved a higher response rate of 58% compared to a response rate of 32% observed in patients who have failed prior curative therapies. Substantial toxicities were observed in this trial. Grade 4 neutropenia was seen in 61-71% of patients and febrile neutropenia with hospitalization occurred in 27-39% of patients. The toxic death rate was 10% (12% vs 9%) (Forastiere et al, 2001). It was concluded that the 24-hour paclitaxel infusion was associated with unacceptable toxicity when combined with cisplatin. Instead, a 3-hour paclitaxel infusion combined with cisplatin was advanced to further testing. A more recent randomized trial conducted by ECOG (E1395) compared the combination of paclitaxel 175 mg/m2 as a 3-hour infusion and cisplatin 75 mg/m2 to a standard cisplatin and 5-FU regimen. No statistically significant difference could be demonstrated either in response rates or survival between the two arms (Murphy et al, 2001). This study, however, indicated that paclitaxel, a member of the taxane class of anti-tumor agent, is active in head and neck cancer.
  Recently, another member anti-tumor class of taxane, Docetaxel (Taxotere) has been shown to be active in advanced head and neck cancer. In a randomized phase III trial of intensification of induction chemotherapy followed by radiation, the addition of docetaxel to the induction regimen of cisplatin and 5-fluoruracil when compared to cisplatin and 5-fluoruracil alone resulted in a 3-month improvement in overall survival (Vermorken et al, 2004). Thus both members of the taxane family, paclitaxel and docetaxel, have proven anti-tumor activity in head and neck cancer.
  New agents to treat head and neck cancer need to be investigated. Abraxane, an albumin-bound formulation of paclitaxel has shown significant single-agent activity in breast cancer and in head and neck cancer. Recently, Abraxane has approved for use in metastatic breast cancer. Given previous randomized phase III trials indicated single agent chemotherapy fared as well as combination chemotherapy regimen in terms of overall survival, this novel formulation should be actively investigated in head and neck cancer.
  Abraxane in solid tumor The clinical database included two single arm studies enrolling a total of 106 patients and one multi-center randomized trial. The multi-center trial was conducted in 460 patients with metastatic breast cancer who were randomized to receive either Abraxane 260 mg/m² administered as a 30-minute infusion or paclitaxel 175 mg/m² given over 3 hours. Sixty-four percent of patients had impaired performance status (ECOG 1 or 2) at study entry. Seventy-nine percent had visceral metastases and 76% had > 3 sites of metastases. Fifty-nine percent of patients had received one or more prior chemotherapy regimens, and 77% had received an anthracycline-containing regimen. The objective response rate verified by central review was 21.5% (95% CI: 16.2% to 26.7%) for Abraxane compared to 11.1% (95% CI: 6.9% to 15.1%) for paclitaxel (p=0.003). The conclusion of this phase III trial is that Abraxane had statistically significant higher target lesion response rate (the trial primary endpoint) (O'Shaughnessy et al, 2003).
  On January 7, 2005 the U. S. Food and Drug Administration approved Abraxane (albumin-bound paclitaxel) for treatment of breast cancer after failure of combination chemotherapy for metastatic disease or relapse within 6 months of adjuvant chemotherapy based on the statistically significant superior response rate from the randomized phase III trial mentioned above. The recommended dose of Abraxane is 260 mg/m² administered intravenously over 30 minutes every 3 weeks. No premedication to prevent hypersensitivity reactions is required prior to Abraxane administration.
  Abraxane in Head and Neck Cancer The role of Abraxane in Head and Neck cancer has been explored in a phase I study (Damascelli et al, 2001). Abraxane was injected intra-arterially (carotid artery) in 31 patients with advanced Head and Neck cancer. The maximum tolerated dose in a single administration was determined to be 270 mg/m2 which is very close to the approved dose of 260 mg/m2. Three patients achieved complete response and 19 patients achieved partial response for a combined response rate of 76%. Side effects are very tolerable including three patients with grade 4 neutropenia, and grade 2 non-hematologic toxicities included: keratitis [1 patient], skin toxicity [5 patients], neurologic toxicities [4 patients], and flu-like syndrome [7 patients]. However, intra-arterial administration is technically challenging with potential serious side effects, cumbersome and not the conventional way of delivering chemotherapy. In another phase 1 study of Abraxane in advanced solid tumors, 3 out of 5 patients with nasopharyngeal carcinoma had responses lasting 25, 18 and 13+ weeks (Teng et al, 2005).
  Given the hint of anti-tumor activity of Abraxane in advanced Head and Neck cancer from the above mentioned studies, this current study will seek to determine the efficacy of Abraxane in recurrent or metastatic head and neck cancer at the dose of 260 mg/m2 given intravenously every 3 weeks in a systemic manner. Abraxane is not FDA approved in the treatment of this study disease; however, it is approved for patient use in the treatment of advanced breast cancer that have failed traditional therapy.
  Abraxane is a natural substance and is far more superior to conventional chemistry. Abraxane is an effective treatment for aggressive cancers because it adversely affects the process of cell division by preventing this restructuring. Other cells are also affected adversely, but since cancer cells divide much faster than non-cancerous cells, they are far more susceptible to Abraxane treatment, thus, the safety of the drug is no more or less then other chemotherapy regimens.
  Human albumin will be used along with the Abraxane.
  Description of Cetuximab (IMC-225) (Erbitux) (NSC-714692) Cetuximab, a chimerized antibody of the IgG1 subclass was originally derived from a mouse myeloma cell line. The chimerization resulted in an antibody with binding affinity to epidermal growth factor receptors (EGFR) greater than the natural ligand epidermal growth factor (EGF). Cetuximab blocks binding EGF and transforming growth factor (TGFa) to EGFR and inhibits ligand-induced activation of this tyrosine kinase receptor. Cetuximab also stimulates EGFR internalization, effectively removing the receptor from the cell surface for interaction with ligand.
  Safety Precaution Cetuximab therapy should be used with caution in patients with known hypersensitivity to Cetuximab, murine proteins, or any component of this product.
  Administration of Cetuximab: In an effort to prevent a hypersensitivity reaction, all patients should be premedicated with dexamethasone 20 mg by IV and diphenhydramine hydrochloride 50 mg by IV given 30-60 minutes prior to the infusion of cetuximab.
  The initial/loading dose of cetuximab is 400 mg/m2 IV administered over 120 minutes. Patients must be continuously observed during the infusion for signs of anaphylaxis and standard resuscitative meds should be in close proximity. Vital signs should be taken prior to, during, post and 1-hour post infusion for the initial dose. For subsequent infusions, vital signs are recommended to be taken to and 1-hour post infusion.
  Following the loading dose, patients will receive weekly treatment with cetuximab IV over 60 minutes. The infusion rate of cetuximab should never exceed 5 mL/min. Patients should be closely monitored for treatment-related adverse events, especially hypersensitivity reactions, during the infusion and post-infusion.
  Cetuximab is used for the treatment of patients with advanced head and neck cancer that has spread to other parts of the body.

Eligibility: Inclusion Criteria:
  -  Each of the criteria in the following section must be met in order for a patient to be eligible for registration.
  -  Patients should have hemoglobin > 9 g/dL; patients may be transfused to achieve this level of hemoglobin.
  -  Alkaline phosphatase. Normal [26-110] IU/L
  -  Bone scan, if clinically indicated. < 2 x institutional upper limit of normal.
  -  Patients should not have known AIDS or HIV-1 associated complex or known history of immune or immunodeficiency disorders because of unknown or potential interactions of anti-retroviral therapy with Abraxane. Additionally, the severely depressed immune system found in HIV-infected patients and the possibility or premature death would compromise study objectives.
  -  Patients should not have active infection.
  -  Patients should not have psychological, familial, sociological, or geographical conditions that do not permit medical follow-up and compliance with study protocol.
  -  Patients should not have any immediate life-threatening complications of their malignancies.
  -  All patients must have histologically or cytologically confirmed carcinoma of the head and neck region. Primary tumor sites include: lip and oral cavity, major salivary glands, pharynx (oropharynx, nasopharynx, hypopharynx), or larynx (supraglottis, glottis, subglottis), nasal cavity and paranasal sinuses, and thyroid.
  -  Patients must have metastatic or locally recurrent squamous cell carcinoma of the head and neck. Patients with locoregional disease must be considered incurable by means of locoregional therapy.
  -  All sites of disease must be assessed and designated as measurable or non-measurable disease as documented by CT, MRI, X-ray physical exam or nuclear exam. All measurable and non-measurable disease must be assessed within 28 days prior to registration.
  -  Patients may have prior chemotherapy for recurrent/metastatic disease. However, all chemotherapy must be completed at least 21 days prior to scheduled start of Abraxane.
  -  Patients must have adequate bone marrow reserve as documented by ANC >=1,500 ul and platelets > 100,000/ ul obtained within 14 days prior to registration.
  -  Patients must have adequate hepatic as documented by serum bilirubin < 1.5 x the institutional upper limit of normal. These tests must be obtained within 14 days prior to registration.
  -  All patients must be 18 years of age or older.
  -  Patients must have a Zubrod performance of 0-3.
  -  Patients must not have prior therapy with Abraxane; this will enable the researchers to assess the patient response rate in patients that have not been treated with Abraxane. If any patient has been treated with Abraxane outside of this study and they are responding the patient would probably continue to be treated as such in their best interest. Patients who have been treated with other taxanes (not Abraxane) previously, can still respond to this new formulation.
  -  Patients with any evidence of active or uncontrolled infection, recent myocardial infection, unstable angina, or life-threatening arrhythmia are not eligible. Potential subjects will be screened for any pre-existing heart conditions.
  -  Patients with baseline grade 3 peripheral neuropathy are not eligible.
  -  Patients with known brain metastasis are not eligible. However, brain-imaging studies are not required for eligibility if the patient has no neurological signs or symptoms. If brain-imaging studies are performed, they must be negative for disease.
  -  Patients who are pregnant are not eligible. There is not enough medical information to know what the risks might be to a breast-fed infant or to an unborn child carried by a mother who is taking part in the study. If patient is of childbearing age, sexual partner and the patient must use proven birth control measures while on the study. Effective methods of contraception are oral contraceptives, diaphragm, condom, contraceptive foam or male/female sterilization. If the patient is breast-feeding, they must stop breast-feeding. If the patient is still having period and can become pregnant, a pregnancy test must be done before taking part in the study. The pregnancy test must be taken 7 days prior to taking part in the study. If the pregnancy test is positive, the patient will not be able to take part in the study.
  -  Sample size justification: On average about 75 head and neck cancer patients are treated at UCI annually. One third of these patients will eventually require and receive chemotherapy for the study disease. Therefore an accrual period of 2 years is expected to accrue a total of 44 patients.
  -  It is assumed that the Abraxane therapy will be of no further interest if the true confirmed response rate is < 5%, but will warrant further study if the response rate is > 20%. Utilizing a two-stage design and statistical tools from the Southwest Oncology Group (SWOG) [http://www.swogstat.org/statoolsout.html] and assuming a power of 90% and a significance level of 5% for sample size calculation, for the first stage of the study, a total of 20 eligible patients will be enrolled. The trial will proceed to the second stage if at least 1 patient achieves a partial or complete response to Abraxane. Given an estimated 10% drop-out rate, 22 patients will be enrolled at stage 1 and 22 patients will be enrolled in stage 2 for a total number of 44 patients enrolled. If a total of at least 5 patients achieve a partial or complete response to Abraxane, the regimen will be considered as worthy of further study.

Relevance to patient case: not relevant