Patient case: 54-year-old female with non-small cell lung cancer; genetic feature: EGFR (D770N)

Clinical trial: Osimertinib Plus Savolitinib in EGFRm+/MET+ NSCLC Following Prior Osimertinib

Summary: This study (the SAVANNAH study) will investigate the efficacy of osimertinib in combination with savolitinib in patients with EGFRm+ and MET+, locally advanced or metastatic NSCLC who have progressed following treatment with osimertinib.

Detailed description: The combination of osimertinib with savolitinib in this study (the SAVANNAH study) will explore if the combination will overcome MET-amplification as a mechanism of resistance. The SAVANNAH study will investigate the efficacy of osimertinib in combination with savolitinib in patients with EGFRm+ and MET+, locally advanced or metastatic NSCLC who have progressed following treatment with osimertinib.
  Eligible patients will be those with histologically or cytologically confirmed diagnosis of EGFRm NSCLC that is locally advanced or metastatic and is not amenable to further surgery or radiotherapy with curative intent. The disease must have progressed following treatment with osimertinib. Patients must have confirmation of MET+ tumour by central FISH, central IHC or certain local NGS testing (requirements summarised in the main body of the protocol and fully explained in the Central Laboratory Manual). In patients centrally confirmed as MET+, MET+ is defined as a) high expression of MET (by IHC) and/or b) increased MET gene copy number (by FISH). Patients must not have received prior or current treatment with savolitinib or another MET inhibitor.
  All patients confirmed as eligible will begin treatment on Day 1 with osimertinib+savolitinib. Treatment will continue od in 28 day cycles until either objective disease progression, unacceptable toxicity occurs, consent is withdrawn or another discontinuation criterion is met.

Eligibility: Inclusion criteria:
  -  Patients must be ≥18 years of age (≥20 years of age in Japan). All genders are permitted.
  -  Histologically or cytologically confirmed locally advanced or metastatic EGFRm+ NSCLC harbouring an EGFR mutation known to be associated with EGFR TKI sensitivity (including either exon 19 deletion and/or L858R) which is not amenable to curative therapy.
  -  Documented radiologic disease progression following treatment with osimertinib (osimertinib does not need to be the most recent therapy).
  -  MET amplification/high expression as determined by FISH (central), IHC (central) or NGS (local) testing on tumour tissue collected following progression on prior osimertinib treatment.
  -  Available tissue from a recent biopsy for MET analysis or willingness to collect additional tissue for central testing.
  -  At least 1 lesion, not previously irradiated, not biopsied during the screening period, that can be accurately measured at baseline as ≥10 mm in the longest diameter (except lymph nodes which must have short axis ≥15 mm) with CT or MRI which is suitable for accurate repeated measurements.
  -  Received at least 1 but no more than 3 prior lines of therapy (may include investigational therapy) in the locally advanced/metastatic setting.
  -  No more than one prior line of chemotherapy regimen
  -  A chemotherapy regimen including a programmed cell death-1 (PD1) or a PD1 ligand 1 (PD L1) agent is acceptable, provided it was not the most recent line of therapy.
  -  No more than 2 prior lines of therapy containing EGFR TKI are acceptable
  -  Adequate haematological function defined as:
  -  Absolute neutrophil count ≥1500/μL
  -  Haemoglobin ≥9 g/dL (no transfusion in the past 2 weeks)
  -  Platelets ≥100,000/μL (no transfusion in the past 10 days)
  -  Adequate liver function
  -  ALT, AST ≤2.5 x ULN with total bilirubin ≤ ULN OR
  -  Total bilirubin >ULN to ≤1.5x ULN with ALT and AST ≤ ULN
  -  Adequate renal function - creatinine <1.5 times the institutional ULN OR a glomerular filtration rate ≥50 mL/min. Confirmation of creatinine clearance is only required when creatinine is >1.5 times ULN.
  -  Adequate coagulation parameters - INR <1.5 x ULN and activated partial thromboplastin time <1.5 x ULN unless patients are receiving therapeutic anti coagulation which affects these parameters.
  -  Patients with known tumour thrombus or deep vein thrombosis are eligible if clinically stable on low molecular weight heparin for ≥2 weeks.
  -  ECOG/WHO performance status of 0 or 1 with no deterioration over the previous 2 weeks and a minimum life expectancy of 12 weeks.
  -  Females of childbearing potential must be using highly effective contraceptive measures and have a negative pregnancy test.
  -  Males with a female partner of childbearing potential should be willing to use barrier contraception during the study and for 6 months following discontinuation of study drug.
  Exclusion criteria:
  -  Unresolved toxicities from any prior therapy greater than Common Terminology Criteria for Adverse Events (CTCAE) Grade 1 at the time of starting study treatment with the exception of alopecia and Grade 2 prior platinum therapy related neuropathy.
  -  As judged by the investigator, active gastrointestinal disease or other condition that will interfere significantly with the absorption, distribution, metabolism, or excretion of oral therapy (eg, ulcerative disease, uncontrolled nausea, vomiting, diarrhoea Grade ≥2, malabsorption syndrome or previous significant bowel resection).
  -  Any of the following cardiac diseases currently or within the last 6 months:
  Unstable angina pectoris Congestive heart failure (New York Heart Association [NYHA] ≥Grade 2) Acute myocardial infarction Stroke or transient ischemic attack Uncontrolled hypertension (BP ≥150/95 mmHg despite medical therapy). Mean resting correct QT interval (QTcF) >470 msec for women and >450 msec for men at Screening, obtained from 3 ECGs using the screening clinic ECG machine derived QTcF value.
  Any factors that may increase the risk of QTcF prolongation or risk of arrhythmic events such as heart failure, chronic hypokalaemia not correctable with supplements, congenital or familial long QT syndrome, family history of unexplained sudden death under 40 years of age in first-degree relatives or any concomitant medication known to prolong the QT interval and cause Torsade de Pointes.
  Any clinically important abnormalities in rhythm, conduction or morphology of resting ECGs, eg, complete left bundle branch block, third degree heart block, second degree heart block, P-R interval >250 msec.
  Acute coronary syndrome
  -  Wide field radiotherapy (including therapeutic radioisotopes such as strontium 89) administered ≤28 days or limited field radiation for palliation ≤7 days prior to starting study drug or has not recovered from side effects of such therapy.
  -  Major surgical procedures ≤28 days of beginning study drug or minor surgical procedures ≤7 days
  -  Evidence of severe or uncontrolled systemic diseases, including renal transplant, active bleeding diatheses or uncontrolled hypertension, which in the investigator's opinion makes it undesirable for the patient to participate
  -  Active hepatitis B or C
  -  Known serious active infection e.g. tuberculosis or human immunodeficiency virus
  -  Presence of other active cancers, or history of treatment for invasive cancer, within the last 5 years. Patients with Stage I cancer who have received definitive local treatment at least 3 years previously, and are considered unlikely to recur are eligible. All patients with previously treated in situ carcinoma (ie, non-invasive) are eligible, as are patients with history of non-melanoma skin cancer.
  -  Spinal cord compression or brain metastases unless asymptomatic, stable and not requiring steroids for at least 2 weeks prior to start of study treatment.
  -  Past medical history of interstitial lung disease(ILD), drug-induced ILD, radiation pneumonitis which required steroid treatment, or any evidence of clinically active ILD.
  -  Inadequate bone marrow reserve or organ function as demonstrated by any of the following laboratory values Absolute neutrophil count <1.5 x 109/L Platelet count <100 x 109/L Haemoglobin <90 g/L
  -  Prior or current treatment with a 3rd generation EGFR-TKI other than osimertinib.
  -  Prior or current treatment with savolitinib or another MET inhibitor (eg, foretinib, crizotinib, cabozantinib, onartuzumab, capmatinib).
  -  Patients who have received ≥4 lines of systemic therapy for NSCLC.
  -  Any cytotoxic chemotherapy, investigational agents or other anticancer drugs for the treatment of advanced NSCLC from a previous treatment regimen or clinical study within 14 days prior to the first dose of study treatment with the exception of monotherapy osimertinib which may continue uninterrupted during screening.
  -  Patients currently receiving (or unable to stop use prior to receiving the first dose of study treatment) medications or herbal supplements known to be strong inducers or strong inhibitors of CYP3A4, strong inhibitors of CYP1A2, or CYP3A4 substrates which have a narrow therapeutic range within 2 weeks of the first dose of study treatment (3 weeks for St John's Wort).
  -  Warfarin is not permitted (low molecular weight heparin is allowed).
  -  Participation in another clinical study with a cytotoxic, investigational product (IP), or other anticancer drug for the treatment of advanced NSCLC if received IP from that study within 14 days of the first dose of study treatment.
  -  Known hypersensitivity to the active or inactive excipients of osimertinib or savolitinib or drugs with a similar chemical structure or class.

Relevance to patient case: possibly relevant