Study of Azacitidine in Combination With Pembrolizumab in R/R AML Patients and in Newly Diagnosed Older Patients
Condition: Acute Myeloid Leukemia
MeSH terms: Leukemia; Leukemia, Myeloid; Leukemia, Myeloid, Acute
Intervention: pembrolizumab; Azacitadine
Intervention description: Intravenous pembrolizumab; Intravenous or subcutaneous
Intervention MeSH terms: Pembrolizumab
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Enrollment: 67.0
Sex: All
Minimum age: 18 Years
Maximum age: 65 Years
Healthy volunteers: No

Summary:

      This is a multicenter, nonrandomized, open-label phase 2 study (with a safety run-in phase)
      of azacitidine (AZA) 75 mg/m2 given IV or SQ on days 1-7 every 28 days in combination with
      pembrolizumab 200 mg given IV every 3 weeks (starting on day 8 of cycle 1). The dose/schedule
      of AZA selected for this study is FDA approved for patients with MDS/AML.
    

Eligibility criteria:

        Inclusion Criteria:

        Cohort #1

          1. Have histologically or cytologically confirmed relapsed or refractory AML (i.e. ≥5%
             blasts by manual differential on bone marrow aspirate/biopsy/flow cytometry),
             excluding acute promyelocytic leukemia (APL; FAB M3; t(15;17))

          2. Be willing and able to provide written informed consent/assent for the trial.

          3. Be > 18 years of age on day of signing informed consent.

          4. Not be appropriate candidate for intensive salvage chemotherapy due to co-morbidities
             or other disease- or treatment-related factors.

             NOTE: Subjects who received prior treatment with hypomethylating agents either for
             Myelodysplastic Syndrome (MDS), Myeloproliferative Neoplasm (MPN), or AML will be
             eligible if they achieved response to hypomethylating agents in the past (PR or CR)
             and did not progress while receiving therapy with hypomethylating agents.

             NOTE: Subjects who had prior allogeneic stem cell transplant (alloHSCT) will be
             eligible as long as they have been at least 3 months after allogeneic HSCT and are off
             of all immune suppression for at least 3 weeks (>21 days) and have no evidence of
             active graft versus host disease (GVHD). Subjects with prior alloHSCT will NOT be
             eligible for enrollment during the safety run in phase.

          5. Demonstrate adequate organ function as defined in Table 1, all screening labs should
             be performed within 14 days of treatment initiation.

          6. ECOG performance status ≤ 2.

          7. A projected life expectancy of at least 12 weeks.

          8. Female subject of childbearing potential should have a negative urine or serum
             pregnancy within 72 hours prior to receiving the first dose of study medication. If
             the urine test is positive or cannot be confirmed as negative, a serum pregnancy test
             will be required.

          9. Female subjects of childbearing potential (Section 5.8.2) must be willing to use an
             adequate method of contraception as outlined in Section 5.8.2 - Contraception, for the
             course of the study through 120 days after the last dose of study medication.

             Note: Abstinence is acceptable if this is the usual lifestyle and preferred
             contraception for the subject.

         10. Male subjects of childbearing potential (Section 5.8.2) must agree to use an adequate
             method of contraception as outlined in Section 5.8.2- Contraception, starting with the
             first dose of study therapy through 120 days after the last dose of study therapy.

             Note: Abstinence is acceptable if this is the usual lifestyle and preferred
             contraception for the subject.

         11. As determined by the enrolling physician or protocol designee, ability of the patient
             to understand and comply with study procedures for the entire length of the study.

        Cohort #2

          1. Have histologically and cytologically confirmed newly diagnosed AML (i.e. ≥ 20% blasts
             by manual differential on bone marrow aspirate/biopsy and/or in peripheral blood),
             excluding acute promyelocytic leukemia (APL; FAB M3, t (15;17))

          2. Be willing and able to provide written informed consent/assent for the trial.

          3. Be ≥65 years of age on day of signing informed consent.

          4. Have received NO prior treatment for AML with the exception of
             hydroxyurea/leukapheresis.

             NOTE: Subjects may have been treated for pre-existent myeloid disorder such as
             Myelodysplastic Syndrome or Myeloproliferative Neoplasm excluding hypomethylating
             agents.

          5. Demonstrate adequate organ function as defined in Table 1, all screening labs should
             be performed within 14 days of treatment initiation.

          6. ECOG performance status ≤ 2.

          7. A projected life expectancy of at least 12 weeks.

          8. Female subject of childbearing potential should have a negative urine or serum
             pregnancy within 72 hours prior to receiving the first dose of study medication. If
             the urine test is positive or cannot be confirmed as negative, a serum pregnancy test
             will be required.

          9. Female subjects of childbearing potential (Section 5.8.2) must be willing to use an
             adequate method of contraception as outlined in Section 5.8.2 - Contraception, for the
             course of the study through 120 days after the last dose of study medication.

             Note: Abstinence is acceptable if this is the usual lifestyle and preferred
             contraception for the subject.

         10. Male subjects of childbearing potential (Section 5.8.2) must agree to use an adequate
             method of contraception as outlined in Section 5.8.2- Contraception, starting with the
             first dose of study therapy through 120 days after the last dose of study therapy.

             Note: Abstinence is acceptable if this is the usual lifestyle and preferred
             contraception for the subject.

         11. As determined by the enrolling physician or protocol designee, ability of the patient
             to understand and comply with study procedures for the entire length of the study.

        Adequate Organ Function Laboratory Values

        White blood cell (WBC) count <30,000 /mcL

        Serum creatinine OR Measured or calculated creatinine clearance (GFR can also be used in
        place of creatinine or CrCl) ≤1.5 X upper limit of normal (ULN) OR ≥60 mL/min for subject
        with creatinine levels > 1.5 X institutional ULN Serum total bilirubin ≤ 1.5 X ULN* AST
        (SGOT) and ALT (SGPT) ≤ 3 X ULN Albumin >2.5 mg/dL International Normalized Ratio (INR) or
        Prothrombin Time (PT) Activated Partial Thromboplastin Time (aPTT) ≤1.5 X ULN unless
        subject is receiving anticoagulant therapy as long as PT or PTT is within therapeutic range
        of intended use of anticoagulants

        ≤1.5 X ULN unless subject is receiving anticoagulant therapy as long as PT or PTT is within
        therapeutic range of intended use of anticoagulants

        Exclusion Criteria:

        Cohort #1

          1. 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 treatment.

             NOTE: Subjects who were treated on a clinical study of allogeneic stem cell transplant
             (alloHSCT) will be eligible if they are at least 3 months after allogeneic HCT and are
             at least 3 weeks (>21 days) off of all immune suppression and have no evidence of
             active GVHD (physiologic corticosteroid replacement therapy for adrenal or pituitary
             insufficiency is allowed). Subjects with prior alloHSCT will not be eligible for
             enrollment during the safety run in phase.

          2. 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 trial
             treatment.

          3. Has a known history of active TB (Bacillus Tuberculosis)

          4. Hypersensitivity to pembrolizumab or any of its excipients.

          5. Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study
             Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events
             due to agents administered more than 4 weeks earlier.

          6. Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy
             within 2 weeks or growth factors within 1 week prior to study Day 1 or who has not
             recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to a previously
             administered agent.

               -  Note: Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and
                  may qualify for the study.

               -  Note: If subject received major surgery, they must have recovered adequately from
                  the toxicity and/or complications from the intervention prior to starting
                  therapy.

          7. Has a known additional malignancy that is progressing or requires active treatment.
             Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the
             skin that has undergone potentially curative therapy or in situ cervical cancer.

          8. Has known active central nervous system (CNS) leukemia. Subjects with previously
             treated CNS leukemia may participate provided that they have documented clearance of
             CNS leukemia and are not actively treated with intrathecal chemotherapy.

          9. Has active autoimmune disease that has required systemic treatment in the past 2 years
             (i.e. with use of disease modifying agents, corticosteroids or immunosuppressive
             drugs). Replacement therapy (eg., thyroxine, insulin, or physiologic corticosteroid
             replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a
             form of systemic treatment. Subjects that require intermittent use of bronchodilators
             or local steroid injections will not be excluded from the study.

         10. Has known history of, or any evidence of active, non-infectious pneumonitis.

         11. Has an active uncontrolled infection requiring systemic therapy (viral, bacterial or
             fungal). Patients with infection under active treatment and controlled with
             antibiotics are eligible.

         12. Has a white blood cell count > 30 x 109/L. NOTE: Leukapheresis and Hydroxyurea is
             permitted to meet this criterion and should be stopped ≥12 hours before starting
             treatment on the study.

         13. Has a history or current evidence of any condition, therapy, or laboratory abnormality
             that might confound the results of the trial, interfere with the subject's
             participation for the full duration of the trial, or is not in the best interest of
             the subject to participate, in the opinion of the treating investigator.

         14. Has known psychiatric or substance abuse disorders that would interfere with
             cooperation with the requirements of the trial.

         15. Is pregnant or breastfeeding, or expecting to conceive or father children within the
             projected duration of the trial, starting with the pre-screening or screening visit
             through 120 days after the last dose of trial treatment.

         16. Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent.

         17. Has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies).

         18. Has known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA
             [qualitative] is detected).

         19. Has received a live vaccine within 30 days of planned start of study therapy. Note:
             Seasonal influenza vaccines for injection are generally inactivated flu vaccines and
             are allowed; however intranasal influenza vaccines (e.g., Flu-Mist®) are live
             attenuated vaccines, and are not allowed.

        Cohort #2

          1. Has received treatment with hypomethylating agent for pre-existent myeloid disorder
             such Myelodysplastic Syndrome (MDS) or Myeloproliferative Neoplasm (MPN).

          2. 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 treatment for pre-existent myeloid disorder
             such as MDS or MPN.

          3. Not be eligible for treatment with a standard cytarabine and anthracycline or similar
             intensive induction chemotherapy due to co-morbidities or other factors, or is
             unwilling to receive intensive induction therapy.

          4. 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 trial
             treatment.

          5. Has a known history of active TB (Bacillus Tuberculosis)

          6. Hypersensitivity to pembrolizumab or any of its excipients.

          7. Has had a prior anti-cancer monoclonal antibody (mAb) within 4 weeks prior to study
             Day 1 or who has not recovered (i.e., ≤ Grade 1 or at baseline) from adverse events
             due to agents administered more than 4 weeks earlier.

          8. Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy
             within 2 weeks or growth factors within 1 week prior to study Day 1 or who has not
             recovered (i.e., ≤ Grade 1 or at baseline) from adverse events due to a previously
             administered agent.

               -  Note: Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and
                  may qualify for the study.

               -  Note: If subject received major surgery, they must have recovered adequately from
                  the toxicity and/or complications from the intervention prior to starting
                  therapy.

          9. Has a known additional malignancy that is progressing or requires active treatment.
             Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the
             skin that has undergone potentially curative therapy or in situ cervical cancer.

         10. Has known active central nervous system (CNS) leukemia. Subjects with previously
             treated CNS leukemia may participate provided that they have documented clearance of
             CNS leukemia and are not actively treated with intrathecal chemotherapy.

         11. Has active autoimmune disease that has required systemic treatment in the past 2 years
             (i.e. with use of disease modifying agents, corticosteroids or immunosuppressive
             drugs). Replacement therapy (eg., thyroxine, insulin, or physiologic corticosteroid
             replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a
             form of systemic treatment. Subjects that require intermittent use of bronchodilators
             or local steroid injections will not be excluded from the study.

         12. Has known history of, or any evidence of active, non-infectious pneumonitis.

         13. Has an active uncontrolled infection requiring systemic therapy (viral, bacterial or
             fungal). Patients with infection under active treatment and controlled with
             antibiotics are eligible.

         14. Has a white blood cell count > 30 x 109/L. NOTE: Leukapheresis and hydroxyurea is
             permitted to meet this criterion and should be stopped ≥12 hours before starting
             treatment on the study.

         15. Has a history or current evidence of any condition, therapy, or laboratory abnormality
             that might confound the results of the trial, interfere with the subject's
             participation for the full duration of the trial, or is not in the best interest of
             the subject to participate, in the opinion of the treating investigator.

         16. Has known psychiatric or substance abuse disorders that would interfere with
             cooperation with the requirements of the trial.

         17. Is pregnant or breastfeeding, or expecting to conceive or father children within the
             projected duration of the trial, starting with the pre-screening or screening visit
             through 120 days after the last dose of trial treatment.

         18. Has received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent.

         19. Has a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies).

         20. Has known active Hepatitis B (e.g., HBsAg reactive) or Hepatitis C (e.g., HCV RNA
             [qualitative] is detected).

         21. Has received a live vaccine within 30 days of planned start of study therapy.