Patient case: 72-year-old male with lung adenocarcinoma; genetic feature: EZR-ROS1 fusion

Clinical trial: Bemcentinib (BGB324) in Combination With Pembrolizumab in Patients With Advanced NSCLC

Summary: This is an open-label, multi-center, single arm, phase II study to assess the anti-tumor activity and safety of bemcentinib when given in combination with pembrolizumab in up to 77 patients with previously treated, advanced adenocarcinoma of the lung. The study will enroll two cohorts of patients with previously treated, advanced adenocarcinoma of the lung: Cohort A will consist of patients who received a maximum of 1 prior line of platinum-containing chemotherapy and no prior immunotherapy of any kind. Cohort B will consist of patients with a maximum of 2 prior lines whereas the most recent line must have included a PD-(L)1 inhibitor. The primary objective is objective response rate.


Eligibility: Inclusion Criteria:
  1. Provision of signed informed consent.
  2. Male and non-pregnant females who are aged 18 years or older at the time of provision of informed consent.
  3. Histopathologically or cytologically documented Stage IV adenocarcinoma non-small cell lung cancer (NSCLC). Note: Patients with a mixed histology including a significant area of adenocarcinoma histology are eligible.
  4. Cohort A only: Has disease progression on or after a prior platinum-containing chemotherapy. Note: Patients with Epidermal growth factor receptor (EGFR) mutations or ALK genomic rearrangements must have documented disease progression on at least one licensed therapy for these indications and may not have received platinum-containing chemotherapy.
  5. Cohort B only:
  1. Has received a maximum of two prior lines of therapy in the advanced setting, with the most recent treatment regimen containing an anti-PD-(L)1-therapy (as monotherapy or in combination).
  2. Must have had disease control (SD, PR or CR) for at least 6 months on most recent treatment containing at least 2 doses of anti-PD-(L)1-therapy.
  3. Has disease progression when entering screening and this must be within 12 weeks of last dose of most recent treatment containing an anti-PD-(L)1 therapy. Progression should have been confirmed in one of the following ways: (i) Having had two scan assessments completed at least 4 weeks apart, both showing progression according to RECIST 1.1 or (ii) having had one scan assessment completed showing disease progression according to standards used for previous therapy combined with rapid disease progression / clinical progression.
  6. Measurable disease as defined by RECIST 1.1 on computed tomography (CT) or magnetic resonance imaging (MRI) and as determined by the site study team. Tumor lesions situated in a previously irradiated area are considered measurable if progression has been demonstrated in such lesions.
  7. Provision of suitable tumor tissue for the analysis of Axl kinase expression and PD-L1 expression. Suitable tumor tissue must consist of a minimum of newly acquired (fresh) tumor tissue sample (as a FFPE block), together with either further newly acquired tumor tissue (i.e. further FFPE block) or an archival tumor tissue sample (as a further FFPE block or further 10 unstained slides). See Section 5.3.13 for further details.
  8. Eastern Cooperative Oncology Group (ECOG) performance score 0 or 1.
  9. Life expectancy of at least 3 months.
  10. Adequate organ function confirmed at Screening within 10 days of treatment initiation - as evidenced by:
  1. Platelet count ≥100,000 /mm3;
  2. Hemoglobin ≥9.0 g/dL (≥5.6 mmol/L);
  3. Absolute neutrophil count (ANC) >1,500 /mm3;
  4. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤2.5 times the upper limit of normal (ULN), or ≤5 times the ULN for patients with liver metastases;
  5. Total bilirubin ≤1.5 times the ULN.
  6. Creatinine ≤1.5 times the ULN or calculated creatinine clearance 60 mL/min (by Cockcroft Gault formula);
  7. International Normalized Ratio (INR) or Prothrombin Time (PT) ≤1.5 times the ULN and Activated Partial Thromboplastin Time (aPTT) ≤1.5 times the ULN. Note: If patient is receiving anticoagulant therapy, then PT or Partial thromboplastin time (PTT) must be within therapeutic range of intended use of anticoagulants;
  11. Female patients of childbearing potential must have a negative urine or serum pregnancy test within 72 hours prior to the first dose of study treatment. If urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required.
  12. Patients (both male and female) of reproductive potential must be willing to practice highly effective methods of contraception throughout the study and for 120 days after the last dose of study medication. Abstinence is acceptable if this is the usual lifestyle for the patient. Female patients are considered NOT of childbearing potential if they have a history of surgical sterility or evidence of post-menopausal status defined as any of the following:
  1. ≥45 years of age and has not had menses for more than 1 year;
  2. Amenorrheic for >2 years without a hysterectomy and oophorectomy and a follicle stimulating hormone (FSH) value in the postmenopausal range upon Screening evaluation;
  3. Post hysterectomy, oophorectomy or tubal ligation. Documented hysterectomy or oophorectomy must be confirmed with medical records of the actual procedure or confirmed by an ultrasound. Tubal ligation must be confirmed with medical records of the actual procedure.
  13. Have resolution of toxic effect(s) of the most recent prior chemotherapy to Grade 1 or less (except alopecia). If the patient received major surgery or radiation therapy of > 30 Gy, they must have recovered from the toxicity and/or complications from the intervention.
  Exclusion Criteria:
  1. Has disease suitable for local therapy administered with curative intent.
  2. Has received more than 1 prior line of chemotherapy for advanced or metastatic adenocarcinoma of the lung. Cohort B: Has received more than two prior lines of therapy for advanced or metastatic adenocarcinoma of the lung. Note: Patients may have received additional prior radiotherapy or chemotherapy in the adjuvant setting, providing it was completed at least 6 months prior to start of study treatment.
  3. Cohort A only: Has received prior therapy with an immunomodulatory agent.
  4. Has a known additional malignancy that is progressing or requires active treatment. Note: Exceptions include basal cell carcinoma of the skin, squamous cell carcinoma of the skin that has undergone potentially curative therapy or in situ cervical cancer.
  5. Has known active central nervous system (CNS) metastases and/or carcinomatous meningitis. Note: Patients with previously treated brain metastases may participate provided they are stable (without evidence of progression by imaging (using the identical modality for each assessment, either MRI or CT scan) for at least 4 weeks prior to the first dose of trial treatment and any neurological symptoms have returned to baseline), have no evidence of new or enlarging brain metastases, and are not using steroids for at least 7 days prior to trial treatment.
  6. History of the following cardiac conditions:
  1. Congestive cardiac failure of >Grade II severity according to the NYHA (Appendix C: defined as symptomatic at less than ordinary levels of activity).
  2. Ischemic cardiac event including myocardial infarction within 3 months prior to first dose.
  3. Uncontrolled cardiac disease, including unstable angina, uncontrolled hypertension (i.e. sustained systolic BP >160 mmHg or diastolic BP >90 mmHg), or need to change medication due to lack of disease control within 6 weeks prior to the provision of consent.
  4. History or presence of sustained bradycardia (≤55 BPM), left bundle branch block, cardiac pacemaker or ventricular arrhythmia. Note: Patients with a supraventricular arrhythmia requiring medical treatment, but with a normal ventricular rate are eligible.
  5. Family history of long QTc syndrome; personal history of long QTc syndrome or previous drug-induced QTc prolongation of at least Grade 3 (QTc >500ms).
  7. Abnormal left ventricular ejection fraction on echocardiography or MUGA (less than the lower limit of normal for a patient of that age at the treating institution or <45%, whichever is lower).
  8. Current treatment with any agent known to cause Torsades de Pointes which cannot be discontinued at least five half-lifes or two weeks prior to the first dose of study treatment.
  9. Screening 12-lead ECG with a measurable QTc interval according to Fridericia's correction >450 ms.
  10. Is currently participating and receiving study therapy or has participated in a study of an investigational agent and received study therapy or used an investigational device within 4 weeks of the first dose of study treatment.
  11. Received chemotherapy or targeted small molecule therapy or radiation therapy within 2 weeks prior to starting study treatment or who has not recovered (i.e. ≤Grade 1 at baseline) from AEs due to a previously administered agent. Note: Patients with ≤Grade 2 alopecia are an exception to this criterion. If the patient received major surgery, they must have recovered adequately from the toxicity and/or complications from the intervention prior to starting therapy.
  12. Received an anti-cancer monoclonal antibody (mAb) within 4 weeks prior to the first dose of study treatment or who has not recovered (i.e. ≤Grade 1 or baseline) from AEs due to agents administered more than 4 weeks earlier.
  13. Major surgery within 28 days prior to start of study treatment and failure to have recovered adequately from the toxicity and/or complications from the intervention prior to the first dose of study treatment. Note: Major surgery does not include procedures for insertion of venous catheters or biopsies.
  14. Received transfusion of blood products (including platelets or red blood cells) or administration of colony stimulating factors (including G-CSF, GM-CSF or recombinant erythropoetin) within 4 weeks prior to the first dose of study treatment. Note: Patients receiving stable dose of growth factors with a haemoglobin value that meets Inclusion Criterion 9b may be included.
  15. Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any other form of immunosuppressive therapy within 7 days prior to the first dose of study treatment.
  16. Active autoimmune disease that has required systemic treatment in past 2 years (i.e. with use of disease modifying agents, corticosteroids or immunosuppressive drugs). Note: Replacement therapy (e.g. thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment.
  17. Known history of human immunodeficiency virus (HIV) (HIV 1/2 antibodies).
  18. Has known active infection with Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV Ribonucleic acid (RNA) [qualitative] is detected). Note: i) Patients with a history of hepatitis B infection are eligible provided they are hepatitis B surface antigen negative ii) Patients with a history of hepatitis C infection are eligible provided they have no evidence of hepatitis C RNA using a qPCR at least 6 months after completing treatment for hepatitis C infection.
  19. Has received a live-virus vaccination within 30 days of planned treatment start. Note: Seasonal flu vaccines that do not contain live virus are permitted.
  20. Has a history of (non-infectious) pneumonitis that required steroids or current pneumonitis.
  21. Has a history of interstitial lung disease.
  22. Inability to swallow or tolerate oral medication.
  23. Existing gastrointestinal disease affecting drug absorption such as celiac disease or Crohn's disease, or previous bowel resection which is considered to be clinically significant or could interfere with absorption.
  24. Known lactose intolerance.
  25. Requires vitamin K antagonists. Note: Patients receiving low doses prescribed to maintain the patency of venous access devices may be included. Note: Factor Xa antagonists are permitted.
  26. Treatment with any of the following: histamine receptor 2 inhibitors, proton pump inhibitors or antacids within 7 days of start of study treatment.
  27. Treatment with any medication which is predominantly metabolized by CYP3A4 and has a narrow therapeutic index.
  28. Known hypersensitivity to bemcentinib, pembrolizumab, or any of their excipients.
  29. Any evidence of severe or uncontrolled systemic conditions (e.g. severe hepatic impairment) or current unstable or uncompensated respiratory or cardiac conditions, or ongoing.
  30. Has active infection requiring systemic therapy (apart from cutaneous infections).
  31. Has received radiation to the lung of >30 Gy within 6 months of first dose.
  32. Has a history or current evidence of any condition, therapy, or laboratory abnormality that might confound the results of the trial, interfere with the patient's participation for the full duration of the trial, or means it is not in the best interest of the patient to participate, in the opinion of the Investigator
  33. Is pregnant or breastfeeding, or expecting to conceive or father children within the projected duration of the trial, starting from Screening through to 120 days after the last dose of study treatment.
  34. Has known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial.
  35. Cohort B only: Has an EGFR mutation or ALK genomic rearrangement.

Relevance to patient case: possibly relevant