A Study of Biomarker-Driven Therapy in Metastatic Colorectal Cancer (mCRC)
Condition: Colorectal Cancer
MeSH terms: Colorectal Neoplasms
Intervention: Cetuximab; FOLFOX induction regimen; Fluoropyrimidine (5-FU/LV or capecitabine); Atezolizumab; Vemurafenib; Bevacizumab; Trastuzumab; Pertuzumab; Cobimetinib; 5-FU/LV
Intervention description: 500 mg/m^2 via IV infusion on Day 1 of every 2-week cycle; Administered per the Investigator's discretion in accordance with locally approved prescribing information.; Per Investigator's discretion: 1600-2400 mg/m^2 administered via 46-hour IV infusion on Day 1 of every 2-week cycle and LV 400 mg/m^2 administered via a 2-hour infusion on Day 1 every 2 weeks or 1000 mg/m^2 twice-daily capecitabine (BID) by mouth given days 1-14 every 2 weeks. The chosen fluoropyrimidine should be administered in accordance with local prescribing information.; 800 mg atezolizumab via 60-minute IV infusion on Day 1 of every 2-week cycle, or a fixed dose of 840 mg; 960 mg vermurafenib BID by mouth; 5 mg/kg bevacizumab via 15-30 minute IV infusion on Day 1 of every 2-week cycle per local prescribing information; Initial loading dose of 8 mg/kg followed by 6 mg/kg for subsequent doses by IV infusion on Day 1 of every 3-week treatment cycle; Initial fixed loading dose of 840 mg followed by 420 mg for subsequent doses by IV infusion on Day 1 of each 3-week treatment cycle; 60 mg orally once daily for 3 weeks followed by a 1-week treatment break; 1600-2400 mg/m^2 5-FU via 46-hour IV infusion in combination with 400 mg/m^2 LV via 2-hour infusion on Day 1 of every 2-week cycle until disease progression per the Investigator's assessment using modified Response Evaluation Criteria in Solid Tumors or death from any cause, whichever occurs first.
Intervention MeSH terms: Bevacizumab; Trastuzumab; Cetuximab; Atezolizumab; Pertuzumab; Capecitabine; Fluorouracil; Vemurafenib
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Enrollment: 609.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No

Summary:

      This randomized, multi-center, active-controlled, open-label, parallel-group study will
      investigate the efficacy and safety of biomarker-driven maintenance treatment for first-line
      mCRC. Participants with mCRC are eligible for entry and cannot have received any prior
      chemotherapy in the metastatic setting. The entire study duration is anticipated to be
      approximately 7.5 years.
    

Eligibility criteria:

        Inclusion Criteria:

          -  ECOG PS of less than or equal to (<=) 2

          -  At least 16 weeks of life expectancy at time of entry into the study

          -  Histologically confirmed colorectal cancer (CRC) with mCRC confirmed radiologically

          -  Measureable, unresectable disease according to RECIST 1.1

          -  No prior chemotherapy for CRC in the metastatic setting

          -  Archival tumor formalin-fixed paraffin-embedded tissue block from the primary tumor
             obtained at the time of the initial diagnosis is available

          -  Adequate hematological, liver and renal function

          -  Agreement to use highly effective measures of contraception

        Exclusion Criteria for All Participants:

          -  Less than 6 months from completion of any prior neoadjuvant or adjuvant chemotherapy,
             radiotherapy

          -  Prior or current treatment with bevacizumab or any other anti-angiogenic drug
             (vascular endothelial growth factor or vascular endothelial growth factor receptor
             therapies or tyrosine kinase inhibitors)

          -  Current or recent (within 10 days of study enrollment) use of aspirin (more than [>]
             325 milligrams per day [mg/day]), clopidogrel (> 75 mg/day), or current or recent
             (within 10 days prior to the start of study induction treatment) use of therapeutic
             oral or parenteral anticoagulants or thrombolytic agents for therapeutic purposes
             (prophylactic uses allowed)

          -  Active infection requiring intravenous antibiotics at the start of study induction
             treatment

          -  Previous or concurrent malignancy, except for adequately treated basal or squamous
             cell skin cancer, in situ cervical cancer, or other cancer for which the participant
             has been disease-free for 5 years prior to study entry

          -  Inadequately controlled hypertension; prior history of hypertensive crisis or
             hypertensive encephalopathy

          -  Clinically significant (active) cardiovascular disease, for example cerebrovascular
             accidents <= 6 months prior to start of study induction treatment, myocardial
             infarction <= 6 months prior to study enrollment, unstable angina, New York Heart
             Association (NYHA) Functional Classification Grade II or greater congestive heart
             failure, or serious cardiac arrhythmia uncontrolled by medication or potentially
             interfering with protocol treatment

          -  Significant vascular disease (e.g., aortic aneurysm requiring surgical repair or
             recent arterial thrombosis) within 6 months of start of study induction treatment

          -  Active symptomatic or untreated central nervous system (CNS) metastases; CNS disease
             other than supratentorial or cerebellar metastases (in other words, patients with
             metastases to midbrain, pons, medulla or spinal cord are excluded); history of or
             known carcinomatous meningitis

          -  Known hypersensitivity to any component of any of the study induction or maintenance
             treatment medications

          -  Pregnancy or lactation

        Exclusion Criteria for Participants in Cohort 1 (MP):

          -  Inability to swallow pills

          -  Refractory nausea and vomiting, malabsorption, external biliary shunt or significant
             bowel resection that would preclude adequate absorption

          -  History or presence of clinically significant ventricular or atrial dysrhythmias

          -  Corrected QT (QTc) interval >= 450 millisecond assessed within 3 weeks prior to
             randomization, long QT syndrome or, uncorrectable electrolyte abnormalities (including
             magnesium) or requirement for medicinal products known to prolong the QT interval

          -  ECOG PS > 2

        Exclusion Criteria for Participants in Cohort 2 (MP):

          -  History of autoimmune disease including but not limited to myasthenia gravis,
             myositis, autoimmune hepatitis, systemic lupus erythematosus, rheumatoid arthritis,
             inflammatory bowel disease, vascular thrombosis associated with antiphospholipid
             syndrome, Wegener's granulomatosis, Sjögren's syndrome, Guillain-Barré syndrome,
             multiple sclerosis, vasculitis, or glomerulonephritis

          -  Prior allogeneic bone marrow transplantation or prior solid organ transplantation

          -  History of idiopathic pulmonary fibrosis (including pneumonitis), drug-induced
             pneumonitis, organizing pneumonia, or evidence of active pneumonitis at most recent
             chest imaging (computed tomography [CT] scan or magnetic resonance imaging [MRI])

          -  Positive test for human immunodeficiency virus (HIV)

          -  Active hepatitis B virus (HBV) or hepatitis C virus (HCV) at Screening

          -  Active tuberculosis

          -  Severe infection within 4 weeks prior to start of maintenance treatment including, but
             not limited to, hospitalization for complications of infection, bacteremia, or severe
             pneumonia; has signs or symptoms of significant infection or has received oral or IV
             antibiotics within 2 weeks prior to start of maintenance treatment

          -  Administration of a live, attenuated vaccine within 4 weeks prior to start of
             maintenance treatment or anticipation that such a live attenuated vaccine will be
             required during the remainder of the study

          -  Prior treatment with cluster of differentiation (CD) 137 agonists, anti-cytotoxic
             T-lymphocyte-associated antigen (CTLA) 4, anti-programmed death-1 (PD-1), or
             anti-programmed death-ligand 1 (PD-L1) therapeutic antibody or pathway-targeting
             agents

          -  Treatment with systemic immunostimulatory agents (including but not limited to
             interferons or interleukin-2) within 4 weeks or five half-lives of the drug, whichever
             is longer, prior to start of maintenance treatment

          -  Treatment with systemic corticosteroids or other systemic immunosuppressive
             medications within 2 weeks prior to start of maintenance treatment, or anticipated
             requirement for systemic immunosuppressive medications during the remainder of the
             study

          -  If receiving receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitor
             (for example, denosumab) and unwilling to adopt alternative treatment such as
             bisphosphonates while receiving atezolizumab

        Exclusion Criteria for Participants in Cohort 3 (MP):

          -  Inability to swallow pills

          -  Left ventricular ejection fraction (LVEF) less than (<) 50 percent (%) as assessed
             after completion of induction treatment by either 2-dimensional echocardiogram or
             multiple-gated acquisition

          -  Clinically significant cardiovascular disease, including unstable angina, history of
             or active congestive heart failure of ≥ NYHA Grade 2, history of or ongoing serious
             cardiac arrhythmia requiring treatment (except for controlled atrial fibrillation
             and/or paroxysmal supraventricular tachycardia).

          -  Current uncontrolled hypertension with or without medication

          -  Current dyspnea at rest due to complications of advanced malignancy or other disease
             requiring continuous oxygen therapy

          -  Insulin-dependent diabetes

          -  Current known infection with HIV, HBV, or HCV (active infection or carriers)

          -  Requirement for concurrent use of the antiviral agent sorivudine (antiviral) or
             chemically related analogues, such as brivudine

          -  Malabsorption syndrome, disease significantly affecting gastrointestinal function,
             resection of the stomach or small bowel, or ulcerative colitis

          -  Known hypersensitivity to murine proteins

        Exclusion Criteria for Participants in Cohort 4 (MP):

          -  Inability to swallow medications

          -  History of autoimmune disease including but not limited to myasthenia gravis,
             myositis, autoimmune hepatitis, systemic lupus erythematosus, rheumatoid arthritis,
             inflammatory bowel disease, vascular thrombosis associated with antiphospholipid
             syndrome, Wegener's granulomatosis, Sjögren's syndrome, Guillain-Barré syndrome,
             multiple sclerosis, vasculitis, or glomerulonephritis

          -  History of idiopathic pulmonary fibrosis (including pneumonitis), drug-induced
             pneumonitis, organizing pneumonia (bronchiolitis obliterans, cryptogenic organizing
             pneumonia), or evidence of active pneumonitis on most recent chest imaging (CT scan or
             MRI)

          -  Malabsorption condition that would alter the absorption of orally administered
             medications

          -  Amylase or lipase ≥ 1.5 times the upper limit of normal within 14 days prior to
             maintenance treatment initiation

          -  Serum albumin less than (<) 2.5 grams per deciliter (g/dL)

          -  LVEF < institutional lower limit of normal or < 50%, whichever is lower

          -  Poorly controlled hypertension

          -  Uncontrolled pleural effusion, pericardial effusion or ascites requiring repeated
             drainage more than once every 28 days. Indwelling drainage catheters are allowed

          -  Unstable angina, new onset angina within last 3 months, myocardial infarction within
             last 6 months and current congestive heart failure ≥ NYHA Grade 2

          -  History of stroke, reversible ischemic neurological defect, or transient ischemic
             attack within 6 months prior to initiation of maintenance treatment

          -  History or evidence of intracranial hemorrhage or spinal cord hemorrhage

          -  Evidence of clinically significant vasogenic edema

          -  Any hemorrhage or bleeding event ≥ National Cancer Institute Common Terminology
             Criteria for Adverse Events Grade 3 within 28 days prior to initiation of maintenance
             treatment

          -  History or evidence of retinal pathology on ophthalmologic examination that is
             considered a risk factor for central serous retinopathy, retinal vein occlusion, or
             neovascular macular degeneration

          -  Positive HIV test

          -  Active HBV or HCV

          -  Active tuberculosis

          -  Severe infection within 4 weeks prior to start of maintenance treatment including, but
             not limited to, hospitalization for complications of infection, bacteremia, or severe
             pneumonia; has signs or symptoms of significant infection or has received oral or IV
             antibiotics within 2 weeks prior to start of maintenance treatment.

          -  Prior allogeneic bone marrow transplantation or prior solid organ transplantation

          -  Administration of a live, attenuated vaccine within 4 weeks prior to start of study
             maintenance treatment or anticipation that such a live attenuated vaccine will be
             required during the study

          -  Prior treatment with CD137 agonists, anti-CTLA4, anti-PD-1, or anti-PD-L1 therapeutic
             antibody or pathway-targeting agents

          -  Prior treatment with a mitogen-activated protein kinase/extracellular signal-regulated
             kinase (ERK) or ERK inhibitor

          -  Treatment with systemic immunostimulatory agents (including but not limited to
             interferons or interleukin-2) within 4 weeks or five half-lives of the drug, whichever
             is longer, prior to start of study maintenance treatment

          -  Treatment with systemic corticosteroids or other systemic immunosuppressive
             medications (including but not limited to prednisone, dexamethasone, cyclophosphamide,
             azathioprine, methotrexate, thalidomide, and anti-tumor necrosis factor agents) within
             2 weeks prior to start of study maintenance treatment, or requirement for systemic
             immunosuppressive medications during the trial.

          -  If receiving a RANKL inhibitor (for example, denosumab), unwilling to adopt
             alternative treatment such as (but not limited to) bisphosphonates, while receiving
             atezolizumab.

          -  Consumption of foods, supplements or drugs that are potent cytochrome P450 3A4
             (CYP3A4) enzyme inducers or inhibitors ≤ 7 days before initiation of study maintenance
             treatment or expected concomitant use during maintenance treatment. These include St.
             John's wort or hyperforin (potent CYP3A4 enzyme inducer) and grapefruit juice (potent
             CYP3A4 enzyme inhibitor)